Mental Health In Low- And Middle-income Countries Research Articles

Effectiveness of combining prevention psychological interventions with interventions that address the social determinants of mental health in low and middle-income countries: protocol of a systematic review and meta-analysis

IntroductionCommon mental health conditions (CMHCs), including depression, anxiety and post-traumatic stress disorder (PTSD), are highly prevalent in low and middle-income countries (LMICs). Preventive strategies combining psychological interventions with interventions addressing...

COVID-19 Pandemic Lessons for Creating Effective Mental Health Safety Nets in Lower Middle-Income Countries.

The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to mental health globally, particularly in low- and middle-income countries (LMICs) such as Pakistan. This narrative review aims to synthesize the literature on the impact of the pandemic on mental health in LMICs, the challenges and opportunities for mental health system reform, and the role of safety nets in promoting mental health.A comprehensive search was conducted in several electronic databases, resulting in 35 articles being included for review. Data were extracted and analyzed to identify key themes and trends.The COVID-19 pandemic has led to a significant increase in the prevalence of mental health problems in LMICs, particularly anxiety and depression. This burden is disproportionately borne by vulnerable populations, including women, front-line workers, and those living in poverty. The pandemic has highlighted pre-existing weaknesses in mental health systems in LMICs, including inadequate funding, lack of trained mental health professionals, and stigmatization of mental illness. However, it has also presented opportunities for reform, such as increased awareness and political will, and the use of technology to expand access to mental health services. Building effective safety nets, including social protection programs and community-based interventions, can promote mental health and address social determinants of mental illness.The COVID-19 pandemic has underscored the urgent need for mental health system reform and the development of effective safety nets in LMICs. Policymakers should prioritize investment in mental health and address the social determinants of mental illness to build more resilient societies.

Using evidence inmental health policy agenda-setting inlow- andmiddle-income countries: a conceptual meta-framework from a scoping umbrella review.

The purpose of this article is to close the gap in frameworks for the use of evidence in the mental health policy agenda-setting in low- and middle-income countries (LMICs). Agenda-setting is important because mental health remains a culturally sensitive and neglected issue in LMICs. Moreover, effective evidence-informed agenda-setting can help achieve, and sustain, the status of mental health as a policy priority in these low-resource contexts. A scoping 'review of reviews' of evidence-to-policy frameworks was conducted, which followed preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Nineteen reviews met the inclusion criteria. A meta-framework was developed from analysis and narrative synthesis of these 19 reviews, which integrates the key elements identified across studies. It comprises the concepts of evidence, actors, process, context and approach, which are linked via the cross-cutting dimensions of beliefs, values and interests; capacity; power and politics; and trust and relationships. Five accompanying questions act as a guide for applying the meta-framework with relevance to mental health agenda-setting in LMICs. This is a novel and integrative meta-framework for mental health policy agenda-setting in LMICs and, as such, an important contribution to this under-researched area. Two major recommendations are identified from the development of the framework to enhance its implementation. First, given the paucity of formal evidence on mental health in LMICs, informal evidence based on stakeholder experience could be better utilized in these contexts. Second, the use of evidence in mental health agenda-setting in LMICs would be enhanced by involving a broader range of stakeholders in generating, communicating and promoting relevant information.

COVID-19 and mental health in 8 low- and middle-income countries: A prospective cohort study.

