Research Article: Packages of Care for Schizophrenia in Low- and Middle-Income Countries

Date Published: October 20, 2009

Publisher: Public Library of Science

Author(s): Jair de Jesus Mari, Denise Razzouk, Rangaswamy Thara, Julian Eaton, Graham Thornicroft, Vikram Patel

Abstract: In the third in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Jair Mari and colleagues discuss the treatment of schizophrenia.

Partial Text: The schizophrenia syndrome, a relatively rare mental disorder, comprises thought disorder, unusual beliefs (delusions), misperceptions (mainly auditory hallucinations), cognitive and affective symptoms, and negative symptoms such as blunted affect, lack of motivation, and an experience of emptiness. The first episode of schizophrenia, which usually occurs when patients are in their early twenties, may have an abrupt or insidious onset. Introspection, defensiveness, and eccentricity can be part of the premorbid personality. Before the onset of psychotic symptoms, social performance and interpersonal relationships can be altered or near to normal. Box 1 shows the International Classification of Disease (ICD) 10 diagnostic criteria for schizophrenia [1].

The World Health Organization (WHO) ATLAS [69] clearly shows the lack of adequate mental health services in many parts of the world, especially in rural areas in LMICs. The best way to tackle the treatment gap in LMICs is to take advantage of the existing primary health care facilities [70] and to make efficient use of the scarce specialised personnel to train nonspecialist health professionals to identify and manage psychiatric disorders [71],[72]. In India, for example, the training of community-level workers has been shown to be an effective way to improve the detection of schizophrenia and other major mental disorders and to improve their treatment or referral to the appropriate centres of care [31],[32],[73]. To improve access to treatment, providers of mental-health services must make deliberate efforts to raise awareness among communities [74] about the treatability of mental illness and about how to access services. They must also endeavour to reduce the stigma and discrimination associated with mental illness. A recent study suggests that the most effective interventions to achieve this aim are direct social contact with people with mental illness at the individual level and the promotion of social marketing (advertising and promotional methods designed to achieve a social good rather than sales of a commodity) at the population level [75].

Our review suggests that recovery in schizophrenia in LMICs can be achieved by using antipsychotics, along with psychosocial education and/or family interventions. The adjunctive use of psychosocial educational strategies can help to improve knowledge and awareness of the condition, lower stigma, and improve understanding of the role of medicines and the importance of compliance to treatment for prevention of relapse. People with schizophrenia may also need support for housing and employment. Although there are few organizations that advocate and defend human rights in LMICs, they can nevertheless actively lobby for better mental-health services. Models for supporting persons with disabilities that emphasise a broad, empowerment- and rights-based approach such as community-based rehabilitation [31],[32] are also applicable to people with mental illness in LMICs. Table 3 proposes a package of care for schizophrenia in LMICs that incorporates these aspects of care and contrasts this package with one that can be provided in HICs.



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