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Biological psychiatry in developing countries
BIOL PSYCHIATRY
357
1985;20:357-359
EDITORIAL
Biological Psychiatry in Developing Countries With billions of people, perhaps as much as half the world's population, living in the so-called Third World of undeveloped countries, it is timely to give some thought to their needs. Problems of mental health in the developing world, though not insubstantial, have often been overshadowed by the attention paid to the more pressing problems of general health, viz., communicable and infectious diseases and malnutrition. Two recent developments, however, may help to rectify this long-standing neglect. First, increasing control is being achieved over general health problems, so that health authorities are now able to include mental illness in their scope of activities. The other development takes its origin from the Alma Ata Declaration and the worldwide compaign for "Health for All by the Year 2000!" As the concept of health in this declaration includes mental health, specific steps are being taken to elevate it to equal status with the physical and social components of health in national health programs. However, beyond these broad policy declarations, at a clinical level, one is confronted by some special and unique aspects of mental illness. First, the figures. Despite the earlier notion that mental illnesses (at least certain types) are infrequent in the unsophisticated cultures of developing countries, there is presently ample evidence to indicate that psychiatric disorders occur with more or less the same frequency found in Western and more advanced countries. It is reliably estimated that over 40 million men, women, and children are suffering from serious untreated mental disorders in developing countries (WHO 1975), which is not surprising, as 90% of the population in these countries receives practically no mental health care. Seen differently, serious mental disorders are likely to affect at least 1% of the population at any point of time and at least 10% at some time in their life. One must also realize that about half the population in many developing countries is under the age of 15 years, thus creating a large burden of child and adolescent disorders. In India alone, the point prevalence of serious mental disorders amounts to 10 million, with neuroses and psychosomatic disorders comprising around 20-30 million. Serious mental retardation is found in 0.5%-1.0% of all children, and drug dependence rates, though still low, show a disturbingly rising trend. Symptoms are expressed by subjects from developing nations in ways that may differ from Western patients. Barring a few exceptions, it is not too difficult to understand that these differences are quite superficial and perhaps result from recorded observations that reflect unfamiliarity with the terminology of mental disorders and mood used in Western cultures. Therefore, there is a need to recognize these culturally influenced differences in mental disorders and, accordingly, a need to develop culture-free rating methods in psychopathology. Significant progress has already been made in this direction with the implementation of multicentered, multinational collaborative studies under the aegis of the World Health Organization. The most notable examples are the contributions from this source in respect to the Present State Examination (PSE) and the Schedule for Standardized Assessment of Depressive Disorders (SADD).
© 1985 Society of Biological Psychiatry
0(]06-3223/85/$03.30
358
BIOLPSYCHIATRY
Editorial
1985;20:357-359
As to the more mundane problems of etiology and treatment, it is quite obvious that insofar as the practice of psychotherapeutic forms of treatment are concerned, one will have to modify the style of therapeutic communication to suit the local sociocnltural situation, yet retain the principles of the process. But substantial differences can also be found in the physical and psychopharmacological treatment modalities. Although the role and effectiveness of modern psychotropic agents in specific disorders is not disputed, the wisdom of unhesitatingly applying psychophannacological data generated for Western patients and conditions to subjects from developing countries is questionable. One must always keep in mind that in constitution (in regard to racial, genetic, and nutritional factors) and in context (in regard to environmental and sociocultural factors), these subjects are quite different from their Western counterparts. Cross-cultural psychopharmacology is thus of some importance. There is, however, a need to emphasize the dearth of wellconducted studies in this area, and the world psychiatric community should feel challenged to take up the task. At a more basic level, some thought must be given to the etiopathogenesis of mental disorders in developing nations. Here, one must make a distinction between biologically and psychologically influenced conditions, only for the purpose of discussion. Assuming that psychological factors and the related social, cultural, and personality factors vary from place to place, one should expect differences both in the frequency and in the manifestations of psychologically influenced disorders (e.g., neuroses, psychosomatic disorders), especially in the two contrasting social and cultural situations exemplified by the advanced and developing countries. However, one would not expect a great difference with regard to the biologically influenced illnesses, at least in their biological manifestations, on the assumption that the biology of individuals is not subject to much change. But on closer examination, this may not hold true, as there is evidence to indicate that biology itself can change with the cultural background in a significant manner (Crow and Felsenstein 1968; Chapple 1970; Paredes and Hepburn 1976). This area too is largely unexplored and thus worthy of further research. It may well be that the forces (climatic, nutritional, health status, mating preferences) that influence biology are different in the two categories