Mental health services in low- and middle-income countries

Abstract Community psychiatry in low- and middle-income countries (LAMIC) is nearly four decades old (German, 1975; Swift, 1972; WHO, 1975). The beginnings of organized mental health care in LAMIC can be traced to the important Sixteenth World Health Organization (WHO) Expert Committee meeting held at Addis Ababa, Ethiopia, in 1974 titled ‘Organization of mental health care in developing countries’ (WHO, 1975). This meeting is important as it not only reviewed the mental health situation in developing countries but outlined a road map for development of services. These guidelines have largely influenced the developments of the last four decades. The important recommendations of this meeting were: ‘Basic mental health care should be integrated with general health services and be provided by non-specialized health workers, at all levels; … countries should, in the first instance carry out one or more pilot programmes to test the practicability of including basic mental health care in an already established programme of health care in a defined rural or urban population; … training programmes, including simple manuals of instructions for training of health workers should be devised and evaluated.’ (WHO, 1975.) The LAMIC faced the challenge of providing mental health care with very limited psychiatric beds in ancient and custodial care institutions, with limited trained mental health professionals, a general population having very limited knowledge about mental disorders, and persons with mental disorders experiencing stigma and discrimination. Fortunately for the LAMIC, the planning of mental health services occurred around the time of the discovery of antipsychotics and antidepressants and the global recognition of the values of community mental health care. Professionals in LAMIC have addressed the mental health needs of the population using innovative approaches, centred around greater emphasis on use of community resources rather than an emphasis on the highly trained mental health professionals. These innovations have included greater partnership with the families of the persons with mental disorders, use of general hospital psychiatry units, integration of mental health with general health care, and using non-specialist personnel for focused interventions like suicide prevention, disaster and conflict mental health care, life skills education, and rehabilitation. The result of these initiatives have been, from a situation of nearly no services for the majority of the persons with mental disorders, to today where there is a developing framework for mental health care in the public, private, and voluntary sectors in a large number of LAMIC. In these developments, LAMIC have been influenced by the local situation as well as international developments. For example, in the initial phase, the existing general health care infrastructure was the primary focus of integration of mental health services. Soon, the increased use of family members, volunteers, counsellors, mentally ill persons, survivors of disasters, parents of children with mental disorders, and the education system occurred. In this way the three principles of community psychiatry — meeting population based needs, use of range of resources, and accessibility — were partially addressed (Thornicroft and Szmukler, 2001). In this chapter, the progress in LAMIC, from the last 40 years of psychiatric services are reviewed towards identification of issues for the future in terms of the priorities, processes, problems, and prospects.