Electronic Letters to:
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eLetters: Electronic letters published:
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Economics and mental health: is cheap medication really the solution?
- Jacob Alexander (25 October 2008)
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Implications and probable associations of DUP in Low income Countries
- Ademola Bello (10 December 2008)
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Jacob Alexander, Snr. Psychiatry Registrar Central Northern Adelaide Health Services, Royal Adelaide Hospital, Adelaide, SA -5000
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dralexander_in{at}yahoo.com Jacob Alexander
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The authors raise a valid point in their article where they point out that the prohibitive cost of medications is often a serious impediment to accessing early and effective treatment in the management of psychosis. It follows, logically therefore, that increasing the availability of subsidised medication will significantly reduce the duration of untreated psychosis (1). Having trained in a low income country (India), my concern is that this does not seem to be the case. Loopholes in current patent laws mean that more than 20 brands of olanzapine and risperidone are available in India at a fraction of ‘Western’ prices (2). Access to treatment is often governed by more complex issues including probably most importantly, access to the machinery that prescribes these treatments. 72.2 % of the Indian population lives in rural India while the majority of its practitioners of modern medicine are concentrated in the urban centres where socio economic conditions are better. Surveys of the geographical distribution of hospitals in India seem to suggest that this is directly linked to the socioeconomic conditions in the region (3) with affluent regions having an increased concentration. Pathways to care in third world countries often involve more readily accessible and culturally acceptable traditional healers contributing to delays in treatment (4). Other issues that delay treatment include stigma, inadequate knowledge about mental illness and competing interests that include the struggle for daily sustenance. I argue that an over all improvement in economic conditions translates into better health care as evidenced by the allocation of more resources to areas such as mental health in the more developed nations. Maslow’s theory on the hierarchy of needs (5) gives one a plausible explanation as to why disadvantaged sections of the community such as the mentally ill and women’s health miss out when resources are allocated in resource poor countries. Making cheap drugs available may not be as effective a tool in shortening the duration of untreated psychosis as an overall improvement in economic conditions as evidenced by an increased GDP. References: 1. Large M, Farooq S,Nielssen O, Slade. Relationship between gross domestic product and duration of untreated psychosis in low- and middle- income countries. The British Journal of Psychiatry (2008) 193: 272-278 2. Adams CE, Tharyan P, Coutinho ES, Stroup ST. The schizophrenia drug- treatment paradox: pharmacological treatment based on best possible evidence may be hardest to practise in high-income countries. The British Journal of Psychiatry (2006) 189: 391-392 3. Official site of the Ministry of Health- India http://mohfw.nic.in/ (accessed on 20th October, 2008) 4. Temmingh HS, Oosthuizen PP. Pathways to care and treatment delays in first and multi episode psychosis. Findings from a developing country.Soc Psychiatry Psychiatr Epidemiol (2008) 43:727–735 5. A.H. Maslow. A Theory of Human Motivation. Psychological Review 50 (1943):370-96. |
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Ademola Bello, CT2 Specialist Registrar Eastleigh Child and Family Guidance Centre, Eastleigh Health Centre, Newtown road, Eastleigh
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ademola.bello{at}nhs.net Ademola Bello
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In the above study the author states that “there appears to be an inverse relationship between income and DUP in LAMI countries”. The author also rightly surmises that we have more work to do in this area. In considering the long term implications of long DUP in LAMI countries, it is also important to consider the nature and diagnostic stability of the psychotic conditions in question – schizophrenia versus affective/ reactive psychosis 1. As a psychiatrist with over three years post graduate experience in Nigeria I can comment that we definitely saw more cases of affective and reactive psychosis although the schizophrenic cases we treated tended to be more debilitating and chronic for the reasons highlighted by the author. There is often a complex interplay of cultural and financial issues in mental healthcare delivery in these countries. More often than not, LAMI countries represent a heterogeneous mix of diverse tribes, languages and cultures; each with its own unique beliefs and attitudes. Psychiatrists that have not worked in LAMI countries should be wary of the “ecological fallacy” in population based research like the one conducted by the author. In proposing probable reasons for the longer DUP in LAMI countries, cultural reasons including religious beliefs and issues of stigmatization appears not to have been considered; these play a huge role in DUP countries2. To procure a solution that will be acceptable to the patients from LAMI countries, it will be necessary to consider their values and beliefs. REFERENCES 1 Bromet, Evelyn J, Naz, Bushra et al. Long-term diagnostic stability and outcome in recent first-episode cohort studies of schizophrenia. Schizophrenia Bulletin, July 2005, vol. 31/3(639-649) 2 Cohen A., Patel V., Thara R., Gureje O. Questioning an axiom: Better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin, March 2008, vol. 34/2(229-244) |
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