of nations, even though the final biological pathways (neurocellular, neurochemical, brain regions) in the development of the illness remain the same. Nowhere is the need for an enthusiastic commitment to Health for All by 2000 greater than in the developing countries, primarily because of the gross disparity between their needs and resources. In most developing countries we find fewer than one psychiatrist and two psychiatric nurses per 100,000 population; in many there are fewer than one psychiatrist and one psychiatric nurse per 1,000,000 population; and in some there are none. However, a practical solution has been found through decentralization and deprofessionalization of mental health services, with integration of the mental health component into the general health services. This is done by initially limiting the focus to severe mental disorders, by prescribing simple procedures and only a few psychotropic substances to control them, and by training primary health care personnel (medical officers and paramedical personnel) for this task. With regard to research, the first priority in developing nations is for the kind that will help improve mental health services. The second research priority will have to be directed at methods to improve the indentification and therapy of mental disorders. It is in this respect that the current thrust of biological psychiatry research is relevant, i.e., development of simple biological tests of mental disorders, improvement in psychopharmacotherapy through studies on dose effects and
Editorial
BIOLPSYCHIATRY
359
1985;20:357-359
biochemical profiles of psychotropic substances, and uncovering of newer biological concomitants of mental disorders. Already in vogue in advanced nations, all this will have to be emulated in developing nations as well. Biological psychiatry may thus prove to be an appropriate ally to the development of mental health services, as it will serve to enhance the effectiveness of these services. Lately, evidence has been forthcoming from the psychiatric literature and the forum provided by the Mental Health Division of the WHO that for these reasons, biological psychiatry is rapidly developing in these countries. B. B. Sethi
References Crow JJ, Felsenstein: (1968) The effect of assortive mating on the genetic composition of a
population. Engenet Q 15:85-97. Chapple ED (1970): Culture and Biological Man. New York: Holt Rinehart & Winston. Peredes JA, Hepburn HJ (1976): The split brain and the culture and cognition paradox. Curr Anthropol 17:121-127. WHO Expert Committee on Mental Health (1975): Organization of Mental Health Services in Developing Countries. Technical Report Series 564. Geneva: World Health Organization.
357
1985;20:357-359
EDITORIAL
Biological Psychiatry in Developing Countries With billions of people, perhaps as much as half the world's population, living in the so-called Third World of undeveloped countries, it is timely to give some thought to their needs. Problems of mental health in the developing world, though not insubstantial, have often been overshadowed by the attention paid to the more pressing problems of general health, viz., communicable and infectious diseases and malnutrition. Two recent developments, however, may help to rectify this long-standing neglect. First, increasing control is being achieved over general health problems, so that health authorities are now able to include mental illness in their scope of activities. The other development takes its origin from the Alma Ata Declaration and the worldwide compaign for "Health for All by the Year 2000!" As the concept of health in this declaration includes mental health, specific steps are being taken to elevate it to equal status with the physical and social components of health in national health programs. However, beyond these broad policy declarations, at a clinical level, one is confronted by some special and unique aspects of mental illness. First, the figures. Despite the earlier notion that mental illnesses (at least certain types) are infrequent in the unsophisticated cultures of developing countries, there is presently ample evidence to indicate that psychiatric disorders occur with more or less the same frequency found in Western and more advanced countries. It is reliably estimated that over 40 million men, women, and children are suffering from serious untreated mental disorders in developing countries (WHO 1975), which is not surprising, as 90% of the population in these countries receives practically no mental health care. Seen differently, serious mental disorders are likely to affect at least 1% of the population at any point of time and at least 10% at some time in their life. One must also realize that about half the population in many developing countries is under the age of 15 years, thus creating a large burden of child and adolescent disorders. In India alone, the point prevalence of serious mental disorders amounts to 10 million, with neuroses and psychosomatic disorders comprising around 20-30 million. Serious mental retardation is found in 0.5%-1.0% of all children, and drug dependence rates, though still low, show a disturbingly rising trend. Symptoms are expressed by subjects from developing nations in ways that may differ from Western patients. Barring a few exceptions, it is not too difficult to understand that these differences are quite superficial and perhaps result from recorded observations that reflect unfamiliarity with the terminology of mental disorders and mood used in Western cultures. Therefore, there is a need to recognize these culturally influenced differences in mental disorders and, accordingly, a need to develop culture-free rating methods in psychopathology. Significant progress has already been made in this direction with the implementation of multicentered, multinational collaborative studies under the aegis of the World Health Organization. The most notable examples are the contributions from this source in respect to the Present State Examination (PSE) and the Schedule for Standardized Assessment of Depressive Disorders (SADD).