The Coronavirus Disease 2019 (COVID-19) pandemic and associated mitigation policies created a global economic and health crisis of unprecedented depth and scale, raising the estimated prevalence of depression by more than a quarter in high-income countries. Low- and middle-income countries (LMICs) suffered the negative effects on living standards the most severely. However, the consequences of the pandemic for mental health in LMICs have received less attention. Therefore, this study assesses the association between the COVID-19 crisis and mental health in 8 LMICs. We conducted a prospective cohort study to examine the correlation between the COVID-19 pandemic and mental health in 10 populations from 8 LMICs in Asia, Africa, and South America. The analysis included 21,162 individuals (mean age 38.01 years, 64% female) who were interviewed at least once pre- as well as post-pandemic. The total number of survey waves ranged from 2 to 17 (mean 7.1). Our individual-level primary outcome measure was based on validated screening tools for depression and a weighted index of depression questions, dependent on the sample. Sample-specific estimates and 95% confidence intervals (CIs) for the association between COVID-19 periods and mental health were estimated using linear regressions with individual fixed effects, controlling for independent time trends and seasonal variation in mental health where possible. In addition, a regression discontinuity design was used for the samples with multiple surveys conducted just before and after the onset of the pandemic. We aggregated sample-specific coefficients using a random-effects model, distinguishing between estimates for the short (0 to 4 months) and longer term (4+ months). The random-effects aggregation showed that depression symptoms are associated with a increase by 0.29 standard deviations (SDs) (95% CI [-.47, -.11], p-value = 0.002) in the 4 months following the onset of the pandemic. This change was equivalent to moving from the 50th to the 63rd percentile in our median sample. Although aggregate depression is correlated with a decline to 0.21 SD (95% CI [-0.07, -.34], p-value = 0.003) in the period thereafter, the average recovery of 0.07 SD (95% CI [-0.09, .22], p-value = 0.41) was not statistically significant. The observed trends were consistent across countries and robust to alternative specifications. Two limitations of our study are that not all samples are representative of the national population, and the mental health measures differ across samples. Controlling for seasonality, we documented a large, significant, negative association of the pandemic on mental health, especially during the early months of lockdown. The magnitude is comparable (but opposite) to the effects of cash transfers and multifaceted antipoverty programs on mental health in LMICs. Absent policy interventions, the pandemic could be associated with a lasting legacy of depression, particularly in settings with limited mental health support services, such as in many LMICs. We also demonstrated that mental health fluctuates with agricultural crop cycles, deteriorating during "lean", pre-harvest periods and recovering thereafter. Ignoring such seasonal variations in mental health may lead to unreliable inferences about the association between the pandemic and mental health.

Depressive and anxiety symptoms and COVID-19-related factors among men and women in Nigeria.

Despite the greater adverse economic impacts in low and middle-income (LAMI) compared to high-income countries, fewer studies have investigated the associations between COVID-19-related stressor and mental health in LAMI countries. The objectives of this study were to determine the associations between COVID-19-related stressors and anxiety and depressive symptoms while controlling for known risk and protective factors and to investigate any sex differences. An online survey was carried out to assess sociodemographic, psychosocial (previous mental health conditions, sexual orientation, intimate partner violence and perceived social support) and COVID-19-related variables. Hierarchical linear regression was carried out with anxiety and depressive symptoms as separate outcomes. Of the COVID-19-related factors, testing positive for COVID-19 infection, having COVID-19 symptoms, having other medical conditions, self-isolating due to COVID-19 symptoms, worry about infection, perception of the pandemic as a threat to income and isolation during the lockdown were significantly associated with higher anxiety and depressive symptoms. Of these, worry about infection, isolation during lockdown and disruption due to the pandemic retained independent associations with both outcomes. The variance in anxiety and depressive symptoms explained by COVID-19-related factors was larger in women (11.8%) compared to men (6.1% and 0.8% respectively). COVID-19-related stressors are associated with higher anxiety and depressive symptoms, with these effects being larger in men compared to women. Enhancing social support can be an affordable strategy to mitigate this risk but this needs to be investigated using appropriate designs.

Community-Based Interventions for the Treatment and Management of Conflict-Related Trauma in Low-Middle Income, Conflict-Affected Countries: a Realist Review

Where low- and middle-income countries have limited economic resources to provide individualized mental health services to people exposed to conflict, community-based interventions may be more appropriate. We aimed to evaluate community level interventions for improving mental health outcomes in Low- and Middle-income countries (LMIC). A realist review of community-based interventions (CBIs) to improve mental health for people in LMIC following conflict. Five databases (Cochrane, PubMed, PsychINFO, Medline, and CINAHL) and a manual search of individual papers. We found 1318 articles, of which 29 were selected. Out of the 29 primary articles, 19 showed successful results, 4 showed mixed results, 1 showed inconclusive results, and 1 showed unsuccessful results. After analyzing the results, we found 3 mechanisms that may influence the effectiveness of these CBIs: the use of lay community members as intervention deliverers, the application of transdiagnostic approaches, and customized outcome assessment tools. Community-based approaches to improve mental health in LMICs are rare and evidence for their effectiveness is limited. Interventions that have a wide scope, train lay mental health workers, and use contextually adapted outcome assessment tools show promise.

