A nuanced perspective?

In their editorial, White & Sashidharan point to the putatively good outcomes in schizophrenia in low- and middle-income countries (LMIC), ‘where populations may not have access to medication-based treatments’. ¹ This evidence is offered as a caution against scaling up biomedical interventions in LMIC. White & Sashidharan then make a plea for ‘a more balanced exchange of knowledge… between high-income countries and LMIC’. However, in only citing evidence from the World Health Organization (WHO) studies of schizophrenia, and neglecting a wealth of evidence from studies in LMIC, they do not heed their own advice for a greater exchange of knowledge. In fact, research conducted by investigators in India, Ethiopia and China suggests that the provision of biomedical treatment does, in fact, improve outcomes in persons with schizophrenia. ² Furthermore, by only citing the WHO studies, White & Sashidharan do not, despite the title of their editorial, offer a nuanced perspective on this question. When considering the evidence from the long-term research on schizophrenia outcomes in LMIC, there is no doubt that the picture is one of heterogeneity and complexity. ² Thus, by only citing the WHO studies, White & Sashidharan fail to acknowledge the work of a large number of psychiatric researchers from LMIC.

It is difficult, if not impossible, to defend the statement, ‘better outcomes for complex mental health difficulties in LMIC… may be a consequence of the multiplicity of treatment/healing options available in LMIC compared with high-income countries’. First, I would hazard to guess that there are as many, if not more, options for treatment and healing in London, New York, Paris and Sydney than there are in New Delhi, Beijing, Lagos and Rio de Janeiro. For example, in much of Indonesia the options for care are so limited or nonexistent that families often resort to pasung, the practice of chaining, shackling or confining psychotic individuals, in an attempt to protect those individuals from harming themselves or others. ³ Second, having a multiplicity of options does not necessarily result in better outcomes. It can also lead to a continuous sampling of ineffective cures offered by charlatans.

I do not mean these comments to be taken as a tacit endorsement of the indiscriminate use of psychotropic medication. Antidepressants and antipsychotics are less effective than desired and both are associated with troubling side-effects. Rather, these comments are offered in the hope that White & Sashidharan, as well as others, will be prompted to provide a truly nuanced perspective on what is needed to improve the lives of individuals who experience severe mental illness, wherever they reside.