© 1985 Society of Biological Psychiatry
0(]06-3223/85/$03.30
358
BIOLPSYCHIATRY
Editorial
1985;20:357-359
As to the more mundane problems of etiology and treatment, it is quite obvious that insofar as the practice of psychotherapeutic forms of treatment are concerned, one will have to modify the style of therapeutic communication to suit the local sociocnltural situation, yet retain the principles of the process. But substantial differences can also be found in the physical and psychopharmacological treatment modalities. Although the role and effectiveness of modern psychotropic agents in specific disorders is not disputed, the wisdom of unhesitatingly applying psychophannacological data generated for Western patients and conditions to subjects from developing countries is questionable. One must always keep in mind that in constitution (in regard to racial, genetic, and nutritional factors) and in context (in regard to environmental and sociocultural factors), these subjects are quite different from their Western counterparts. Cross-cultural psychopharmacology is thus of some importance. There is, however, a need to emphasize the dearth of wellconducted studies in this area, and the world psychiatric community should feel challenged to take up the task. At a more basic level, some thought must be given to the etiopathogenesis of mental disorders in developing nations. Here, one must make a distinction between biologically and psychologically influenced conditions, only for the purpose of discussion. Assuming that psychological factors and the related social, cultural, and personality factors vary from place to place, one should expect differences both in the frequency and in the manifestations of psychologically influenced disorders (e.g., neuroses, psychosomatic disorders), especially in the two contrasting social and cultural situations exemplified by the advanced and developing countries. However, one would not expect a great difference with regard to the biologically influenced illnesses, at least in their biological manifestations, on the assumption that the biology of individuals is not subject to much change. But on closer examination, this may not hold true, as there is evidence to indicate that biology itself can change with the cultural background in a significant manner (Crow and Felsenstein 1968; Chapple 1970; Paredes and Hepburn 1976). This area too is largely unexplored and thus worthy of further research. It may well be that the forces (climatic, nutritional, health status, mating preferences) that influence biology are different in the two categories of nations, even though the final biological pathways (neurocellular, neurochemical, brain regions) in the development of the illness remain the same. Nowhere is the need for an enthusiastic commitment to Health for All by 2000 greater than in the developing countries, primarily because of the gross disparity between their needs and resources. In most developing countries we find fewer than one psychiatrist and two psychiatric nurses per 100,000 population; in many there are fewer than one psychiatrist and one psychiatric nurse per 1,000,000 population; and in some there are none. However, a practical solution has been found through decentralization and deprofessionalization of mental health services, with integration of the mental health component into the general health services. This is done by initially limiting the focus to severe mental disorders, by prescribing simple procedures and only a few psychotropic substances to control them, and by training primary health care personnel (medical officers and paramedical personnel) for this task. With regard to research, the first priority in developing nations is for the kind that will help improve mental health services. The second research priority will have to be directed at methods to improve the indentification and therapy of mental disorders. It is in this respect that the current thrust of biological psychiatry research is relevant, i.e., development of simple biological tests of mental disorders, improvement in psychopharmacotherapy through studies on dose effects and
Editorial
BIOLPSYCHIATRY
359
1985;20:357-359
biochemical profiles of psychotropic substances, and uncovering of newer biological concomitants of mental disorders. Already in vogue in advanced nations, all this will have to be emulated in developing nations as well. Biological psychiatry may thus prove to be an appropriate ally to the development of mental health services, as it will serve to enhance the effectiveness of these services. Lately, evidence has been forthcoming from the psychiatric literature and the forum provided by the Mental Health Division of the WHO that for these reasons, biological psychiatry is rapidly developing in these countries. B. B. Sethi
References Crow JJ, Felsenstein: (1968) The effect of assortive mating on the genetic composition of a
population. Engenet Q 15:85-97. Chapple ED (1970): Culture and Biological Man. New York: Holt Rinehart & Winston. Peredes JA, Hepburn HJ (1976): The split brain and the culture and cognition paradox. Curr Anthropol 17:121-127. WHO Expert Committee on Mental Health (1975): Organization of Mental Health Services in Developing Countries. Technical Report Series 564. Geneva: World Health Organization.