2

The Magnitude of the Problem

Neurological, psychiatric, and developmental disorders exact a profound economic and personal toll in developing countries. Brain disorders affect the highest human faculties and, left untreated, can destroy a person's dignity, productivity, and autonomy. Yet despite their importance, these disorders have been largely ignored by public and private health systems in developing countries as compared with diseases that are better understood.[1]

Health policy on brain disorders has long been limited by the following misperceptions:

  • The illnesses are a problem in the developed but not the developing world.

  • They do not cause mortality.

  • They are not amenable to treatment.

  • They are too expensive to manage in developing countries.

This report seeks to counter each of these notions, the first of which is addressed in this chapter. The impact of brain disorders in developing countries is reviewed from several perspectives: the impact on nations and communities in terms of the overall disease burden due to death and disability, the impact on individuals and families due to lost time, lost productivity, stigmatization and discrimination, the reinforcing roles of poverty and gender inequality, and the lack of capacity to address these problems.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 2 The Magnitude of the Problem Neurological, psychiatric, and developmental disorders exact a profound economic and personal toll in developing countries. Brain disorders affect the highest human faculties and, left untreated, can destroy a person's dignity, productivity, and autonomy. Yet despite their importance, these disorders have been largely ignored by public and private health systems in developing countries as compared with diseases that are better understood.[1] Health policy on brain disorders has long been limited by the following misperceptions: The illnesses are a problem in the developed but not the developing world. They do not cause mortality. They are not amenable to treatment. They are too expensive to manage in developing countries. This report seeks to counter each of these notions, the first of which is addressed in this chapter. The impact of brain disorders in developing countries is reviewed from several perspectives: the impact on nations and communities in terms of the overall disease burden due to death and disability, the impact on individuals and families due to lost time, lost productivity, stigmatization and discrimination, the reinforcing roles of poverty and gender inequality, and the lack of capacity to address these problems.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World EFFECTS ON COMMUNITIES AND NATIONS The Disease Burden Prompted by estimates of the disease burden first published in 1993, health leaders have begun to recognize the major role of brain disorders in the overall burden of disease.[1,2 and 3] Governments and public health policy makers are starting to investigate the impact of this burden on communities and nations (see, for example, Box 2-1 on the 1999 report of the U.S. Surgeon General). Previous comparisons of the contribution of various disorders to the overall burden of disease were based most commonly on the cause of death alone, or sometimes years of life lost (YLLs) by cause. These comparisons dramatically underestimated the importance of brain disorders because these conditions tend to be chronic (not an acute cause of death) and therefore are rarely listed as the immediate cause of death in official records.[ 2,4] Yet depression, epilepsy, and other brain disorders often cause many years of serious disability. Brain disorders are responsible for at least 27 percent of all years lived with disability (YLDs) in developing countries.1 [5] With the exception of Sub-Saharan Africa, brain disorders are the leading contributors to YLDs in all regions of the world (see Table 2-1).[5] In these calculations, the disability-adjusted life year, or DALY (a variant of the better known quality-adjusted life years, or QALY), assesses both disability and premature mortality in a single measure. In combining assessments of YLLs and YLDs, current DALY estimates highlight the significant contribution of brain disorders to the overall disease burden in developing countries (see Table 2-2).[5] Absent data on most developmental disabilities and many adult neurological diseases,2 1998 estimates for brain disorders still show these conditions responsible for nearly 34 percent of all noncommunicable disease DALYs in developing countries (see Figure 2-1). Table 2-2 and Figure 2-2 show the contribution of brain disorders to all DALYs and mortality in developing countries. These conditions account for nearly 15 percent of DALYs and 12 percent of mortality among all disease categories. 3 [6] Current DALY calculations for developing countries, however, reflect only a portion of the disease burden imposed by brain disorders. These sizable cal- 1   The percentage distribution of YLDs attributed to brain disorders is estimated using the 1990 data for neuropsychiatric conditions (25.5 percent), the cerebrovascular disease component of cardiovascular disease (approximately one percent), and the self-inflicted injury component of intentional injuries (approximately .5 percent). 2   Data on such developmental disorders as mental retardation, cerebral palsy, and autism along with adult neurological conditions such as peripheral nerve disease and severe migraine were not accounted for in the estimates of the 1996 Global Burden of Disease study. 3   Category I: Communicable disease, maternal and perinatal conditions and nutritional deficiencies; Category II: Non-communicable disease; and Category III: Injuries.