Policy and Service Implications
Many attempts have been made during the past 50 years to have mental health care placed higher on national and international agendas. In 1974, a WHO Expert Committee on the Organization of Mental Health Services in Developing Countries (WHO 1975) made the following recommendations:
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Develop a national mental health policy and create a unit within the Health Ministry to implement it.
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Budget for workforce development, essential drug procurement, infrastructure development, data collection, and research.
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Decentralize service provision and integrate mental health into primary health care.
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Train and supervise primary health care providers in mental health using specialist mental health staff.
Thirty years later, international agencies, nongovernmental organizations, and professional bodies continue to make those exact recommendations. One reason for the lack of action in mental health has been the paucity of information on the cost-effectiveness of mental health interventions. Advocacy without the necessary science can readily be ignored in countries with massive health problems and meager resources. This chapter aims to address this deficiency.
Symptoms of mental disorders are often attributed to other illnesses, and mental disorders are often not considered health problems (Jacob 2001). Many nonscientific explanations for mental illness exist, and stigma exists to varying degrees everywhere (Weiss and others 2001) with widespread delays or failure to seek appropriate care (James and others 2002).
When care is sought, a hierarchy of interventions comes into play, ranging from self-help, informal community support, traditional healers, primary health care, specialist community mental health care, and psychiatric units in general hospitals to specialist long-stay mental hospitals. The mix of interventions depends on the availability of resources within a country or region (Saxena and Maulik 2003). The more resource-constrained the country or region is, the greater is the reliance on self-help, informal community support (especially family-based), and primary health care.
Traditional healers are often the first source individuals with mental illness and their families turn to for professional assistance (see, for example, Abiodun 1995). A recent review of common mental disorders among primary health clinics and traditional healers in urban Tanzania showed that the prevalence of common mental disorders among those attending traditional healers was double that of patients at primary health care centers (Ngoma, Prince, and Mann 2003). Traditional healers are a heterogeneous group and include faith healers, spiritual healers, religious healers, and practitioners of indigenous or alternative systems of medicine. In some countries, they are part of the informal health sector, but in other countries, traditional healers charge for their services and should be considered part of the private health care sector. Often, traditional healers have high acceptability and are accessible; at times, traditional healers work closely (and apparently effectively) with conventional mental health services (Thara, Padmavati, and Srinivasan 2004). Alternatively, animosity and competition can exist, and recent examples of human rights violations by traditional healers demonstrate the heterogeneity of this group of providers.
The formal diagnosis and treatment of mental disorders occur in both primary and specialist health services. Examples in nearly a dozen countries now show it is feasible and practicable to treat common mental disorders in primary health care settings (for example, Chisholm and others 2000; De Jong 1996; Mohit and others 1999). The challenge is to enhance systems of care by taking effective local models and disseminating them throughout a country.
Concern has been expressed that the more sophisticated psychotherapies used in mental health care are beyond the human resources of developing countries. However, basic psychological therapies can be effective, though there is some evidence, at least for depression, that the newer drug therapies are more cost-effective than psychological therapies (Patel and others 2003). Psychoeducational family intervention has been shown to be suitable for rehabilitation in schizophrenia in rural China (Ran and others 2003) and to be cost-effective compared with other standard treatment (Xiong and others 1994). Evidence also shows that nurses can replace physicians as primary health care providers in certain circumstances without loss of effectiveness (Climent and others 1978). Primary care practitioners need support to develop skills and experience in diagnosing and treating mental disorders: they need a sustainable supply of medicines, access to supervision, and incentives to see patients with mental illness (Abas and others 2003). Community approaches using low-cost, locally available resources may improve treatment adherence and clinical outcomes even in rural and underresourced settings (Chatterjee and others 2003; Srinivasa Murthy and others 2005).
In most countries, acute inpatient beds are being moved from mental hospitals into general or district hospitals. Although this policy potentially improves accessibility and increases the links with, and support provided to, primary mental health care, concerns can be raised as to whether general hospitals can adapt to provide adequate services to people with severe mental disorders. However, such services have been effectively established in a number of countries (see, for example, Alem and others 1999; Kilonzo and Simmons 1998), showing this form of service delivery to be feasible when it is clinically indicated.
Nongovernmental organizations are important providers of mental health care. An estimated 93 percent of African and 80 percent of Southeast Asian countries have nongovernmental organizations in the mental health sector. They provide diverse services—including advocacy, informal support, housing, suicide prevention, substance misuse counseling, dementia support, rehabilitation, research, and other programs—that complement, or in some cases substitute for, public and private clinical services (Levkoff, Macarthur, and Bucknall 1995; Patel and Thara 2003).
Services for children and adolescents, the majority of the population in many developing countries, are even more deficient than those for adults. Priority needs to be given to these services (Rahman and others 2000). At the other end of the life spectrum, many developing countries are facing aging populations with grossly underdeveloped aged care services (Levkoff, Macarthur, and Bucknall 1995). The high level of civil conflict and natural disasters requires attention to postconflict and posttrauma mental health conditions. The prevalence of these disorders is demonstrated by a recent study (Livanou, Basoglu, and Kalendar 2002) showing that, of 1,000 survivors of the August 1999 earthquake in Turkey, the incidence of PTSD was 63 percent and of depression was 42 percent.
Specialist mental health providers, especially mental hospitals, tend to focus the services they provide on the lower-prevalence, higher-disability disorders, such as schizophrenia and bipolar disorder. Modern treatments, if available and used, allow most patients to be treated effectively out of hospital. Specifically, the use of antipsychotic and mood-stabilizing drugs and the development of strategies for community-based treatment have led to the closing of large numbers of psychiatric inpatient beds in many countries and their replacement with community services and general hospital psychiatric units (for example, Larrobla and Botega 2001).
However, in some countries, the majority of psychotic patients remain in long-term inpatient facilities that engage in custodial care, which is often of poor quality; moreover, basic rights are often violated at such facilities (van Voren and Whiteford 2000). Even if the quality of care is reasonable, accessibility is a problem: these hospitals are often situated in urban areas, but populations are largely rural and have limited transportation (Saraceno and others 1995). Furthermore, the concentration of resources in these facilities can leave little for other service components (Gallegos and Montero 1999). For example, in Indonesia, 97 percent of the mental health budget is spent on public mental hospitals (Trisnantoro 2002). For many developing countries, the debate about the role of, or problems with, mental hospitals is subsumed within a gross deficiency of psychiatric beds of any kind.
The priority for virtually all countries is generating sufficient resources for primary mental health care and deciding how to expand and best use scarce specialist resources. The quality of care is often very poor, and huge variations exist in resource availability between countries (Saxena and Maulik 2003; WHO 2001). Very few countries have what could be considered an optimal mix of these services, and there are no universally accepted planning parameters. However, conceptual models for developing national mental health policy and guidelines for service planning exist that can be useful in developing countries (Tansella and Thornicroft 1998; Townsend and others 2004; WHO 2003).
