THE EARLY AND EFFECTIVE TREATMENT FOR SEVERE MENTAL ILLNESS (SMI) IN LOW AND MIDDLE INCOME (LAMI) COUNTRIES: A PUBLIC HEALTH CHALLENGE

saeed Farooq

摘要

The common mental disorders such as depression and anxiety are highly prevalent psychiatric disorders. Only one disorder i.e. depression is to become second leading cause of burden of disease in developing countries and it is appropriate that these disorders are major focus for policy and treatment initiatives. However, less prevalent but much more disabling disorders such schizophrenia and bipolar affective disorder receive much less attention. These disorders are generally grouped together as serious mental illnesses (SMI). Schizophrenia, bipolar affective disorders and other non-organic psychosis are major disorders included in the SMI category and it is generally agreed that the SMI have a prevalence of about 4% in low and middle income (LAMI) countries. ? The economic, social and human costs of SMI are well documented. Schizophrenia, the major disorder in SMI is the 6th leading cause of YLD (Years lost due to disability) in LAMI countries ahead of iron deficiency anaemia which is a major public health priority in these countries.1 The large indirect costs associated with medical complications, substance abuse and transmission of diseases such as TB and HIV and higher mortality are yet to be quantified. A US study estimated the economic costs of SMI to be around $317 excluding the costs associated with comorbid conditions, incarceration, homelessness, and early mortality, which was equivalent to more than $1,000/year for every man, woman, and child in the United States.2 The estimates for LAMI countries are not available but are likely to be much higher than these. ? The treatment gap for schizophrenia is estimated to be 70-90% in LAMI countries.3 This staggering treatment gap arises from poor treatment adherence which generally is in excess of 50% in schizophrenia, almost total lack of primary care involvement in the treatment of psychosis and poor access to treatment. Inadequate supply chain management for antipsychotic medicine is also a major barrier in maintaining continuity of medication in these countries. Both ‘push systems' (where medications are regularly distributed to health facilities) and ‘pull systems' (where health facilities forecast their needs and order medications when required) have been tried but with little success.4 ? A major problem is the long period during which the patients suffering from 1st episode of SMI do not receive the treatment. Duration of untreated psychosis (DUP) - the period between the onset of psychosis and initiating the treatment in the first episode psychosis (FEP) - is 125.0 weeks in LAMI countries compared to 63.4 weeks in the high income countries. Such a long DUP in LAMI countries is associated with poorer response to treatment, disability and possibly increased mortality.5,6 ? This becomes a humanitarian crisis in conflict situations such as that going on in Khyber Pukhtunkhwa at present. In these situations people with SMI are least likely to receive any attention. Being unable to seek help and with no effective voice in the community, those suffering from SMI badly neglected. There are reports from the conflicts areas that people suffering from psychosis are chained at times for years in these situations. The neglect is further exacerbated by narrow focus on conditions such as post-traumatic stress disorder (PTSD) in these settings. Considering that almost one third of the world's population live in conflict-affected low-income countries, providing effective care for those suffering from psychosis is a huge challenge.7 ? This is ironic considering that effective treatments are available for most of these psychiatric disorders. Take for example, schizophrenia which is arguably the most severe mental illness and most common diagnostic category in psychotic disorders. Contrary to common perception about two thirds of patients suffering from schizophrenia either have recovery after one or two episodes or remain relatively well with treatment. The treatment for schizophrenia is not that expensive. A patient suffering from schizophrenia is likely to remain well with treatment which on average costs about Rs. 2000. This compares quite favourably with other chronic disorders such as diabetes and hypertension. ? However, a major challenge in case of schizophrenia like other chronic physical disorders is maintaining the long term treatment. In Medicine, where practitioners are not faced with challenges such as lack of insight, almost half of interventions to improve the treatment adherence seem to fail.8 As a result of the widespread problem of adherence, substantial numbers of patients do not get the required benefit of medical treatment which results in poor health outcomes and increased health care costs. Not surprisingly, it has been claimed that increasing the effectiveness of adherence interventions may have far greater impact on the health of the population