Relationship between childhood trauma, personality, social support and depression in women attending general medical clinics in a low and middle-income country

BackgroundAssociations between childhood trauma, personality, and Major Depressive Disorder (MDD) have been well established in studies conducted in high-income countries. However, there are limited studies on these associations in low and middle-income countries (LMICs), where MDD is highly prevalent. We assessed the relationships between childhood trauma, personality, and MDD in women in Karachi, Pakistan. MethodIn this cross-sectional study of 455 female patients attending general medical outpatient clinics, a diagnosis of MDD was confirmed using the Structured Clinical Interview for DSM-IV (SCID); retrospective reports of childhood trauma were collected using the childhood trauma questionnaire (CTQ); and Big Five personality traits were assessed using the NEO Personality Inventory Revised (NEO PI-R). Other measures included the Life Events Questionnaire (LEQ) and the Multidimensional Scale of Perceived Social Support (MSPSS). Factors independently associated with MDD were determined using logistic regression analyses. ResultsOf the 455 women recruited between August 1, 2011 and July 31, 2013, 242 (53%) had a diagnosis of MDD. Women with MDD were significantly more likely to be separated, had more stressful life events and higher CTQ scores. Higher perceived social support, conscientiousness and extraversion were independently associated with significantly reduced odds of MDD. There were no significant associations between CTQ scores and any of the NEO PI-R subscales. LimitationsRatings of childhood trauma were based on retrospective recall. ConclusionMDD and a history of childhood trauma were highly prevalent in Pakistani women attending general medical clinics. Interventions to prevent childhood trauma and promote social support in women may improve public mental health in LMICs like Pakistan.

Research, education and capacity building priorities for violence, abuse and mental health in low- and middle-income countries: an international qualitative survey

PurposeDespite the World Health Organization and United Nations recognising violence, abuse and mental health as public health priorities, their intersection is under-studied in low- and middle-income countries (LMICs). International violence, abuse and mental health network (iVAMHN) members recognised the need to identify barriers and priorities to develop this field.MethodsInformed by collaborative discussion between iVAMHN members, we conducted a pilot study using an online survey to identify research, education and capacity building priorities for violence, abuse and mental health in LMICs. We analysed free-text responses using thematic analysis.Results35 senior (29%) and junior researchers (29%), non-government or voluntary sector staff (18%), health workers (11%), students (11%) and administrators (3%) completed the survey. Respondents worked in 24 LMICs, with 20% working in more than one country. Seventy-four percent of respondents worked in sub-Saharan Africa, 37% in Asia and smaller proportions in Latin America, Eastern Europe and the Middle East. Respondents described training, human resource, funding and sensitivity-related barriers to researching violence, abuse and mental health in LMICs and recommended a range of actions to build capacity, streamline research pathways, increase efficiency and foster collaborations and co-production.ConclusionThe intersection between violence, abuse and mental health in LMICs is a priority for individuals with a range of expertise across health, social care and the voluntary sector. There is interest in and support for building a strong network of parties engaged in research, service evaluation, training and education in this field. Networks like iVAMHN can act as hubs, bringing together diverse stakeholders for collaboration, co-production and mutually beneficial exchange of knowledge and skills.

Reducing the stigma of mental health disorders with a focus on low- and middle-income countries.

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.

Student, teacher, and caregiver perceptions on implementing mental health interventions in Ugandan schools.