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 2-1 Mental Health: A Report of the U.S. Surgeon General In 1999, the U.S. Department of Health and Human Services issued its first Surgeon General's report on the topic of mental health. The report describes recent defining trends in research, treatments, care provision, and public opinion; reviews current knowledge on mental health care for children, adults, and the elderly; and charts a course for improving access to mental health services and effective treatment for mental disorders. About 10 percent of the U.S. adult population uses mental health services in the health sector in any given year, with another 5 percent seeking such services from social service agencies, schools, or religious or self-help groups. Yet despite the relative abundance of mental health care in the United States, as compared with most developing countries, critical gaps exist between those who need mental health care and those who receive service, as well as between optimally effective treatment and the care many people actually receive. Many of the findings in the Surgeon General's report concur with those in this volume. In the United States, as well as in much of the developing world, the stigma of having a mental illness represents a major barrier to treatment. A lack of awareness of the range of treatments for mental illness also hinders access to effective care. Financial barriers prevent many people from seeking mental health care, and capacity is limited by personnel shortages in several key fields. The two main findings of the Surgeon General's report are equally applicable in the developing world and in the United States: The efficacy of mental health treatments is well documented, and A range of treatments exists for most mental disorders. Accordingly, several recommended courses of action based on these findings are also relevant in a broader context: to fight stigmatization by dispelling myths about mental illness and by increasing public awareness of the effectiveness of existing treatments; to establish effective, evidence-based community mental health services; to facilitate access to mental health care by increasing potential points of entry and reducing financial barriers; and to provide “culturally competent ” treatment that recognizes individual differences. While focusing on a subset of the brain disorders discussed in this volume, the Surgeon General's report emphasizes the central importance of the brain. “We recognize that the brain is the integrator of thought, emotion, behavior, and health,” states Surgeon General David Satcher, M.D., Ph.D, in his preface to the report. “Indeed, one of the foremost contributions of contemporary mental health research is the extent to which it has mended the destructive split between ‘physical' and ‘mental' health.” Source: [7]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World FIGURE 2-1 Non-communicable disease DALYs attributable to brain disorder, estimates for 1998. FIGURE 2-2 Burden of brain disorders as a percentage of total disease burden in low- and middle-income countries, estimates for 1998. Source:[6]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World culations are surely lower-bound estimates of the true impact of brain disorders because they do not fully incorporate many of the known neurological and psychiatric sequelae of infectious, nutritional, genetic, and perinatal disorders, as well as environmental exposures. 4 Current data estimating the prevalence of brain disorders is considered inadequate because many patients in developing countries, particularly children with developmental disorders, do not receive medical care. In the United States, 12 to 18 percent of children are estimated to be disabled in some way.[ 8] Comparable measures would be expected to be substantially higher in developing countries, where children are exposed more frequently to infectious diseases and nutritional deficiencies. While improvements in health care and sanitation are enabling more children to survive infancy in developing countries, concomitant efforts to reduce the occurrence of the number of disabled children is very likely to rise.[ 5] Brain disorders in general are expected to play an increasingly important role in the disease burden of developing countries during the next two decades. Data for 1990 on the burden of disease in developing countries have been projected to 2020,[5] based on trends in cause-specific mortality rates, life expectancy, income per capita, human capital, smoking intensity, and HIV and tuberculosis infection rates. One projected calculation is that unipolar depression (the fourth leading cause of DALYs in 1990 for all age groups and the leading cause of DALYs among those aged 15 to 44) will become the leading cause among all age groups combined in 2020 (see Table 2-3, Table 2-4 through Table 2-5). This projected increase in DALYs attributable to depression reflects not only an aging population, but also recent increases in the rate of depression among younger people. Stroke, ranked as the tenth leading cause of DALYs in developing countries in 1990 (see Table 2-3), is projected to be the fifth leading cause in 2020 (see Table 2-5). Improvements in the reliability and validity of data and collection methods for brain disorders in developing countries may well reveal an even greater contribution to disease burden estimates. It should be noted that in calculating disease burden estimates (e.g., YLDs and DALYs), the years of productive life lost as a result of disability are weighted according to expert opinion regarding the severity of a given disability. For example, the disability caused by major depression is estimated by panels of experts as approximately equivalent to that caused by blindness or paraplegia, while the disability caused by schizophrenia lies between that caused by paraplegia and quadriplegia.[4] The assumptions and judgments underlying DALY 4   Neurological and psychiatric sequelae not fully expressed in current DALY estimates include those caused by infectious disease (e.g.. cerebral malaria, HIV encephalopathy, and congenital rubella), nutritional deficiencies (e.g., iodine-deficiency syndrome and vitamin A blindness), perinatal conditions (e.g., birth trauma), genetic conditions (e.g., phenylketonuria and Duchenne's muscular dystrophy), and environmental exposures (e.g.. fetal alcohol syndrome and lead poisoning).

