Intended for healthcare professionals


Mental healthcare in low and middle income countries

BMJ 2014; 349 doi: (Published 25 November 2014) Cite this as: BMJ 2014;349:g7086
  1. Robert E Drake, professor of psychiatry and community and family medicine1,
  2. Agnes Binagwaho, minister of health2,
  3. H Castillo Martell, director general3,
  4. Albert G Mulley, director4
  1. 1Dartmouth College, Hanover, New Hampshire, USA
  2. 2Department of Health, Kigali, Rwanda
  3. 3National Institute of Mental Health, Lima, Peru
  4. 4Dartmouth Center for Health Care Delivery Science, Hanover, New Hampshire, USA
  1. Correspondence to: R E Drake Robert.E.Drake{at}

Should not replicate the inefficient, inaccessible, and insensitive Western model

The global burden of disease is shifting rapidly from infectious disease to chronic non-infectious disease, with mental and substance use disorders the leading cause of years lost to disability in 2010 worldwide.1 Meanwhile, the movement for global mental health, largely based on evidence based treatments from wealthy countries, has been rapidly gaining momentum.2 Evidence for the effectiveness of these treatments is, however, often silent on culture, context, and preferences of patients. The failure to listen to people and to consider context has led to substantial waste and harm in wealthy countries.3 These concerns should be central in the global mental health movement and will be emphasised at the Salzburg Global Seminar session on mental health in December 2014, which will include teams from more than 12 countries.

Wealthy countries, whether they have market driven or state planned systems, have created expensive and inefficient mental healthcare. Government, industry, and experts make decisions at the top, while people who are at risk, those with serious illnesses, families, and particularly minority communities are left out of the decision making process and often out of the care system entirely. For example, even with the exorbitant healthcare spending in the United States, the mental health system fails to reach more than half of people with the most serious mental disorders.4

Low and middle income countries have limited resources to replicate healthcare systems in high income countries, but why should they emulate inefficient, inaccessible, insensitive systems? Alternative approaches may be more efficient, more scalable, and more sensitive to culture, needs, and context.5 Traditional models of mental illness in many countries emphasise recovery, non-medicalised approaches, families, religion, and extensive use of lay health workers. In addition, nearly all countries have widespread mobile phone networks that may permit progressive use of health technologies. Finally, not having to dismantle inefficient systems maintained by vested interests represents an enormous advantage.

Listen to the people

Low and middle income countries could develop alternative behavioural health systems by emphasising a few strategies. They should start by listening to people and empowering citizens, families, traditional supports, lay health workers, cultures, and communities to define their needs and design systems they want. Well informed patients and families can express preferences and participate in creating systems of care, including technology tools, that respond to personal and community needs.6 Mental health should be for everyone: all people benefit from maternal and child health, strong families, education, stress management training, social support, meaningful work, and self management.7 Local stakeholders understand context and prefer spending limited resources on these local services. Local learning communities could monitor outcomes, learn from data, engage in continuous quality improvement, and perhaps prevent medical fraud.

These countries should also continue to train lay health workers and generalists rather than specialists. Lay health workers, backed up by medical generalists (primary care nurses and doctors), currently provide over 90% of mental healthcare worldwide. They can learn to manage depression, anxiety, psychosis, and substance misuse, just as they learn to manage malaria, HIV, and tuberculosis. On the other hand, specialists tend to develop a selective inattention to matters outside their expertise, thereby missing context and creating silos of care, overdiagnosis, and overtreatment.8 Wealthy countries are now spending billions of dollars trying to convert systems that are based on specialists back into integrated models of care so that they can control excessive treatments.

Community based psychosocial interventions should be emphasised rather than drug treatments. Peer and family supports, meditation, employment, and technology tools are generally effective, have few side effects, and are more durable than psychiatric drugs.9 10 Wealthy countries spend huge resources on medications, mainly because of advertising and lobbying rather than because they are effective; a rational mental health system would rely on judicious use of generic drugs. Engaging indigenous religious and healing communities is critical. For example, after 400 years of genocide, historical trauma, and attempts at forced assimilation, many Native American tribes in the US are developing and using culture bound treatments for medical problems.11 Evidence based practices from wealthy countries often need to be adapted to local context and culture,12 13 but disregard for traditional healing creates backlash by disrespecting cultural beliefs, workforces, and context.

Finally, low and middle income countries should embrace new technologies that can provide education, prevention, assessment, treatment of acute illnesses, and management of long term illnesses.10 These tools extend the reach of healthcare workers and are often effective by themselves—generally as effective as well trained mental health professionals.10 Most people with mental disorders accept and value these tools highly; the tools can be translated to other languages and cultures; and the mobile phone infrastructure to deliver them broadly exists already.

Building on their strengths, low and middle income countries have the opportunity to create innovative, efficient, and culturally sensitive mental health systems and avoid the mistakes of high income countries.


Cite this as: BMJ 2014;349:g7086


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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