The vast majority of children and adolescents in low and middle-income countries (LMICs) lack access to interventions for mental health problems. Schools provide a critical platform for evidence-based intervention delivery for young people. However, a significant need exists to understand the implementation context and strategies for delivering school mental health interventions in LMICs. We conducted a focused ethnography to explore students', teachers', and caregivers' perspectives on implementing evidence-based mental health interventions (EBIs) within a widespread violence prevention program in Uganda. Data collection occurred in Kampala, Uganda, using two schools that have previously implemented an evidence-based violence prevention program widely used in Ugandan schools schools, the Good School Toolkit (GST). Trained, local researchers facilitated four focus group discussions (FGDs) with caregivers (n = 22), four FGDs with teachers (n = 25), and in-depth interviews with primary school students (n = 12). Verbatim transcripts were analyzed using a framework analysis approach. Participants revealed a school culture that promotes schools' responsibility to students beyond academics, including positive teacher-student relationships. Participants recommended an implementation process that trains teachers and students in screening and referral, peer group delivery, and is accompanied by a school-wide approach to stigma reduction and mental health literacy. Participants fundamentally agreed that teachers could be trained as intervention facilitators. This study highlights the potential advantage of leveraging an existing intervention that already addresses implementation factors, such as school culture, as a fertile platform for implementing interventions for child and adolescent mental health in LMICs. Despite the growth of implementation research for child and adolescent mental health, the study of implementation science for child and adolescent mental health in low and middle-income countries (LMICs) remains scarce. Schools provide a critical platform for evidence-based intervention delivery for young people. However, a significant need exists to understand the implementation context and strategies for delivering school mental health interventions in LMICs. This study provides rich qualitative data describing the context and influences for the successful implementation of mental health interventions in LMIC schools. We conducted interviews and focus groups with teachers, students, and caregivers to determine their perspectives on implementing evidence-based mental health interventions (EBIs) within a widespread violence prevention program in Uganda. Participants revealed a school culture promoted by the existing program that promotes schools' responsibility to students beyond academics, including positive teacher-student relationships. Findings suggest the existing program provides fertile ground for the successful implementation of evidence-based mental health interventions in schools.

Where is the global in global mental health? A call for inclusive multicultural collaboration.

To the editor: Common mental health disorders, like depression and anxiety, account for 45% of the global disease burden on youths aged 15–29.1 This challenge is particularly significant in low and middle-income countries (LMICs) where risk factors such as poverty, limited treatment options and stigma restrict access to care and exacerbate the burden and magnify the impact of mental disorders.2 3 Given these barriers, there is an urgent need for research dedicated to expanding mental healthcare for young people in LMICs. Because of the global public health challenge characterized by adolescent mental health disorders, there have been increased efforts over the last two decades to expand treatment options for youths in LMICs. These efforts-conducted under the umbrella of global mental health research-have improved our understanding of the efficacy and acceptability of various kinds of mental health interventions for young people in LMICs. However, there are concerns that these efforts may risk the imposition of Western values and approaches. Researchers from high-income countries (HICs) may bring assumptions about diagnostic classification, aetiology and treatment that may not be appropriate for LMICs.4 To address this risk, and enhance cultural validity, some investigators have emphasised the value of collaborating with colleagues from LMICs in designing and implementing interventions for these settings.5 Without such collaboration with community partners, well-intentioned efforts may risk relying on false assumptions about the generalisability of Western-derived intervention development and research methods across diverse populations in LMICs.4 A possible consequence of the status quo is that mental health interventions in LMICs may fail to adequately consider and address salient features of adolescent mental health in LMICs. Indeed, scholars have noted several unique obstacles that investigators face when deploying interventions in LMICs. These include a paucity of mental health experts, differences in help-seeking attitudes and cultural factors …

Mental health of transitional aged youth in Nicaragua: Perceptions and experiences of educators

