Primary Care

Learning from low income countries: mental health

BMJ 2004; 329 doi: (Published 11 November 2004) Cite this as: BMJ 2004;329:1138
  1. Kwame McKenzie (, senior lecturer in psychiatry1,
  2. Vikram Patel, reader in international mental health2,
  3. Ricardo Araya, reader3
  1. 1 Royal Free and University College Medical School and Barnet, Enfield and Haringey Mental Health NHS Trust, Department of Mental Health Sciences, London NW3 2PF
  2. 2 London School of Hygiene and Tropical Medicine, London WC1E 7HT
  3. 3 Division of Psychiatry, Cotham House, Bristol BS6 6JL
  1. Correspondence to: K McKenzie

    Organising mental health services to harness the support of the family and community may improve outcomes


    Thirty one per cent of all years lived with disability are due to mental illness. Mental health problems are important in every country, even those with high burdens of illness due to infectious diseases.1

    Wealthy countries generally have more services to combat mental health problems than low income countries. In many low income countries there is typically one psychiatrist per population of 1 000 000, with little or no multidisciplinary team and few regular drugs. Given this mismatch, it is easy to conclude that there is little that psychiatry in developed countries can learn from poorer countries, but this is not the case.

    Services in low income countries are often greatly under-resourced, under strain, and leave most people with mental health problems with no care. But there are examples of different ways to treat or prevent mental illness from which high income countries can learn. Some are born from the ingenuity of necessity, others from cultural knowledge.26

    We do not aim to idealise low income countries, to demonise high technology and psychiatric care, or to offer the stereotype of cohesive traditional communities as a panacea, which could undermine the development of appropriate services. We simply present examples that challenge the orthodox, make us pause to think, and offer rational models for provision of care that high income countries may consider useful.

    The pathways to care and prevention

    The figure shows a pathway through care for someone in psychological distress. This illustrates the variety of levels at which the cited interventions work.

    Pathway through care for someone in psychological distress

    Prevention of mental illness by social support

    Pathways to care in high income countries usually neglect community services and factors in operation before statutory care is sought. The development of provision of traditional care …

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