Perspectives from resource poor settings

Over the last decade, concern has been mounting over the excess mortality in persons and populations with mental, neurological and substance use disorders, and the health and economic burden they represent1, 2. It has been stated that excess mortality in persons with severe mental disorders (SMD) is a “right to health” issue and that the lack of access to effective physical health care is a form of “structural discrimination”3. Liu et al4 propose and describe a multilevel model for understanding the relationships among risk factors and correlates of excess mortality in persons with SMD, and a framework for interventions at the individual, health system and socio‐environmental levels. They also outline priorities for clinical practice, policy and research to enable a move towards health equity for those with SMD. I will critique the otherwise robust paper from the perspective of its relevance for resource poor settings.

Liu et al quote sophisticated evidence which shows that persons with SMD − i.e., schizophrenia and other psychotic disorders, bipolar disorder, and moderate‐to‐severe depression − die 10 to 20 years earlier than the general population; and that the majority of deaths in persons with SMD are due to preventable physical diseases, especially cardiovascular disease, respiratory disease, infections, diabetes mellitus and cancers. However, they overstate the case when they claim that this is also true regarding low‐ and middle‐income countries (LMICs). Systematic reviews of population‐based epidemiological studies conducted to inform the Global Burden of Disease estimates showed that nationally representative data for mortality in persons with SMD were virtually non‐existent across LMICs. Such data were available from just five LMICs for schizophrenia and one LMIC for major depression5.

Quantifying mortality presents several challenges in LMICs, because many deaths are not medically certified, and different data sources and diagnostic approaches are used to derive cause‐of‐death estimates6. The need to improve and expand sources of national mortality estimates should be emphasized. It is hoped that documents presenting evidence of relevance to LMICs carefully parcel out the actual evidence from those countries themselves rather than making generalizations mostly based on high‐income country estimates.

Infections may be a particularly important factor related to premature mortality among persons with SMD in LMICs, accounting for half or more of the excess mortality in these settings7, 8. This should be covered in greater detail in a framework for interventions, beyond the HIV risk management implied under “sexual and other behavioural risks”, because tuberculosis and other infections relevant to “local settings” account for at least as much mortality as HIV in people with SMD.

Based largely on data derived from management of schizophrenia, Liu et al state that appropriate administration of medications can reduce excess mortality in persons with SMD. This is a problematic statement in a situation where moderate‐to‐severe depression, a condition that explains a greater proportion of population attributable risk than schizophrenia and bipolar disorder1, 2, is included in SMD, as guidelines on its management are less medication‐centric9. An overemphasis on pharmacological solutions has been a regrettable trend in response to mental health problems in LMICs10.

Almost missing in the discussion is the fact that health care delivery in LMICs is dominated by primary health centres, with the bulk being provided by general physicians, nurses and ancillary health workers. Many recommendations based around coordination between mental and physical health care divisions sit uneasily against the reality of primary health centre based care in LMICs, where coordination may be required more in terms of referral between sub‐primary, primary and specialist care rather than between specialists of different disciplines.

The proposed framework is not configured to assess whether more holistic and sustainable culturally appropriate interventions for LMICs could be useful. Instead, it mostly focuses on health strategies successfully used in North America and Europe, with emphasis on active engagement in surveillance, education and care. These strategies may or may not translate well to LMIC settings. The authors describe facilitators and barriers to application of recommendations and provide advice on how the recommendations can be put into practice, but do not assess resource implications for application of recommendations and monitoring in under‐resourced settings.

Another issue relates to the responsibility and capacity of the state to provide adequate care for its citizens11. Persons with SMD tend to live in less safe neighbourhoods, have less access to healthy foods, and have less opportunities to be involved in healthy activities, which may contribute to poor lifestyle behaviours. The proposed framework for intervention largely shies away from comments on structural economic, political and social determinants of mortality in SMD. Rates of inequality and inequity within countries affect the distribution of health and welfare resources, so advances in medical science and health and social welfare sector responses by themselves cannot reduce mortality and morbidity. Moreover, the emphasis on chronic disease self‐management and parity in service access, in the absence of structural correctives, may facilitate the erosion of traditional state‐centred mechanisms of care and the will to care11.

Finally, the proposed framework for intervention assumes that improved care for comorbid physical disorders would strengthen the overall response to SMD. However, it is possible that the focus on mortality rather than disability, in the resource strapped settings of LMICs, may draw attention away from the mental disorders in general and towards risk factors that are supposed to underlie both physical and mental illnesses.

Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India