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World estimates are complex and have been controversial. Some of the problems involve the relative value of living assigned to each age group, the comparative severity of different disabilities at different ages, diagnoses of diseases and their classifications, the presumption of disability weights as universal, and the accuracy and completeness of data sets for each country (see Appendix B for additional information on measurement limitations). The estimates will continue to be refined as stronger data and more widely tested assumptions become available. Meanwhile, current estimates using this indicator have provided the public health community with a valuable way to rank the impact of various diseases on health and to recognize the major role of diseases that cause a high level of disability.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-1 Percentage distribution of years lived with disability (YLDs) for specific causes, 1990   Region Condition Group EME FSE IND CHN OAI SSA LAC MEC Developed Developing World All Causes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 I. Communicable, maternal, perinatal and nutritional conditions 5.5 7.8 33.6 18.9 28.5 39.3 19.0 24.6 6.3 27.8 24.4 A. Infectious and parasitic diseases 2.6 3.0 14.3 6.4 12.6 22.4 9.7 6.4 2.7 12.3 10.7 B. Respiratory infections 0.3 0.4 1.4 1.4 1.4 1.3 1.0 1.8 0.4 1.4 1.2 C. Maternal conditions 0.6 1.9 4.7 1.9 4.0 5.8 2.7 5.0 1.1 4.0 3.5 D. Conditions arising during the perinatal period 0.5 0.5 3.5 1.1 1.7 3.2 1.6 2.9 0.5 2.3 2.0 E. Nutritional deficiencies 1.5 2.0 9.8 8.2 8.7 6.6 4.1 8.6 1.7 7.9 6.9 II. Noncommunicable diseases 86.7 79.5 43.7 66.9 56.1 39.8 67.3 61.5 84.2 54.8 59.5 A. Malignant neoplasms 3.8 2.5 0.6 1.2 0.9 0.5 0.8 0.5 3.3 0.8 1.2 B. Other neoplasms 1.2 1.1 0.2 0.6 0.4 0.4 0.8 0.4 1.2 0.4 0.5 C. Diabetes mellitus 3.2 1.5 1.0 0.5 1.0 0.3 1.3 1.5 2.6 0.9 1.1 D. Endocrine disorders 1.7 0.7 0.1 0.4 0.4 0.9 2.1 1.2 1.4 0.7 0.8

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World E. Neuro-psychiatric conditions 47.2 37.6 20.9 30.7 28.5 16.3 34.6 25.4 43.9 25.5 28.5 F. Sense organ diseases 0.2 0.2 3.4 2.0 2.7 2.9 1.4 2.0 0.2 2.5 2.1 G. Cardiovascular diseases 6.2 7.1 3.6 3.5 2.9 1.6 2.4 3.8 6.5 3.0 3.6 H. Respiratory diseases 6.1 7.1 5.0 14.0 4.7 6.6 6.1 7.8 6.5 7.7 7.5 I. Digestive diseases 4.1 5.5 2.4 5.1 5.8 3.6 4.3 7.1 4.6 4.5 4.5 J. Genito-urinary diseases 1.1 2.0 0.5 0.8 0.8 0.9 1.3 3.4 1.4 1.1 1.2 K. Musculo-skeletal diseases 8.0 10.2 1.6 3.6 3.1 1.5 6.9 1.8 8.8 2.9 3.8 L. Congenital anomalies 2.0 14.8 3.2 3.0 2.6 3.1 2.8 3.6 1.9 3.0 2.9 M.Oral conditions 1.8 1.8 1.2 1.1 2.0 0.6 2.4 3.0 1.8 1.5 1.6 III. Injuries 7.9 12.7 22.8 14.2 15.4 20.9 13.6 13.9 9.5 17.4 16.1 A. Unintentional injuries 7.1 10.7 22.4 12.9 14.6 16.3 12.3 10.0 8.3 15.4 14.3 B. Intentional injuries 0.8 2.0 0.4 1.3 0.8 4.6 1.4 3.9 1.2 1.9 1.8 Note: EME = Established Market Economies; FSE = Formerly Socialist Economies of Europe; IND = India; CHN = China; OAI = Other Asia and Islands; SSA = Sub-Saharan Africa; LAC = Latin America and the Caribbean; MEC = Middle Eastern Crescent Source: [5]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-2 Contribution of brain disorders to disability-adjusted life years (DALYs) and Mortality in low- and middle-income countries, estimates for 1998. Condition DALYs (1,000s) % of Total DALYs Deaths (1,000s) % of Total Deaths All Disease 1,274,259   45,897   Brain Disorders Unipolar major depression 51,217 4.02 0 0 Stroke 36,407 2.86 4,213 9.20 Self-inflicted injuries 19,095 1.50 818 1.80 Bipolar affective disorder 14,421 1.13 15 0.03 Alcohol dependence 13,553 1.06 42 0.09 Psychoses 11,984 0.94 40 0.08 Obsessive compulsive disorders 10,062 0.79 0 0 Alzheimer's disease and other dementias 5,527 0.43 111 0.24 Drug dependency 4,782 0.38 7 0.02 Panic disorders 4,710 0.37 0 0 Epilepsy 4,659 0.37 60 0.13 Post traumatic stress disorders 1,896 0.15 0 0 Multiple sclerosis 1308 0.10 20 0.04 Parkinson's disease 621 0.05 30 0.07 Other neuropsychiatric disorders 9,308 0.73 170 0.37 Total Brain Disorders 189,550 14.90 5,526 12.00 Source: [6]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-3 Causes of DALYs (percentage total) in descending order, 1990   Developing Regions   Rank Disease or Injury DALYs (1,000s) % of Total   All causes 1,218,244   1 Lower respiratory infections 110,506 9.1 2 Diarrheal diseases 99,168 8.1 3 Conditions arising during the perinatal period 89,193 7.3 4 Unipolar major depression 41,031 3.4 5 Tuberculosis 37,930 3.1 6 Measles 36,498 3.0 7 Malaria 31,705 2.6 8 Ischemic heart disease 30,749 2.5 9 Congenital anomalies 29,441 2.4 10 Cerebrovascular 29,099 2.4 11 Road traffic accidents 27,253 2.2 12 Chronic obstructive pulmonary disease 25,771 2.1 13 Falls 24,232 2.0 14 Iron-deficiency anaemia 23,465 1.9 15 Protein-energy malnutrition 20,758 1.7 16 War 18,868 1.6 17 Tetanus 17,513 1.4 18 Violence 15,632 1.3 19 Self-inflicted injuries 15,199 1.3 20 Drownings 14,819 1.2 Source: [5]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-4 Ten leading causes of DALYs at ages 15–44 years in developing regions, 1990 Both Sexes       Males     Females     Rank Disease or Injury DALYs (1,000s) Cumulative % Disease or Injury DALYs (1,000s) Cumulative % Disease or Injury DALYs (1,000s) Cumulative % Developing Regions   All causes 357,437   All causes 180,211   All causes 177,277   1 Unipolar major depression 35,398 9.9 Unipolar major depression 12,658 7.0 Unipolar major depression 22,740 12.8 2 Tuberculosis 19,451 15.3 Road traffic accidents 11,387 13.3 Tuberculosis 8,703 17.7 3 Road traffic accidents 14,321 19.4 Tuberculosis 10,747 19.3 Iron-deficiency anemia 7,135 21.8 4 War 12,382 22.8 Violence 9,844 19.3 Self-inflicted injuries 6,526 25.5 5 Iron-deficiency anemia 12,033 26.2 Alcohol use 8,420 24.8 Obstructed labor 6,033 28.9 6 Self-inflicted injuries 12,004 29.5 War 7,448 29.4 Chlamydia 5,364 31.9 7 Violence 11,448 32.7 Bipolar disorder 5,601 36.7 Bipolar disorder 5,347 34.9 8 Bipolar disorder 10,948 35.8 Self-inflicted injuries 5,478 39.7 Maternal sepsis 5,226 37.8 9 Schizophrenia 9,514 38.5 Schizophrenia 5,068 42.5 War 4,934 40.6 10 Alcohol use 9,371 41.1 Iron-deficiency anemia 4,898 45.3 Abortion 4,856 43.4 Source: [5]