ABSTRACTMental illnesses contribute to a large proportion of the disease burden in children and adolescents in low and middle-income countries (LMICs). There is limited research completed in LMICs about paediatric mental health, particularly related to youth. School is a place where many adolescents first seek mental health support. This study examined how educators in Nicaragua view youth mental health and how mental health can be supported in LMIC schools. Focus groups were completed with teachers serving youth from a variety of socioeconomic settings within León, Nicaragua. The study was completed from an Interpretivist theoretical paradigm and coding of qualitative data was completed consistent with Constructivist Grounded Theory. Educators described their roles in as detecting mental health problems and liasing with other supports; they noted barriers as cross-sector integration and social challenges. Educators felt that youth would be better served by improving integration of care, addressing structural factors, and providing more teacher supports. A model for addressing youth mental health in LMICs could include a stepped-care approach with schools providing preventative programming as well as developing within school referral strategies for youth with higher needs. There may be a role for the use of community health promoters.

Mental Health in low-and middle income countries (LMICs): Going beyond the need for funding

Despite being globally recognised as an important public health issue, mental health is still less prioritised as a disease burden in many Low-and Middle-Income Countries (LMICs). More than 70% of the global mental health burden occurs in these countries. We discussed mental health issues in LMICs under themes such as abuse and mental illness, cultural influence on mental health, need for dignity in care, meeting financial and workforce gaps and the need for national health policy for the mental health sector. We highlighted that although mental health education and health care services in most LMICs are poorly resourced; there is an urgent need to address issues beyond funding that contribute to poor mental health. In order to meet the increasing challenge of mental health illness in LMICs, there is a need for effort to address cultural and professional challenges that contribute to poor mental health among individuals. We have a notion that mental health should be integrated into primary health care in LMICs. Creating awareness on the impact of some cultural attitudes/practices will encourage better uptake of mental health services and increase the ease when discussing mental health issues in these countries which can contribute to reducing the poor mental health in LMICs.

Global mental health and the National Institute of Mental Health Research Domain Criteria.

The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project presents innovative ways of investigating mental illness based on behavioral and neurobiological measures of dimensional processes. Although cultural psychiatrists have critiqued RDoC's implications and limitations for its under-developed focus on context and experience, RDoC presents opportunities for synergies with global mental health. It can capture aspects of clinical or sub-clinical behavior which are less dependent upon Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and perhaps better elucidate the role of culture in disease expression and resilience. Aim/Results: This article uses the example of migration to describe several starting points for new research: (1) providing components for building an investigable conceptual framework to understand individual's mental health, resilience and adjustment to migration challenges or social adversities in low- and middle-income countries (LMICs) and (2) identifying measurable factors which determine resilience or vulnerability, to guide development and evaluation of targeted prevention, treatment and recovery strategies for mental health in LMICs. In such ways, RDoC frameworks could help put the new cutting edge neurobiological dimensional scientific advances in a position to contribute to addressing mental health problems amid social adversities in LMICs. However, this would require a much-expanded commitment by both RDoC and global mental health researchers to address contextual and experiential dimensions.

Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan

There is growing interest in the relationship between socioeconomic status (SES), poverty, and mental health in low and middle-income countries (LMIC). However, it is not clear whether a gradient approach focused on a wider SES distribution or a binary poverty approach is more salient for mental health in LMIC. Yet this distinction has implications for interventions aimed at improving population health. We contribute to the literature by examining how multiple indicators of socioeconomic status, including gradient SES and binary poverty indicators, contribute to prenatal depression symptoms in a LMIC context. Prenatal depression is an important public health concern with negative sequela for the mother and her children. We use data on assets, education, food insecurity, debt, and depression symptoms from a sample of 1154 pregnant women residing in rural Pakistan. Women who screened positive for depression participated in a cluster randomized controlled trial of a perinatal depression intervention; all women were interviewed October 2015-February 2016, prior to the start of the intervention. Cluster-specific sampling weights were used to approximate a random sample of pregnant women in the area. Findings indicate that fewer assets, experiencing food insecurity, and having household debt are independently associated with worse depression symptoms. The association with assets is linear with no evidence of a threshold effect, supporting the idea of a gradient in the association between levels of SES and depression symptoms. A gradient was also initially observed with woman’s educational attainment, but this association was attenuated once other SES variables were included in the model. Together, the asset, food insecurity, and debt indicators explain 14% of the variance in depression symptoms, more than has been reported in high income country studies. These findings support the use of multiple SES indicators to better elucidate the complex relationship between socioeconomic status and mental health in LMIC.

