Mental healthcare in low and middle income countriesBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7086 (Published 25 November 2014) Cite this as: BMJ 2014;349:g7086
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Drake et al make several good points about the potential dangers of emulating the ‘inefficient, inaccessible and insensitive Western model’ of mental health care in low and middle income countries. One might well say similar things about physical health care systems. In either case however a rejection of the good parts of Western health care would be unfortunate.
Knapp and colleagues (1) have shown that a range of early identification and intervention programmes for mental disorder are cost-effective to the NHS and other public and non-public sectors in the short, medium and long-term. Some, including early intervention for psychosis can save the NHS money within a year. Others, such as early diagnosis and treatment of depression at work can have wider social benefits in the same timeframe. These savings and benefits may not apply in all countries and health care systems but they surely merit consideration. Further, the WHO (2) have shown that specific interventions such as psychosocial and antidepressant treatment are ‘very cost-effective’ interventions for panic disorder and depression throughout the world, and that psychosocial treatments plus older antipsychotic and mood stabilising drugs are ‘cost-effective’ for schizophrenia and bipolar disorder.
Two recent reports from UK agencies give additional and complementary perspectives. The UK's All-Party Parliamentary Group on Global Health and Mental Health (3) presents examples of both good and bad aspects of mental health services in many parts of the world, as well as an evidence-base for global action. It is important to acknowledge, for example, that patients can still be caged, chained or subjected to abusive traditional approaches in many countries and that Western mental health services are not all bad. The report summarises the growing body of research showing that there are cost-effective solutions to mental health problems that even the poorest countries could implement and benefit from. These include improving social and economic environments, integrating mental health into general health care, using trained and non-specialist health workers to provide culturally appropriate community care, increasing access to self-help and empowering people with mental health problems to support and advocate for themselves and each other. It almost goes without saying that we could do these better here as well. Equally, as the report makes clear, Western mental health services could learn from initiatives in other countries.
As the Overseas Development Institute (4) stress, mental (ill) health does not receive due policy attention due to stigma and a lack of coherence across the mental health community. The mental health community have to work together to achieve shared goals such as reducing stigma and increasing funding for mental health services across the globe.
1.Knapp M, McDaid K, Parsonage M. Mental health promotion and mental illness prevention: the economic case. Department of Health, 2011.
2.Chisholm D, on behalf of WHO-CHOICE. Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organisation. World Psychiatry 2005; 4: 37-44.
3. Mental Health for Sustainable Development. UK's All-Party Parliamentary Group on Global Health and Mental Health, 2014.
4. Mackenzie J. Global mental health from a policy perspective: a context analysis. Overseas Development Institute 2014.
Competing interests: I have received personal fees from Janssen, Roche and Sunovion, and research grants from Abbvie, Roche and Pfizer.
Re: Mental healthcare in low and middle income countries- Case for Cultural Adaptation of Psychological Interventions
Drake and colleagues (2014) make an excellent case for culturally adapted, relevant services and interventions for mental illness in low and middle income countries. Cognitive behaviour therapy (CBT) is now recognised as a key evidence-based therapy that is widely used across the globe for various illnesses (Hoffman et al. 2012). However the concepts and constructs used in therapy have been criticised as being rooted in Western cultures and not consistent with cultural beliefs elsewhere. Cultural relevance is essential (Rathod et al, 2008) and practice needs to be adapted to fit a variety of cultural backgrounds (Rathod, 2014). Adapting an intervention carries inherent challenges and risks like presuming global understanding from knowledge of the culture or subculture – stereotyping - when the intervention should allow latitude and flexibility for an assessment of every individual's personal values. Cultural adaptation also inevitably modifies evidence based treatments and the dilemma exists as to when fidelity to the core intervention is lost and when adaptation compromises the effectiveness of an intervention.