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World CONCLUSION To compete in international markets and to build stronger national and local infrastructures, developing countries must produce well-educated workers, a process that begins with prenatal care and continues through the adult years of employment. Since many brain disorders interfere not only with health but also with education, they present an especially insidious limitation to developing economies. The consequences for a country's development of ignoring the burden imposed by these disorders are clearly large, and growing larger. These disorders create, special problems for developing countries not only because of the scarcity of resources available to address them but also because of their mutually reinforcing relationship with poverty. Poor women bear an even heavier burden than poor men as a result of several gender-specific risk factors, many of which are preventable. The implementation of cost-effective interventions can help to reduce the impact of these disorders and break this debilitating cycle. Thus, poverty and gender inequality, which contribute greatly to the burden of brain disorders in developing countries, should be viewed as a target of the recommendations made in this report. Despite the increasingly significant contribution of brain disorders to disease burden, these conditions are largely missing from the international health agenda.[1] Stigma, discrimination, economic and gender inequalities, and lack of capacity for addressing these add to their burden in developing countries. Recognizing the importance of brain disorders is the first step toward reducing this burden. The process can be further advanced through increased understanding of the social and economic effects of brain disorders as well as through provision of cost-effective care. REFERENCES 1. R. Desjarlais, L. Eisenberg, B. Good, and A. Kleinman. World Mental Health. Oxford University Press: New York, 1995. 2. World Bank. World Development Report: Investing in Health Research Development World Bank: Geneva, 1993. 3. N. Sartorius, T. B. Ustun, J. A. Costa e Silva, D. Goldberg, Y. Lecrubier, J. Ormel, et al. An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on “Psychological Problems in General Health Care.” Archives of General Psychiatry Oct,50(10):819–824, 1993. 4. T. B. Ustun. The Global Burden of Mental Disorders. American Journal of Public Health Sept. 89(9), 1999. 5. C. Murray and A. Lopez, eds. The Global Burden of Disease. The Harvard Press: Boston, 1996.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 6. WHO (World Health Organization). The World Heath Report. World Health Organization: Geneva, 1999. 7. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. U.S. Department of Health and Human Services Administration, Center for Mental Health Services. National Institutes of Health, National Institute of Mental Health : Rockville, MD, 1999. 8. T.W. Langfitt. Presentation to IOM Committee on Neurological, Psychiatric, and Developmental Disorders in the Developing World, 2000. 9. K. Kahn and S.M. Tollman. Stroke in rural south Africa: Contributing to the little known about a big problem. South Africa Medicine Journal 89,63–65, 1999. 10. D. Kebede, A. Alem, T. Shibre, A. Fekadu, D. Fekadu, A. Negash et al. The Bitajira-Ethiopia study of the course and outcome of schizophrenia and bipolar disorders. I. Description of study settings, methods and cases. Unpublished manuscript, 1999. 11. R. Goeree, B.J. O'Brien, P. Goering, G. Blackhouse, K. Agro, A. Rhodes, et al. The economic burden of schizophrenia in Canada. Canadian Journal of Psychiatry Jun;44(5),464–472, 1999. 12. M. Zhang, K.M. Rost, J.C. Fortney, and G. R. Smith. A community study of depression treatment and employment earnings Psychiatric Service Sep;50(9),1209–1213, 1999. 13. L.L. Judd, M.P. Paulus, K.B. Wells, and M.H. Rapaport. Socioeconomic burden of subsyndromal depressive symptom and major depression in a sample of the general population. American Journal of Psychiatry Nov;153(11),1411–1417, 1996. 14. J. Westermeyer. Economic losses associated with chronic mental disorder in a developing country. British Journal of Psychiatry 144,475–481, 1984. 15. S.V. Thomas. Money matters in epilepsy. Neurology India Dec;48(4),322–329, 2000. 16. G.E. Simon, D. Revicki, J. Heiligenstein, L. Grothaus, M. Von Korff, W.J. Katon, and T.R. Hylan. Recovery from depression, work productivity, and health care costs among primary care patients. General Hospital Psychiatry May-Jun;22(3),153–162, 2000. 17. W. Mak, J.K. Fong, R. T. Cheung, and S. L. Ho. Cost of epilepsy in Hong Kong: Experience from a regional hospital Seizure Dec;8(8),456–464, 1999. 18. Health-related quality of life among persons with epilepsy—Texas, 1998. Morbidity Mortality Weekly Report Jan 19;50(2),24–26, 35, 2001. 19. L.M. Brass. The impact of cerebrovascular disease. Diabetes, Obestiy and Metabolism Nov;2 Supplement 2,S6–S10, 2000. 