Pharmacological and psychosocial management of mental, neurological and substance use disorders in low- and middle-income countries: issues and current strategies

Abstract

Mental, neurological, and substance use disorders (MNS) are among the largest sources of medical disability in the world, surpassing both cardiovascular disease and cancer. The picture is not different in low- and middle-income countries (LAMIC) where the relative morbidity associated with MNS is increasing, as a consequence of improvement in general health indicators and longevity. However, 80 % of individuals with MNS live in LAMIC but only close to 20 % of cases receive some sort of treatment. The main aim of this article is to provide non-specialist health workers in LAMIC with an accessible guide to the affordable essential psychotropics and psychosocial interventions which are proven to be cost effective for treating the main MNS. The MNS discussed in this article were selected on the basis of burden, following the key priority conditions selected by the Mental Health Action Programme (mhGAP) developed by the World Health Organization (WHO) (anxiety, stress-related and bodily distress disorders; depression and bipolar disorder; schizophrenia; alcohol and drug addiction; and epilepsy), with the addition of eating disorders, because of their emergent trend in middle-income countries. We review best evidence-based clinical practice in these areas, with a focus on drugs from the WHO Model List of Essential Medicines and the psychosocial interventions available in LAMIC for the management of these conditions in primary care. We do this by reviewing guidelines developed by prestigious professional associations and government agencies, clinical trials conducted in LAMIC and systematic reviews (including Cochrane reviews) identified from the main international literature databases (MEDLINE, EMBASE and PsycINFO). In summary, it can be concluded that the availability and use of the psychotropics on the WHO Model List of Essential Medicines in LAMIC, plus an array of psychosocial interventions, can represent a cost-effective way to expand treatment of most MNS. The translation of these findings into policies can be achieved by relatively low supplementary funding, and limited effort engendered by governments and policy makers in LAMIC.