We found that outcomes were significantly worse in African Caribbean and Black African groups participating in a large randomised controlled trial of CBT for psychosis (Rathod et al. 2005) and this led to qualitative (Rathod et al. 2010) and quantitative (Rathod et al, 2013) research. Experiences of patients, clinicians and lay members from minority cultural communities were used to adapting CBT using a framework proposed by Tseng et al. (2005). Trials of adapted therapies have been performed with positive results in psychosis and depression in the UK, United States, Pakistan and China and this is expanding to other countries (Rathod et al, 2015). Such work now needs replicating, developing and implementing.
Drake, R. et al. (2014). Mental healthcare in low and middle income countries. British Medical Journal; 349:g7086.
Hofmann, S., Asnaani, A., Vonk, I., Sawyer, .A. and Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy Research, 36(5): 427–440.
Rathod, S., Kingdon, D., Smith, P. and Turkington, D. (2005). Insight into schizophrenia: the effects of cognitive behavioral therapy on the components of insight and association with sociodemographics – data on a previously published randomised controlled trial. Schizophrenia Research, 74: 211–219.
Rathod S, Naeem F, Phiri P, Kingdon D. (2008). Expansion of psychological therapies The British Journal of Psychiatry, 193: 256.
Rathod, S., Phiri, P., Kingdon, D., Gobbi, M. (2010). Developing Culturally sensitive Cognitive behaviour therapy for Psychosis for Ethnic minority patients by Exploration and Incorporation of Service Users’ and Health Professionals' Views and Opinions. Journal of behavioural and Cognitive Psychotherapies, 38; 511-33.
Rathod, S. (2014). Developing Culturally adapted cognitive behaviour therapy for mental disorders. Social Psychiatry today; Official newspaper of the World Association of Social Psychiatry and Royal College of Psychiatrists Jubilee Congress 2014; page 3.
Rathod S., Phiri, P., Harris, S., Underwood, C., Thagadur, M., Padmanabi, U., & Kingdon D. (2013). Cognitive behaviour therapy for psychosis can be adapted for minority
ethnic groups: A randomised controlled trial. Schizophrenia Research, 143(2–3), 319–326.
Tseng, W. S. (1999). Culture and psychotherapy: Review and practical guidelines. Transcultural Psychiatry, 36, 131–179.
Rathod, S., Kingdon, D., Pinninti, N., Turkington, D., Phiri, P. (2015). Cultural adaptation of CBT for serious mental illness – A guide for training and practice. Wiley.
Competing interests: No competing interests
Thank you for your very interesting views in this article.
Almost half the world's population lives in countries where, on average, it is estimated that there is one psychiatrist to serve 200 000 or more people and other resources to provide holistic psychosocial interventions are even scarcer. This is despite mental health being a fundamental component of the WHO’s definition of health and a key priority.
It is well recognised that mental health is affected by a range of socio-economic factors that need to be addressed holistically through comprehensive strategies with appropriate plans for promotion, prevention, treatment and recovery from mental illnesses. To be able to do so, health systems worldwide need to be geared up to meet and adequately fulfil the needs of the population they serve. It has been acknowledged that between 76% and 85% of people with severe mental disorders possibly do not receive any treatment for their disorder in low and middle-income countries, with the corresponding range for high income countries also being quite high, between 35% and 50%.1 This gap between the need for treatment and provision of services is well recognised by the WHO too.
However again it is down to governments and those who are in a position to make policies, to allocate adequate resources and make mental health a priority.
As the authors point out, it is obvious to recognise that there is no single universal model which can be applied across the world, however allocating adequate resources, using evidence based models and empowering service users to make educated choices in keeping with their cultural values could only help them to overcome any hindrances in service delivery and also be in keeping with their own value systems.
Priority should also be directed at overcoming the stigma, mental illness sufferer’s face across the world, irrespective of their country of origin, which too may be a great hindrance to accessing and adhering to any treatment plans that may potentially cure them completely.
1 Mental health action plan 2013-2020.
Available at : http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf?ua=1
Competing interests: No competing interests