20. C. S. Dewa and E. Lin. Chronic physical illness, psychiatric disorder and disability in the workplace. Social Science and Medicine Jul;51(1),41–50, 2000. 21. P.E. Greenberg, T. Sisitsky, R.C. Kessler, S.N. Finkelstein, E.R. Berndt, J.R. Davidson, et al. The economic burden of anxiety disorders in the 1990s, Journal of Clinical Psychiatry Jul;60(7),427–435, 1999. 22. R. J. Wyatt and I. Henter. An economic evaluation of manic-depressive illness—1991. Social Psychiatry and Psychiatric Epidemiology Aug;30(5),213–219, 1995. 23. P. Kind and J. Sorensen. The costs of depression. International Clinic of Psychopharmacology Jan;7(3-4),191–195, 1993. 24. A. Stoudemire, R. Frank, N. Hedemark, M. Kamlet, and D. Blazer. The economic burden of depression. General Hospital Psychiatry Nov;8(6),387–394, 1986. 25. D.R. Gwatkin and M. Guillot. The Burden of Disease Among the Global Poor. World Bank: Washington D.C., 2000.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 26. M. Bartley. Unemployment and ill health: understanding the relationship. Journal of Epidemiology and Community Health 48,333–337, 1994. 27. J.E. Ritsher, V. Warner, J.G. Johnson, and B.P. Dohrenwend. Inter-generational longitudinal study of social class and depression: A test of social causation and social selection models. British Journal of Psychiatry Apr;178(40, S84–S90, 2001. 28. S. Soepatmi. Developmental outcomes of children of mothers dependent on heroin or heroin/methadone during pregnancy. Acta Paediatrica Nov; 404 (Supplement),36–39, 1994. 29. B. Maughan and G. McCarthy. Childhood adversities and psychosocial disorders. British Medical Bulletin Jan;53(1),156–169, 1997. 30. B.T. Zima, K.B. Wells, B. Benjamin, and N. Duan. Mental health problems among homeless mothers: Relationship to service use and child mental heatlh problems. Archives of General Psychiatry Apr;53(4),332–338, 1996. 31. G. Scambler and A. Hopkins. Being epileptic; coming to terms with stigma. Social Health and Fitness 8,26–43, 1986. 32. E. Friedson. Profession of Medicine: A study of sociology of applied knowledge Russell Sage: New York, 1970. 33. G.L. Albrecht, V.G. Walker, and J. A. Levy. Social distance from the stigmatized: A test of two theories. Social Science and Medicine 16(14),1319–1327, 1982. 34. G.L. Birbeck. Barriers to care for patients with neurologic disease in rural Zambia Archives of Neurology Mar 57(3),414–417, 2000. 35. A. Jablensky, J. McGrath, H. Herrman, D. Castle, O. Gureje, M. Evans, et al. Psychotic disorders in urban areas: An overview of the Study on Low Prevalence Disorders. Australian and New Zealand Journal of Psychiatry 34,221–236, 2000. 36. R. Padmavathi, S. Rajkumar, N. Kumar, A. Manoharan, and S. Kamath. Prevalence of schizophrenia in an urban community in Madras. Indian Journal of Psychiatry 31,233–239, 1987. 37. B.S. Singhal. Neurology in developing countries. Archives of Neurology 55,1019–1021, 1998. 38. M. Gourie-Devi, P. Satishchandra, and G. Gururaj. National workshop on public health aspects of epilepsy. Annals of the Indian Academy of Neurology 2,43–48, 1999. 39. L. Jilek-Aall, W. Jilek, J. Kaaya, L. Mkombachepa, and K. Hillary. Psychosocial study of epilepsy in Africa. Social Science and Medicine 45,783–795, 1997. 40. S.D. Shorvon and P.J. Farmer. Epilepsy in developing countries: a review of epidemiological, sociocultural, and treatment aspects. Epilepsia 29(1),S36–S54, 1988. 41. P. Jallon. Epilepsy in developing countries. Epilepsia 38(10),1143–1151, 1997. 42. K. K. Hampton, R.C. Peatfield, T. Pullar, H.J. Bodansky, C. Walton, and M. Feely. Burns because of epilepsy. British Medical Journal 296(11),16–17, 1988. 43. H.T. Rwiza, I. Mtega, and W.B. P. Matiya. The clinical and social characteristics of epilepsy patients in the Ulanga District, Tanzania. Journal of Epilepsy 5,162–169, 1993. 44. M. Berrocal. Burns and epilepsy. Acta Chirurgiae Plasticae 39(1),22–27, 1997. 45. L. Jilek-Aall. Morbus sacar in Africa: Some religious aspects of epilepsy in traditional cultures. Epilepsia Mar;40(3),382–386, 1999. 46. World Bank. World Development Report. World Bank: Washington D.C., 2000. 47. M. Sundar. Suicide in farmers in India (letter). British Journal of Psychiatry 175,585–586, 1999.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 48. V. Patel, R. Araya, M.S. Lima, A. Ludermir, and C. Todd. Women, Poverty and Common Mental Disorders in four restructuring societies. Social Science and Medicine 49,1461–1471, 1999. 49. D. Sinha. Psychological concomitants of poverty and their implications for education. In: Perspectives on Educating the Poor. Atal, Y. ed. Abhinav Publications: New Delhi, pp. 57–118, 1997. 50. G. Halliday, S. Banerjee, M. Philpot, and A. Macdonald. Community study of people who live in squalor. Lancet Mar 11;355(9207),882–886, 2000. 51. M. Olfson, S. Shea, A. Feder, M. Fuentes, Y. Nomura, M. Gameroff, et al. Prevalence of anxiety, depression, and substance use disorder in an urban general medicine practice. Archives of Family Medicine Sep–Oct;9(9),876–883, 2000. 52. G.R. Glover, M. Leese, and P. McCrone. More severe mental illness is more concentrated in deprived areas British Journal of Psychiatry Dec; 175,544–548, 1999. 53. H. Freeman. Mental health and the environment. British Journal of Psychiatry Feb;132,113–124, 1978. 54. D.K. Pal, A. Carpio, and J.W. Sander. Neurocysticercosis and epilepsy in developing countries. Journal of Neurology, Neurosurgery, and Psychiatry Feb;68(2),137–143, 2000. 55. A.J. McMichael. The urban environment and health in a world of increasing globalization: issues for developing countries. Bulletin of the World Health Organization 78(9),1117–1126, 2000. 56. S. Tong, Y.E. von Schirnding, and T. Prapamontol. Environmental lead exposure: A public health problem of global dimensions Bulletin of the World Health Organization 78(9),1068–1077, 2000. 