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Mental health service at primary health care and essential medicines for mental disorders and Epilepsies
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Kapil Dev Upadhyaya Senior Consultant Psychiatrist, Nepal. |
Mental and behavioural disorders affect more than 25% of people at some time during their lives. Around 20% of all patients seen by primary health care professionals have one or more mental disorder. People should access mental health services closer to their homes, thus keeping their families together and maintaining their daily activities. Mental health services delivered in primary care minimize stigma and discrimination, and remove the risk of human rights violation. However, common misunderstandings about the nature of mental disorders and their treatment have contributed to the neglect of mental health services. Despite the potential to successfully treat mental disorders, only a small minority of those in need receive such treatment. The common misunderstandings are:
• Mental disorders affect a small group of population
• Mental disorders cannot be treated
• People with mental disorders are violent or unstable and therefore should be locked
The notion that mental disorders are problems of industrialized and relatively richer parts of the world is simply wrong. The belief that rural communities, relatively unaffected by the fast pace of modern life, have no mental disorders is also incorrect (World Health Organization, 2001).
Surveys carried out in the seven study countries namely Brazil, Canada, Germany, Mexico, Netherlands, Turkey and USA (for more information www.hcp.med.harvard.edu/icpe) showed that Mental disorders are among the most burdensome of all classes of diseases because of their high prevalence and chronicity, early age of onset, and resulting serious impairment (World Health Organization, 2000). The core disorders included in the surveys were anxiety disorders (panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder), mood disorders (major depression, dysthymia and mania), and substance-use disorder (alcohol and drug abuse and dependence).
Wells et al (1989), have shown that the effects of major depression, one of the most common mental disorders, on a wide range of quality-of-life outcomes are comparable to, and in some cases greater than the effects of such chronic physical disorders as hypertension, diabetes and arthritis, to name but a few. Because of their early age of onset, mental disorders have powerful adverse effects on critical life – course transitions such as educational attainment (Kessler et al., 1995), teenage childbearing (Kessler et al., 1997), marital instability and violence (Kessler et al., 1998).
Mental and behavioural disorders are estimated to account for 12% of the global burden of disease, yet the mental health budgets of the majority of the countries constitute less than 1% of their total health expenditures (World Health Organization, 2001).
Schizophrenia is a disorder associated with high levels of social burden and cost, as well as an incalculable amount of individual pain and suffering. However, there is evidence that the outcome of care can be as successful as it is in many other diseases treated by medical or surgical procedures (World Health Organization, 1998).
Mental disorders represent four of the 10 leading causes of disability worldwide.
Leading causes of disability
1. HIV/AIDS
2. Unipolar depressive disorders
3. Road traffic accidents
4. Tuberculosis
5. Alcohol use disorders
6. Self-inflicted injuries
7. Iron-deficiency anaemia
8. Schizophrenia
9. Bipolar affective disorder
10. Violence
Treatment gap in epilepsy
Epilepsy affects about 50 million people worldwide, of whom 80% live in developing countries (World Health Organization, 2000). The difference between the number of people with active epilepsy and the number who are appropriately treated in a given population at a given point in time is known as treatment gap. Meinardi et al (2001) estimate that 90% of people with epilepsy in developing countries are inadequately treated. The possible reason for the high treatment gap include fear of stigmatization, cultural beliefs, lack of knowledge about the medical nature of epilepsy, illiteracy, economic issues, distance to health facilities, inadequate supply of antiepileptic drugs, and lack of prioritization by health authorities (Wang et al., 2003).
Epilepsy imposes a large economic burden on the health care system of countries. There is also a hidden burden associated with stigma and discrimination against the patient and even their family in the community, workplace, school and home. Many patients with epilepsy suffer severe emotional distress, behavioural disorders and extreme social isolation (World Health Organization: Regional Office for South-East Asia, 2004).
The World Health Report 2001 (WHO) in its overview recommends these ten action plans:
1. Provide Treatment in Primary Care:
The management and treatment of mental disorders in primary care is a fundamental step which enables the largest number of people to get easier and faster access to services.
2. Make Psychotropic Drugs Available:
Essential psychotropic drugs should be provided and made constantly available at all levels of health care. These medicines should be included in every country’s essential drugs list, and the best drugs to treat conditions should be made available whenever possible.
