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Correspondence |
Affective Disorders Unit, Bethlem Royal Hospital, Beckenham BR3 3BX, UK
Beechhurst Unit, District General Hospital, Chorley PR7 1PP, UK
We read with interest the editorial on community psychiatry in developing countries (Jacob, 2001). Historically, in the West, community psychiatry arose in the context of the deinstitutionalisation movement and anti-psychiatry. In developing countries, however, the impetus for developing community-based care was the lack of universally accessible services. Thus, without any ideological baggage to contend with, the emphasis should be on integrated services rather than an artificial schism between hospital and community psychiatry.
We agree with Jacob that psychiatrists should concentrate on what they know best — the identification and treatment of mental illness. The mental health programmes in many developing countries set lofty goals of primary prevention that cannot succeed unless backed by overall social and economic development. But we take issue with his inclusion of epilepsy as a potential target of community psychiatry. It is the authors' experience, while working at the Community Psychiatry Unit at Bangalore, India, that this results in the programme becoming a glorified antiepileptic medication clinic.
Jacob's criticism of vertical mental health programmes ignores the practical reality that there is a limit to what generic health workers can deliver given their commitments to other public health programmes such as immunisation. A practical way of getting around this would be to have mental health workers, based at primary health centres, whose skills are intermediate between community psychiatric nurses and generic health workers. There is also a need to develop simple psychosocial interventions which can be delivered by these workers and draw from the strengths of the family or the local community. Community-based rehabilitation is also a priority area as the prevalent concept of good prognosis of mental disorders in developing countries is being challenged (Mojtabai et al, 2001).
One of the stated goals of community psychiatry is to deliver evidence-based treatments to people with mental disorders (Szmukler & Thornicroft, 2001). It may be heartening for psychiatrists in developing countries to know that the conventional psychotropic medications still remain first-line treatments (Geddes et al, 2001; Barbui & Hotopf, 2001). The challenge is to ensure that all primary health centres stock essential psychotropic medications and that primary care physicians are trained in the detection and management of common disorders.
REFERENCES
Barbui, C. & Hotopf, M. (2001)
Amitriptyline v. the rest: still the leading antidepressant after 40
years of randomised controlled trials. British Journal of
Psychiatry, 178, 129
-144.
Geddes, J., Freemantle, N., Harrison, P., et al
(2000) Atypical antipsychotics in the treatment of
schizophrenia: systematic overview and meta-regression analysis.
British Medical Journal,
321, 1371
-1376.
Jacob, K. S. (2001) Community care for people
with mental disorders in developing countries. Problems and possible
solutions. British Journal of Psychiatry,
178, 296
-298.
Mojtabai, R., Varma, V. K., Malhotra, S., et al
(2001) Mortality and long-term course in schizophrenia with a
poor 2-year course. A study in a developing country. British
Journal of Psychiatry, 178, 71
-75.
Szmukler, G. & Thornicroft, G. (2001) What is ‘community psychiatry’? In Textbook of Community Psychiatry (eds G. Thornicroft & G. Szmukler), pp. 1 -12. Oxford: Oxford University Press.
Department of Psychiatry, Christian Medical College, Vellore 632002, India
Drs Ranjith and Duddu argue that primary health care workers, because of their commitments to physical health needs, are not able to deliver mental health care. While this is partly true, I believe that the accomplishment of programmes that have been successfully integrated into primary care depends upon empowerment of the primary care staff to manage these problems. Physicians, nurses and community health workers in many developing countries, with their limited training, are not confident in managing mental disorders. Changes in the basic curriculum, training of trainers within primary care and ongoing support in fieldwork are necessary for skills to be transferred. The empowerment of primary care staff to tackle mental health problems is mandatory for the success of such programmes. Obstetric and immunisation services in many parts of the developing world have succeeded because of such empowerment and consequent integration into primary care.
The successful treatment of epilepsy in many mental health programmes is because the primary care staff are confident and competent in managing these disorders. The lack of these components in the management of psychoses and depression has resulted in programmes mainly treating subjects with epilepsy. The absence of other programmes for treating seizure disorders in the community would argue for retention of this component within mental health initiatives.
The problems of mental illness are complex, with implications for health care, the economy, and social and cultural practices. The current approaches have not delivered reasonable health care in many parts of the developing world. There are no simple solutions. There is a need for debate to generate new and different initiatives in order to overcome the present inertia. A combination of approaches, which harness the available resources, may be more successful than a single strategy.
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