57. R. Perez-Escamilla and E. Pollitt. Causes and consequences of intrauterine growth retardation in Latin America. Bulletin of the Pan American Health Organization 26(2),128–147, 1992. 58. N.M.J. Van der Put, F. Gabreels, E.M.B. Stevens, J.A.N. Smeitink, F. J. M. Trijbels, and T.K. A. P. Eskes, et al. A second common mutation in the methylenetetra hydrofolate reductase gene: An additional risk factor for neural-tube-defects? American Journal of Human Genetics 62,1044–1051, 1998. 59. B. Lozoff, E. Jimenez, and A. W. Wolf. Long-term developmental outcome of infants with iron deficiency. New England Journal of Medicine 325(10),687–694, 1991. 60. WHO (World Health Organization). ICD-10:International statistical classification of diseases and related health problems, 10th revision. World Health Organization: Geneva, 1992. 61. A. Sommer and K. P. West, Jr. The duration of the effect of Vitamin A supplementation. American Journal of Public Health. Mar; 87(3),467–469, 1997. 62. N. Scheper-Hughes. The madness of hunger: Sickness, delirium, and human needs. Culture, Medicine and Psychiatry Dec;12(4),429–458, 1988. 63. N. Scheper-Hughes. Death Without Weeping: The Violence of Everyday Life in Brazil. University of California: Berkeley, p. 547, 1992. 64. B. A. de Santana, M. M. Fukujima, and R.M. de Oliveiria. Socioeconomic characteristics of patients with stroke. Arq Neuropsichiatr [Portugese] 54(3),428–432, 1996. 65. V. Patel, J. Perieira, L. Coutinho, R. Fernandes, J. Fernandes, and A. Mann. Psychological disorder and disability in primary care attenders in Goa, India. British Journal of Psychiatry 171,533–536, 1998.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 66. V. Patel, E. Simunyu, and F. Gwanzura. The pathways to primary mental health care in Harare, Zimbabwe. Social Psychiatry and Psychiatric Epidemiology 32,97–103, 1997. 67. K. Saeed, R. Gater, A. Hussain, and M. Mubbashar. The prevalence, classification and treatment of mental disorders among attenders of native faith healers in rural Pakistan. Social Psychiatry and Psychiatric Epidemiology Oct;35(10),480–485, 2000. 68. G.L. Birbeck. Seizures in rural Zambia. Epilepsia Mar;41(3),277–281, 2000. 69. A. Singh and A. Kaur. Epilepsy in rural Haryana–Prevalence and treatment seeking behaviour. Journal of the Indian Medical Association Feb;95(2),37–39, 1997. 70. A. F. Mirsky. Perils and pitfalls on the path to normal potential: The role of impaired attention. Journal of Clinical Experimental Neuropsychology 17(4),481–498, 1995. 71. J.E. Miller. Developmental screening scores among preschool-aged children: The roles of poverty and child health. Journal of Urban Health 75(1),135–152, 1998. 72. M. Haq and K. Haq. Human Development in South Asia: The Education Challenge. Oxford University Press: Karachi, 1999. 73. V. McLoyd. Socioeconomic disadvantage and child development. American Psychologist 53(2),185–204, 1998. 74. I. Heath, A. Haines, Z. Malenica, J. Oulton, Z. Liepando, D. Kaseje, et al. Joining together to combat poverty. Croatian Medical Journal Online (http://www.vms.cmj.2000/410104.htm), 2000. 75. G. Alvarez. The neurology of poverty. Social Science and Medicine 16(9),945–950, 1982. 76. J. L. Aber, N. G. Bennett, D. C. Conley, and J. Li. The effects of poverty on children's health and development. Annual Review of Public Health 18,468–483, 1997. 77. E. Pollitt. Poverty and child development: Relevance of research in developing countries to the United States. Child Development 65,283–295, 1994. 78. R. J. Hackett, L. Hackett, and P. Bhakta. The prevalence and associated factors of epilepsy in children in Calicut District, Kerala, India. Acta Paediatrica 86(11),1257–1260, 1997. 79. D.J.P. Barker and C. Osmond. Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales. In: D.J.P. Barker, ed. Fetal and Infant Origins of Adult Disease. British Medical Journal: London, 1992. 80. T. A. Pearson. Cardiovascular disease in developing countries: Myths, realities, and opportunities. Cardiovascular Drugs and Therapy 13,95–104, 1999. 81. G. Lewis, P. Bebbington, T.S. Brugha, M. Farrell, B. Gill, R. Jenkins, et al. Socioeconomic status, standard of living and neurotic disorder. Lancet 352,605–609, 1998. 82. B.P. Dohrenwend, I. Levav, P.E. Strout, S. Schwartz, S. Naveh, B.C. Link et al. Socioeconomic status and psychiatric disorders: The causation-selection issue. Science Feb 21;255(5047) 946–952, 1992. 83. S. Weich and G. Lewis. Poverty, unemployment and the common mental disorders: A population-based cohort study. British Medical Journal 317,115–119, 1998. 84. G. Lewis and A. Sloggett. Suicide, deprivation and unemployment: Record linkage study. British Medical Journal 317,1283–1286, 1998. 85. S. V. Thomas and V. B. Bindu. Psychosocial and economic problems of parents of children with epilepsy Seizure 8,66–69, 1999. 86. E. Bahar, A.S. Henderson, and A.J. Mackinnon. An epidemiological study of mental health and socioeconomic conditions in Sumatera, Indoniesia. Acta Psychiatrica Scandinavica 85(4),257–263, 1992.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 87. D.J. Gunnell, T.J. Peters, R.M. Kammerling, and R.J. Brooks. Relation between parasuicide, suicide, psychiatric admissions, and socioeconomic deprivation. British Medical Journal 311,226–230, 1995. 88. S. Jejeebhoy. Wife-beating in rural India: A husband's right? Evidence from survey data. Economic and Political Weekly (3),855–862, 1998. 89. D. B. Mumford, K. Saeed, I. Ahmad, S. Latif, and M. Mubbashar. Stress and psychiatric disorder in rural Punjab: A community study British Journal of Psychiatry 170,473–478, 1997. 90. J. Broadhead and M. Abas. Life events and difficulties and the onset of depression among women in a low-income urban setting in Zimbabwe. Psychological Medicine 28,29–38, 1998. 91. J. Cooper and N. Sartorius, eds. Mental Disorder in China, Gaskell: London, 1996. 92. M. Gibbon. The use of romal and informal health care by female adolescents in eastern Nepal. Health Care for Women International Jul–Aug;19(4),343–360, 1998. 