Elsevier

The Lancet

Volume 370, Issue 9591, 15–21 September 2007, Pages 991-1005
The Lancet

Series
Treatment and prevention of mental disorders in low-income and middle-income countries

https://doi.org/10.1016/S0140-6736(07)61240-9Get rights and content

Summary

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak—especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Introduction

The previous two reviews in this Series on global mental health5, 6 have summarised how mental disorders are related to other health conditions, and described the gap between needs and services for mental health, especially in low-income and middle-income countries. We investigated whether interventions to treat and prevent mental disorders are sufficiently effective and affordable to support a substantial scaling-up of such services in low-income and middle-income countries. Although evidence for the effectiveness of such interventions is robust, most of it has been derived from high-income countries.7, 8 Because differences in sociocultural factors and health systems probably limit the generalisability of evidence to low-income and middle-income countries,9 we restricted our review to evidence gathered in these countries. We focused on four mental disorders that pose the greatest burden in adults and children: depression, schizophrenia, alcohol-use disorders, and developmental disabilities (cognitive disabilities or mental retardation, attention deficit hyperactivity disorder, and autism). Interventions in conflict or emergency-affected contexts are a special case, but must be considered since they continue to affect vast numbers of people in low-income and middle-income countries. Finally, we consider the implications of evidence for such interventions on policy and practice.

Section snippets

Global evidence for clinical treatments

We identified 11 501 trials worldwide that assessed interventions for the treatment or prevention of schizophrenia, depression, developmental disabilities, or alcohol-use disorder. Table 1 shows that most of this evidence is derived from high-income countries.7, 8 Fewer than 1% of identified trials were from low-income countries and only about a tenth of identified trials were from low-income and middle-income countries. Of these trials, about two-thirds (958/1521) were from China, and more

Cost-effectiveness of clinical treatments

We reviewed all controlled trials (placebo or usual care), published since 2001, that assessed cost-effective clinical interventions for treatment of depression and schizophrenia, as described in DCP2.1 13 of the 361 depression trials and four of the 1137 schizophrenia trials were included. We included all identified trials of interventions for alcohol misuse and developmental disability in low-income and middle-income countries, since so few of these studies were available and since DCP2 did

Prevention

Preventive strategies aim to reduce: the incidence, prevalence, and recurrence of mental disorders; the time spent with symptoms; the risks for such mental illnesses; and the effects of illness on affected people, their families, and society.3 Meta-analytic reviews of controlled trials, almost exclusively from high-income countries, have showed substantial mean effect sizes for preventive trials targeted at depressive symptoms.99, 100, 101 In school-aged children and adolescents, preventive

Mental health interventions during and after emergencies

Although mental disorders are commonly encountered in emergency situations associated with conflict or natural disaster, research about the outcome of interventions done in the midst of such emergencies is rare. Humanitarian agencies now recommend implementation of mental health interventions and psychological support during and after emergencies.132 Most research on mental health interventions during acute emergencies has focused on post-traumatic stress disorder. However, there has been much

Investment in mental health interventions

Decisions about investment in mental health systems can be based on at least three economic criteria: the economic consequences of no investment; the amount of investment needed to address identified needs; and the cost-effectiveness of investment in relation to competing public-health needs. Moreover, non-economic criteria, such as equitable access to health care, human rights protection, and poverty reduction, might be at least as important within the broader process of setting priorities in

Implications for policy and practice

We conclude that effective, locally feasible, and affordable treatments for depression and schizophrenia in low-income and middle-income countries do exist; however, less evidence exists for the effectiveness of interventions to treat developmental disabilities in childhood or alcohol-use disorders. Evidence suggests that social interventions to support mental health in the midst of emergencies might be effective, as might social interventions for the prevention of depression, substance abuse,

Search strategy

We searched the PsiTri database (EU Mental Health library) and the separate registers of trials held by Cochrane groups (Depression, Anxiety and Neurosis Group; Drugs and Alcohol Group; Schizophrenia Group, and Developmental, Psychosocial and Learning Problems Group) for studies of the treatment of mental disorders. We also did a manual search of the online databases PubMed and Medline. We searched for “depression”, “schizophrenia”, “developmental disabilities”, “mental retardation”, and

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