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

Re: Mental healthcare in low and middle income countries

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.

19 December 2014
Stephen M Lawrie
Head of Psychiatry
University of Edinburgh
KennedyTower, Royal Edinburgh Hospital, Edinburgh EH10 5HF