93. R. Warner. Recovery from Schizophrenia: Psychiatry and Political Economy. Routledge and Kegan Paul: London:, 1985. 94. C.E. Okojie. Gender inequalities of health in the Third World. Social Science and Medicine 39(9),1237–1247, 1994. 95. S. Malik. Women and mental health. Indian Journal of Psychiatry 35,3–10, 1993. 96. V. Pearson. Goods on which one loses: Women and Mental Health in China. Social Science and Medicine 45,1159–1173, 1995. 97. B. Davar. The Mental Health of Indian Women: A Feminist Agenda. Sage: New Delhi, 1999. 98. G. W. Brown and T.O. Harris. Social Origins of Depression: A Study of Psychiatric Disorder in Women. Free Press: New York, 1978. 99. S. Guatam. Post partum psychiatric syndromes: Are they biologically determined? Indian Journal of Psychiatry 31,31–42, 1989. 100. G.W. Brown, M. Bhrolchain, and T. Harris. Social class and psychiatric disturbance among women in an urban population. Sociology 9,225–257, 1975. 101. V. Makosky. Sources of stress: events or conditions? In: Lives in Stress: Women and Depression. Belle, D., ed. Sage Publications: Beverly Hills, California, pp.35–53, 1982. 102. I. Blue, M.E. Bucci, S. Jaswal, A. Ludermir, and T. Harpham. The mental health of low-income urban women: case studies form Bombay, India; Olinda, Brazil; and Santaigo, Chile. In: Urbanization and Mental Health in Developing Countries, Harpham, T., Blue, T., eds. Avebury: Aldershot, pp.75–101, 1995. 103. R. Kessler. The effects of stressful life events on depression. Annual Review of Psychology 48,191–214, 1997. 104. A. Kleinman, J. Kleinman, and L. Sing. The Transforming of Social Experience in Chinese Society. Special Issue of Culture, Medicine, and Society 23(1),1–156, 1999. 105. V. Hendrick, L.L. Altshuler, and R. Suri. Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics Mar–Apr;39(2),93–101, 1998. 106. P.J. Lucassen, F. J. Tilders, A. Salehi, and D. F. Swaab. Neuropeptides vasopressin (AVP), oxytocin (OXT) and corticotropin-realesing hormone (CRH) in the human hypothalamus: Activity changes in aging, Alzheimer's disease and depression. Aging (Milano) 9(4),48–50, 1997.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 107. L. Dennerstein, J. Astbury, and C. Morse. Psychosocial and Mental Health Aspects of Women's Health. World Health Organization : Geneva, 1993. 108. M.C. Inhorn. Kabsa (a.k.a. mushahara) and threatened fertility in Eygpt. Social Science and Medicine Aug;39(4),487–505, 1994. 109. R. Kumar. Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, Nov;29(6),250–264, 1994. 110. S. Nhitawa, V. Patel, and S.W. Acuda. Predicting postnatal mental disorder with a screening questionnaire: A prospective cohort study from a developing country. Journal of Epidemiology and Community of Health 52,262–266, 1998. 111. Y.A. Aderibigbe, O. Gureje, and O. Omigbodun. Postnatal emotional disorders in Nigerian women. British Journal of Psychiatry 163,645–650, 1993. 112. M. E. Reichenheim and T. Harpham. Maternal mental health in a squatter settlement in Rio de Janeiro British Journal of Psychiatry 159,683–690, 1991. 113. L. Murray and P. Cooper. The impact of postpartum depression on child development. Internal Review of Psychiatry 8,55–63, 1997. 114. P. Cooper, M. Tomlinson, L. Swartz, M. Woolgar, L. Murray, and C. Molteno. Postpartum depression and the mother-infant relationship in a South African peri-urban settlement. British Journal of Psychiatry 175,554–558, 1999. 115. J. Holden. The role of health visitors in postnatal depression. International Review of Psychiatry 8,79–86, 1996. 116. R. L. Fishbach and B. Herbert. Domestic violence and mental health: Correlates and conundrums within and across cultures. Social Science and Medicine 45,1161–1170, 1997. 117. M.K. Chapo, P. Somse, A.M. Kimball, R.V. Hawkins, and M. Massanga. Predictors of rape in the Central African Republic. Health Care for Women International Jan-Feb;20(1),71–79, 1999. 118. E. Mulugeta, M. Kassaye, and Y. Berhane. Prevalence and outcomes of sexual violence among high school students Ethiopian Medical Journal Jul;36(3),167–174, 1998. 119. D.M. Menick and F. Ngoh. [Sexual abuse in children in Cameroon]. Médecine tropicale: Revue du corps de santé colonial 58(3),249–252, 1998. 120. A.L. Coker and D.L. Richter. Violence against women in Sierra Leone: Frequency and correlates of intimate partner violence and forced sexual intercourse. African Journal of Reproductive Health Apr;2(1),61–72, 1998. 121. R. Knight, A. Hotchin, C. Bayly, and S. Grover. Female genital mutilation—Experience of The Royal Women's Hospital, Melbourne. Autralian New Zealand Journal of Obstetrics and Gynecology Feb;39(1),50–54, 1999. 122. K. Jain, K.A. Maheshwari, and N. Agarwal. Genital injuries in sexually abused young girls. Indian Pediatrics Dec;35(12),1218–1220, 1998. 123. M. D. Stein and L. Hanna. Use of mental health services by HIV-infected women. Journal of Women's Health 6,569–574, 1997. 124. F. K. Judd and A.M. Mijch. Depressive symptoms in patients with HIV infection. Australian and New Zealand Journal of Psychiatry 30,104–109, 1996. 125. A. J. Leblanc, S. A. London, and C. S. Aneshensel. The physical costs of AIDS care-giving. Social Science and Medicine 45,915–923, 1997.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 126. M. Mbizvo, A. Mashu, T. Chipato, E. Makura, R. Bopoto, Fotrell. Trends in HIV-1 and HIV-2 prevalence and risk factors in pregnant women in Harare, Zimbabwe. Central African Journal of Medicine 42,14–21, 1996. 127. D. Sonali. An Investigation into the Incidence and Causes of Domestic Violence in Sri Lanka. Women in Need (WIN): Colombo, Sri Lanka, 1990. 128. S. Toft, ed. Domestic Violence in Papua New Guinea. Law Reform Commission Occasional Paper NO. 19, Port Moresby, Papua New Guinea, 1986. 