Psychiatric services in developing countries

We read with interest the editorial on community psychiatry in developing countries (Jacob, 2001). Historically, in the West, community psychiatry arose in the context of the deinstitutionalisation movement and anti-psychiatry. In developing countries, however, the impetus for developing community-based care was the lack of universally accessible services. Thus, without any ideological baggage to contend with, the emphasis should be on integrated services rather than an artificial schism between hospital and community psychiatry.

We agree with Jacob that psychiatrists should concentrate on what they know best — the identification and treatment of mental illness. The mental health programmes in many developing countries set lofty goals of primary prevention that cannot succeed unless backed by overall social and economic development. But we take issue with his inclusion of epilepsy as a potential target of community psychiatry. It is the authors' experience, while working at the Community Psychiatry Unit at Bangalore, India, that this results in the programme becoming a glorified antiepileptic medication clinic.

Jacob's criticism of vertical mental health programmes ignores the practical reality that there is a limit to what generic health workers can deliver given their commitments to other public health programmes such as immunisation. A practical way of getting around this would be to have mental health workers, based at primary health centres, whose skills are intermediate between community psychiatric nurses and generic health workers. There is also a need to develop simple psychosocial interventions which can be delivered by these workers and draw from the strengths of the family or the local community. Community-based rehabilitation is also a priority area as the prevalent concept of good prognosis of mental disorders in developing countries is being challenged (Mojtabai et al, 2001).

One of the stated goals of community psychiatry is to deliver evidence-based treatments to people with mental disorders (Szmukler & Thornicroft, 2001). It may be heartening for psychiatrists in developing countries to know that the conventional psychotropic medications still remain first-line treatments (Geddes et al, 2001; Barbui & Hotopf, 2001). The challenge is to ensure that all primary health centres stock essential psychotropic medications and that primary care physicians are trained in the detection and management of common disorders.