机译：常见的精神疾病，例如抑郁症和焦虑症是高度流行的精神疾病。在发展中国家，只有一种疾病（即抑郁症）将成为疾病负担的第二大主要原因，这些疾病是政策和治疗计划的主要重点是适当的。但是，诸如精神分裂症和双相情感障碍之类的不那么普遍但更具残疾能力的疾病受到的关注却少得多。这些疾病通常被归类为严重精神疾病（SMI）。精神分裂症，双相情感障碍和其他非器官性精神病是SMI类别中的主要疾病，并且普遍认为SMI在中低收入（LAMI）国家的患病率约为4％。？ SMI的经济，社会和人力成本有据可查。精神分裂症是SMI的主要疾病，在铁缺乏性贫血之前，这是LAMI国家中导致YLD（因残疾而损失的年）的第六大主要原因，而缺铁性贫血是这些国家的主要公共卫生重点。 > 1 与医疗并发症，药物滥用以及结核病和艾滋病毒等疾病的传播以及更高的死亡率相关的大量间接成本尚未量化。一项美国研究估计，SMI的经济成本约为317美元，不包括与合并症，监禁，无家可归和早期死亡相关的成本，相当于美国每个男人，女人和孩子每年超过1,000美元。 2 无法获得LAMI国家的估算值，但可能会大大高于这些估算值。？在LAMI国家，精神分裂症的治疗缺口估计为70-90％。 3 这种令人震惊的治疗缺口是由于治疗依从性差而引起的，在精神分裂症中通常超过50％，几乎完全缺乏原发性精神病治疗的护理参与和难以获得治疗的机会。抗精神病药的供应链管理不足也是在这些国家维持药物连续性的主要障碍。已经尝试了“推系统”（定期将药物分配到医疗机构）和“拉系统”（其中医疗机构预测其需求并在需要时订购药物），但收效甚微。 4 ？一个主要问题是患有SMI发作1 的患者长期无法接受治疗。在LAMI国家，未治疗的精神病（DUP）的持续时间-精神病发作到开始首次发作的精神病（FEP）之间的时间-为125.0周，而高收入国家为63.4周。在LAMI国家，如此长的DUP与对治疗，残疾的不良反应以及可能增加的死亡率有关。 5,6 ？在当前开伯尔·普赫图赫瓦等冲突局势下，这已成为人道主义危机。在这些情况下，患有SMI的人最不可能受到关注。由于无法寻求帮助并且在社区中没有有效的声音，遭受SMI困扰的人们被严重忽视。冲突地区的报道称，在这些情况下，精神病患者有时会被捆绑多年。在这些情况下，如果只关注诸如创伤后应激障碍（PTSD）等疾病，则会进一步加剧这种忽视。考虑到世界上将近三分之一的人口生活在受冲突影响的低收入国家，为精神病患者提供有效的护理是一项巨大的挑战。 7 ？具有讽刺意味的是，考虑到对大多数这些精神病患者都可以采用有效的治疗方法。以精神分裂症为例，它可以说是精神病中最严重的精神疾病和最常见的诊断类别。与通常的看法相反，约三分之二的精神分裂症患者在一两次发作后恢复或在治疗中保持相对良好。精神分裂症的治疗并不那么昂贵。患有精神分裂症的患者可能会继续接受治疗，平均费用约为Rs。 2000年。这与其他慢性疾病（例如糖尿病和高血压）相比非常有利。？但是，像其他慢性身体疾病一样，精神分裂症的主要挑战是维持长期治疗。在医学界，从业人员不会面临缺乏洞察力的挑战，因此几乎有一半的干预措施无法改善治疗依从性。 8 由于普遍存在依从性问题，患者没有获得所需的医疗待遇，这会导致健康状况不佳并增加医疗费用。不足为奇的是，有人声称提高依从性干预措施的有效性可能会对人们的健康产生更大的影响

THE EARLY AND EFFECTIVE TREATMENT FOR SEVERE MENTAL ILLNESS (SMI) IN LOW AND MIDDLE INCOME (LAMI) COUNTRIES: A PUBLIC HEALTH CHALLENGE

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