Migration and Mental Health in Low- and Middle-Income Countries: A Systematic Review

Objective: Rural-to-urban migration within low- and middle-income countries (LMICs), and migration from one LMIC to another, are prevalent forms of international migration. Migration may be associated with adverse mental health outcomes. The aim of the current study is to systematically review the literature on migration and mental health between and within LMICs. Methods: This systematic review of PubMed, PsycINFO, Embase, Web of Science, and PILOTS, identified 2,818 total records published between 1991 and 2016, with 139 of these assessed for eligibility. Two authors reviewed full text to assess if they met inclusion criteria, extracted data, and applied a quality assessment to all included studies. Results: The search identified 37 articles that met the inclusion criteria, based on 28 separate studies. All studies apart from one were cross-sectional studies, and studies utilized a range of sampling methods. In all, 19 of these studies were conducted in China. Studies addressed a range of mental health outcomes, and variation in prevalence was reported. Research questions addressed determinants of mental health outcomes, including analysis of risk and protective factors, such as social, cultural, and economic determinants; migration-related risk factors; and substance use. Conclusions: Limitations in study design and methodological rigor of studies indicate a limited evidence base concerning migration and mental health in LMICs. Expansion of research to different regions, utilization of adapted and validated measurement instruments, and longitudinal research could significantly strengthen the evidence base.

Economic crisis and mental health – findings from low- and middle income countries

Summary Background: There is consistent evidence of an inverse relationship between poverty and mental health. However, the influence of economic crises on mental health is not well studied and there are very few data particularly from low- and middle income countries (LAMICs). This review discusses theories and views on the impact of economic crises on mental health in LAMICs and reports the results of two empirical studies. Result: It appears that relative deprivation and the social and psychological meaning of deep changes in the economic situation of a person, a family or a group, have a greater effect on mental health than just material circumstances and unemployment.

Functional impairment and mental health functioning among Vietnamese children.

Functional impairment is a key indicator of need for mental health services among children and adolescents, often a stronger predictor of service usage than mental health symptoms themselves. Functional impairment may be of particular importance in low- and middle-income countries (LMIC) because of its potential to focus policy on treatment of child mental health problems which is generally given low priority in LMIC. However, few studies have assessed functional impairment in LMIC. The present study assessed rates of functional impairment among children in Vietnam, as a case example of an LMIC, as well as effects of other risk/protective factors of particular relevance to LMIC (e.g., whether the family lived in an urban or rural area; family structure variables such as grandparents living with the family). 1314 parents of children 6-16years old from 10 Vietnamese provinces were interviewed. The overall rate of functional impairment among Vietnamese children was 20%, similar to rates in high-income countries such as Germany and the United States, suggesting that LMIC status may not be associated with dramatic increases in functional impairment in children. Functional impairment was significantly greater among mental health cases than non-cases, with increases of over 550% associated with mental health caseness. A number of other risk factors (e.g., marital status) had smaller but significant effects. Mental health problems are a major but not the sole contributor to functional impairment among Vietnamese children. The pragmatic significance of this research lies in its potential to affect public awareness and policy related to child mental health in LMIC.

Globalization of psychiatry – A barrier to mental health development

The concept of globalization has been applied recently to ways in which mental health may be developed in low- and middle-income countries (LMICs), sometimes referred to as the ‘Third World’ or developing countries. This paper (1) describes the roots of psychiatry in western culture and its current domination by pharmacological therapies; (2) considers the history of mental health in LMICs, focusing on many being essentially non-western in cultural background with a tradition of using a plurality of systems of care and help for mental health problems, including religious and indigenous systems of medicine; and (3) concludes that in a post-colonial world, mental health development in LMICs should not be left to market forces, which are inevitably manipulated by the interests of multinational corporations mostly located in ex-colonizing countries, especially the pharmaceutical companies.

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

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.