3. Give Care in the Community:
Community care has a better effect than institutional treatment on the outcome and quality of life of individuals with chronic mental disorders.
4. Educate the Public:
Public education and awareness campaigns on mental health should be launched in all countries.
5. Involve Communities, Families and Consumers:
Communities, families and consumers should be included in the development and decision-making of policies, programmes and services.
6. Establish National programmes, Policies, and Legislation
7. Develop Human Resources
8. Link with other Sectors:
Sectors other than health, such as education, labour, welfare, and law, and nongovernmental organizations should be involved in improving mental health of communities.
9. Monitor Community Mental Health:
The mental health of communities should be monitored by including mental health indicators in health information and reporting system.
10.Support more research
Cost-effective intervention package in Mental Disorders and Epilepsies
In developing countries, much of the mental health care and spending is reported to be out of pocket. Individuals purchase modern and traditional treatment if they can afford to do so. Although a large private health sector exists in low income countries, the quality and cost vary. Although unregulated markets fail in health, they fail even more in mental health. It is unlikely that a country will be able to rely on an unregulated private sector to deliver services that will reduce the burden of mental disorders.
Table 1 – Essential psychotropic medications |
Psychotic disorders |
CHLOROPROMAZINE Injection 25 mg (hydrochloride)/ml Oral liquid 25 mg (hydrochloride) /5ml Tablet 100 mg (hydrochloride) FLUPHENAZINE (decanoate or enantate) Injection 25 mg/ml HALOPERIDOL Injection 5 mg/ml Tablet 2 mg; 5 mg |
Depressive disorder |
AMITRYPTILINE Tablet 25 mg (hydrochloride) FLUOXETINE Capsule 20 mg (hydrochloride) |
Bipolar disorders |
CARBAMAZEPINE Tablet 100 mg; 200 mg LITHIUM CARBONATE Tablet 300 mg VALPROIC ACID Tablet 200 mg; 500 mg |
Generalized anxiety and sleep disorders |
DIAZEPAM Tablet 2 mg: 5 mg |
Obsessive-compulsive disorders and panic attacks |
CLOMIPRAMINE Tablet 10 mg; 25 mg (hydrochloride) |
Medicines used in substance dependence programmes |
METHADONE Concentrate for oral liquid 5mg/ml; 10mg/ml Oral liquid 5 mg/5ml; 10 mg/5ml BUPRENORPHINE Sublingual tablets 2 mg; 8 mg |
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In the WHO EML the above have been selected for the treatment and control of mental disorders
Selection of Antiepileptic drugs (AEDs)
The pharmacological treatment of epilepsy has been extensively studied primarily in high income countries. Many controlled clinical trials have tested the efficacy of older AEDs such as Phenobarbitone and Phenytoin and newer AEDs such as Carbamazepine and Valproic acid, in controlling seizure frequency and their safety when prescribed in monotherapy or in combination. However, there is a lack of definitive evidence on the difference between the older and newer medications. Phenobarbitone is a cost- effective drug in the management of epilepsy and its benefit far exceeds its side-effects. It remains the drug of choice for large-scale, community-based programmes particularly in rural and remote areas. The Global Campaign Against Epilepsy, jointly sponsored by WHO, the International League Against Epilepsy and the International Bureau for Epilepsy advocates the use of Phenobarbitone for closing the currently high treatment gap in low income countries (World Health Organization: Regional Office for South-East Asia, 2004).
Conclusion & Recommendations
Integration of mental health service including the management of epilepsy at the primary health care will reduce the treatment gap in mental disorders and epilepsies. Free drug supply at primary health care level for the treatment of depressive disorders (Amitryptiline and Fluoxetine), psychotic disorders (Chlorpromazine and Haloperidol), and epilepsies (Phenobarbitone) is necessary to treat these common disorders. All the essential medicines for mental disorders, as recommended by WHO, has to be there in the essential list of drugs for the treatment of mental disorders and epilepsies. If Chloropromazine, Amitryptiline and Phenobarbitone are included in the free list of medicines at the primary health centers and district hospitals, a large number of patients suffering from psychosis, depression and epilepsy will benefit. This step will help to reduce the treatment gap in these disorders.
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