Early intervention in psychosis in developing coun‐tries: evidence and action

Abstract

In the recent forum on early intervention for psychosis in World Psychiatry 1, Ndetei highlights the lack of progress in bringing about early intervention in psychosis in Africa, where more than 50% of the population is under the age of 25 2. Ndetei also points out that almost all the research about early intervention is conducted in developed countries. In our recent review of the duration of untreated psychosis (DUP) in low and middle income (LAMI) countries, we employed exhaustive search strategies, but were only able to locate data from 18 of over 150 LAMI and only 3 of over 50 African countries 3. The low priority given to mental health in LAMI countries 4, 8 and the widely accepted but controversial notion that schizophrenia carries a better prognosis in developing countries might have hindered the development of services for psychosis. We found that the average mean DUP in studies from LAMI countries was 125.0 weeks compared with 63.4 weeks in studies from high-income countries (p=0.012). Using the data on gross domestic product (GDP), we demonstrated that within the studies from LAMI countries, mean DUP fell by 6 weeks for every $1000 of GDP purchasing power parity. In a related paper, we reviewed the studies from LAMI countries that investigated an association between DUP and at least one of the following outcome measures: psychotic symptoms, cognitive function, social disability or mortality. The DUP in LAMI countries was significantly associated with higher ratings of positive symptoms and social disability, a finding similar to that reported in high-income countries 9. In addition, two studies 10, 11 suggest a strong association between DUP and subsequent mortality from physical illness. The “good prognosis” hypothesis seems less tenable when the high prevalence of partially and never treated cases of psychosis in developing countries and the long DUP for those who do receive treatment is taken into consideration. The adverse consequences of long DUP, and the increased morbidity and mortality from infections and malnutrition among those with mental illness, confirm the need for a vigorous approach to early intervention in developing countries. This approach, however, needs to take social and economic realities of developing countries into account. One of the interventions could be to pro-vide antipsychotic treatment free of cost at least for the initial two years, the “critical period” in the course of schizophrenia, as the cost of the drugs appears to be the main barrier to access the treatment. This could be under the supervision of a close relative who is trained to supervise and monitor the patient medication, with the patient’s consent 12. The development of early intervention in psychosis services in LAMI countries faces formidable obstacles. However, the seri-ously mentally ill in LAMI regions are among the most disadvantaged people on earth. Making treatment available is a moral neces-sity and providing early treatment is likely to be cost-effective.