129. S. Valdez and E. Shrader-Cox. Estudio Sobre la Incidencia de Violencia Domestica en una Microregion de Ciudad nezahualcoyotl. Centro de Investigacion y Lucha Contra la Violencia Domestica: Mexico City, 1991. 130. N. Almeida-Filho, J. J. Mari, E. Coutinho, J. F. Franca, J. Fernandes, S. B. Andreoli, and E. A. Busnello. Brazillian multicentric study of psychiatric morbidity. Methodological features and prevalence estimates. British Journal of Psychiatry 171,524–529, 1997. 131. J.C. Campbell and L.A. Lewandowski. Mental and physical health effects of intimate partner violence on women and children. Psychiatric Clinics of North America 20,353–374, 1997. 132. N. Malhotra and M. Snood. Sexual assault—A neglected public health problem in the developing world. International Journal of Gynaecology and Obstetrics Dec;71(3),257–258, 2000. 133. G.M. Carstairs. Death of a Witch: A Village in North India, 1950–1981. Hutchinson: London, 1983. 134. L. Cohen. No Aging in India. University of California Press: Berkeley, 1998. 135. E. Chinyadza, I. M. Moyo, T. M. Katsumbe, D. Chisvo, M. Mahari, D. E. Cock, O. L. Mbengeranwa. Alcohol problems among patients attending five primary health care clinics in Harare city. Central African Journal of Medicine 36,26–32, 1993. 136. T. F. Babor and M. Grant. Programme on Substance Abuse. Project on identification and management of alcohol-related problems. World Health Organization: Geneva, 1992. 137. C. Pritchard. Suicide in the People's Republic of China categorized by age and gender: Evidence of the influence of culture on suicide. Acta Psychiatrica Scandinavica May;93(5),362–367, 1996. 138. M.M. Khan and H. Reza. The pattern of suicide of Pakistan. Crisis 21(1),31–35, 2000. 139. A. Alem, D. Kebede, L. Jacobsson, and G. Kullgren. Suicide attempts among adults in Butajira, Ethiopia. Acta Psychiatrica Scandinavica (supplement); 397,70–76, 1999. 140. C. La Vecchia, F. Lucchini, and F. Levi. Worldwide trends in suicide mortality, 1955–1989. Acta Psychiatrica Scandinavica Jul;90(1),53–64, 1994. 141. World Health Organization (WHO). Stroke trends in the WHO MONICA Project. Stroke 28,500–506, 1997. 142. P. Thorvaldsen, K. Asplund, K. Kuulasmaa et al. Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease. Stroke 26,361–367, 1995. 143. Bulletin of the Indian Academy of Neurology Nov/Dec 8(3) Bangalore India, 1999. 144. R.S. Murthy. Rural psychiatry in developing countries. Psychiatric Services Jul;49(7):967–969, 1998.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 145. V. Patel. Personal communication 2000. 146. Data from the African Medical and Research Foundation, http://www.amref.org/, 2000. 147. Data from the HR Program (Observatory) at Pan American Health Organization (PAHO), 2000. 148. Koon Sik Min. Data from the Sam Yook Rehabilitation Center. Personal communication 2000. 149. Hisao Sato, Japan College of Social Work, 2000. 150. B.S. Singhal. Bombay Hospital Institute of Medical Sciences, personal communication 2000. 151. A. Gallo Diop. Centre Hospitalier Universitarie De Fam, Dakar, Senegal. Personal communication, 2000. 152. Annual Congress of the Neurology Association of South Africa, 1998. 153. CIA World Fact Book, 2000. 154. Pan American Health Organization Scientific Publication, 561. 155. Data from the Uruguay Medical Society, 2001. 156. Meeting on Promotion of Psychiatry and Mental Health in Africa, 2000. 157. World Bank. Entering the 21st Century World Development Report 1999/2000. Oxford University Press: New York, 2000. 158. A. Alem. Human rights and psychiatric care in Africa with particular reference to the Ethiopian situation. Acta Psychiatrica Scandinavica (supplement) 399,93–96, 2000. 159. A. Mohit, K. Saeed, D. Shahmohammadi, J. Bolhari, M. Bina, R. Gater, et al. Mental health manpower development in Afghanistan: A report on a training course for primary health care physicians. Eastern Mediterrean Health Journal Mar;5(2),373–377, 1999. 160. V. Ganju. The mental health system in India. History, current system, and prospects International Journal of Law and Psychiatry May-Aug;23(3–4):393–402, 2000. 161. Data from the Institute of Psychiatry, Ain Shams University. Cairo, Egypt, 2000. 162. WHO Estimates of Health Personnel in http://who.int.org.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World This page in the original is blank.

OCR for page 21
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World SUMMARY OF FINDINGS: Integrating Care of Brain Disorders into Health Care Systems Although most developing countries have a system of primary health care, the services available vary widely among communities. They may involve private care (specialists, physicians, or traditional healers) or care provided by governmental or nongovernmental organizations (specialists, physicians, nurses, and other health care workers). Specialists are few and physicians limited; both are concentrated in the cities. Successful management of brain disorders through community-based primary care clinics requires guidance and training of health care workers. This must be followed by monitoring, continuing education, and periodic and continued support of clinics and their staffs by secondary and tertiary facilities, such as district hospitals and centers for training and research. Cost-effectiveness studies using established methods can best guide public investments in management of brain disorders. Optimal approaches to prevention and treatment of these disorders will vary with local needs and costs. Primary health care requires the support of robust national and local policies to adequately address the specific needs of different communities. International expertise and resources will be needed from development banks, international organizations, nongovernmental organizations, health professionals, research institutions, and others to establish comprehensive health care for brain disorders in developing countries.