Why a public health approach?

The high prevalence, effects on vulnerable and economically productive populations, costs to society and the availability of effective interventions that can be applied at a population level mean that schizophrenia fulfils most criteria required for a public health approach. ^{Reference Baltussen and Niessen6} Schizophrenia is the sixth leading cause of years lost due to disability (YLD) in LAMI countries. Put into perspective, iron deficiency anaemia, which is a major public health priority in these countries, causes 2.4% of total YLD, whereas schizophrenia is responsible for 2.8% of all YLD. ⁷ Schizophrenia causes more disability than osteoarthritis and only slightly less than that caused by cataracts in LAMI countries. ⁷ Evidence from LAMI countries shows that interventions for disorders such as schizophrenia are affordable and just as cost-effective as, for example, antiretroviral treatment for HIV/AIDS. ^{Reference Eaton, McCay, Semrau, Chatterjee, Baingana and Araya8}

Most people with schizophrenia in LAMI countries receive little or no treatment. In a cohort of 321 patients with schizophrenia who were identified systematically by screening large populations in rural Ethiopia, the majority (89.6%) were treatment-naive at entry. During 5-year follow-up, only about 6% had received antipsychotic treatment continuously. ^{Reference Teferran, Shibre, Fekadu, Medhin, Wakwoya and Al9} There seems to be a causal link between endemic poverty and access to treatment for psychosis. In a study that investigated DUP and its relationship with gross domestic product purchasing power parity (GDPppp) based on International Monetary Fund data, we showed that in LAMI countries an additional $1000 of per capita GDPppp was associated with a decline in mean DUP of 10 weeks. ^{Reference Large, Farooq, Nielssen and Slade2} Therefore, a public health approach that ensures free access to treatment as discussed below can go a long way in reducing this unacceptably long DUP.

The paradigm for early intervention in psychosis

It is evident that early intervention in psychosis needs to become a major public health priority in LAMI countries, perhaps more than any other part of the world. The primary aim in LAMI countries should be to ensure access to treatment at the earliest possible stage. The emphasis should be on preventing relapse by regular supply of essential medication, maintaining treatment adherence, engaging service users and treating emerging symptoms effectively.

One approach suggests that all patients presenting with first-episode psychosis should be provided with free access to treatment during the initial critical period. ^{Reference Farooq, Nazar, Irfan, Akhter, Gul and Irfan10} The treatment is provided using a standardised approach and progress is monitored with the help of simple outcome measures. The medication is provided under close supervision of a relative, who is trained for this purpose, or a health worker. ^{Reference Farooq, Nazar, Irfan, Akhter, Gul and Irfan10} A brief family education programme that has been implemented and evaluated in a LAMI-country setting can be used for this purpose. ^{Reference Farooq, Nazar, Irfan, Akhter, Gul and Irfan10,Reference Farooq, Nazar, Akhter, Irfan and Naeem11} A programme that provides free access to treatment and monitors outcome and adherence with taking medication is only feasible if it is time limited. Most early intervention programmes in high-income countries focus on the initial 3–5 years in first-episode psychosis. The empirical evidence for the optimum duration of such programmes is lacking. In view of economic constraints, it is suggested that early intervention programmes in LAMI countries should target at least the initial 2 years after diagnosis, the ‘critical period’ in the course of the illness, which is the strongest predictor of long-term outcome and disability. ^{Reference Harrison, Hooper, Craig, Laska, Siegel and Wanderling12} This is also consistent with evidence that shows that clinical interventions targeting non-adherence in schizophrenia should continue for at least 18 months. ^{Reference Zygmunt, Olfson, Boyer and Mechanic13}

Early intervention services in high-income countries rarely aim to reduce long DUP, ^{Reference Bird, Premkumar, Kendall, Whittington, Mitchell and Kuipers4} as this is not feasible because of schizophrenia's low incidence and a lack of easy-to-detect markers for its early diagnosis. However, the exceptionally long DUP in LAMI countries results from different cultural, religious and economic factors, ^{Reference Farooq, Large, Nielssen and Waheed3} which may be more amenable to preventative efforts. Most patients with first-episode psychosis are referred by relatives and traditional healers. This could be addressed by a population-based programme to improve awareness about the disorder and the services available through establishing a close network of community mental health workers with members of grass-root health services and social welfare organisations. ^{Reference Teferran, Shibre, Fekadu, Medhin, Wakwoya and Al9} In rural communities, key informants, individuals who are familiar with the health status of members of the community they live in, can assist with this and have been shown to be cost-effective. ^{Reference Isaac and Kapur14} In urban centres, educational programmes for general practitioners and primary care workers to help raise awareness about early diagnosis and treatment will be required. Access to free treatment as part of a public health programme that is widely publicised can lead to heightened awareness and early help-seeking over time.

It can be argued that focus on the early phase of psychosis can divert meagre resources from later phases of the illness and other health priorities. Ideally, care should be provided through all phases of illness but this is a far cry for most LAMI countries, where less than 1% of the health budget is spent on mental health. The provision of effective care during the critical period in the initial years will help to reduce severe disability in the long term. In the absence of formal social care networks and an almost total lack of rehabilitation, chronic disability leads to poverty ⁷ and breakdown of the informal systems of care, resulting in grotesque conditions and violations of human rights. Estimates for providing a core package of care for schizophrenia concluded that the cost for this will neither be large when compared with other disorders, nor make unreasonable demands on overall budgetary allocations. ^{Reference Eaton, McCay, Semrau, Chatterjee, Baingana and Araya8}

Early intervention based on this model will help to put mental health on the public health agenda, the lack of which has been identified as one of the key barriers to service development. ^{Reference Eaton, McCay, Semrau, Chatterjee, Baingana and Araya8} It is vitally important that small-scale programmes are piloted and the lessons learnt from these programmes should then be used for devising population-based services not only for early intervention in psychosis but for other psychiatric disorders. A public health intervention such as this will be the best practical measure to reduce stigma. When patients' conditions improve with the restoration of their social functioning, the community's explanatory model of schizophrenia often shifts from a magico-religious to a medico-social viewpoint. A service based on these principles will also help to provide very useful epidemiological information that could inform treatment, prevention and guidelines for management of schizophrenia in resource-poor settings, which are lacking at present. The resources must be mobilised for a global fund for such a public health programme. Patients with psychosis in LAMI countries may be among the most disadvantaged people on earth. They deserve access to basic treatment as much as those with conditions such as HIV and tuberculosis, for which many poor states around the world provide free access to treatment.