x Abu Dhabi, UAETuesday 23 January 2018

The global war on mental illness is being lost

Psychiatric patients in the so-called developing world have better outcomes than their counterparts in developed nations.

Adam hears voices, sometimes subjecting him to a running commentary on whatever he is trying to do. 

It's as if there are malevolent sport commentators trapped in his head giving a play-by-play of each mundane act, and offering disparaging opinions: "That was not a good play, Bob. "You betcha' Bob, I have not seen a play as bad as this since I don't know when. 

"Question is, Bob, can Adam come back from this?

"I think not, Bob, I think not." 

In addition to the annoying voices, Adam routinely suspects that people are conspiring to harm him. He misinterprets well-meant comments as coded threats, and reads sly put-downs into the most innocuous of small-talk. 

Adam, like an estimated 51 million other people on the planet, is suffering from severe psychotic symptoms. His current psychiatrist calls his condition schizophrenia, his previous one called it bipolar disorder, the one before that diagnosed schizo-affective disorder.

Next Sunday, October 10, marks world mental health day. However, unlike other branches of medicine, psychiatry has very little to celebrate. Patients like Adam are no better off today than they were at the dawn of modern psychiatry more than 100 years ago. This is the position taken by the British clinical psychologist Richard Bentall in his award-winning book Madness Explained. Prof Bentall argues that psychiatry with its biomedical assumptions is fatally flawed. There are others who go further still, suggesting that modern psychiatry has in fact worsened the plight of many people experiencing severe mental illness.

The author and investigative journalist Robert Whitaker examined psychiatric records going back to 1955, and estimated that since then the US has experienced a six-fold increase in mental illness. The war on "crazy" is not being won. One of the ironies is that psychiatric patients in the so-called developing world actually have better outcomes than their counterparts in developed/overdeveloped nations. Among UAE residents, medical tourism is common and costly; travelling to Germany, the UK or the US for treatment is fairly common. But can you imagine getting on a plane to Mogadishu or Kandahar in search of better medical outcomes? If your medical complaint is psychiatric, then such an act might actually make some sense.

In the late 1960s, the World Health Organisation undertook "the International pilot study of schizophrenia". The study aimed to explore the universality of the concept of schizophrenia. In every country in the study, investigators were able to find patients that met the clearly defined criteria for schizophrenia. What was more striking, however, was that the outcomes of the illness varied widely in each nation. After five years of follow-up, patient outcomes in developing nations were far superior to those in western industrialised nations.

For example, 27 per cent of patients in the developing world experienced a single illness episode followed by complete recovery. Only 7 per cent of patients from industrialised nations experienced such a favourable outcome. Furthermore, by the end of the study 65 per cent of the patients from developing nations were judged to have only minor social impairment, whereas just 56 per cent of patients from developed nations were able to function as well.

These unexpected findings prompted additional research, and the WHO launched a further study that was published in 1996. This second study explored the outcomes of mental illness in general across 10 nations. Again, the results pointed to better outcomes in developing nations. Over the two year follow-up period, 36 per cent of patients in developing nations experienced a full recovery, compared to only 16 per cent in industrialised nations.

The bottom line is that better-resourced, better-staffed psychiatric services in the industrialised nations failed to secure better outcomes for people experiencing severe mental illness. Obviously these findings are open to several interpretations: the anti-psychiatry camp might see this as further evidence of psychiatry's failure. But perhaps within developing nations there are socio-cultural factors that are therapeutic in the context of psychiatric illness. Perhaps in developing nations there are more opportunities for meaningful human interaction, more intact family structures, and greater connection to functioning spiritual narratives.

Perhaps by the time a nation makes the "big time", and sheds its "developing nation" status, it has to a large extent lost many of these factors that may promote mental health. We gain brain scanning technology, western-educated psychiatrists, and the best pharmacology money can buy, but we increasingly lose our minds. Psychiatry as a discipline needs a rethink. As the UAE continues to develop its health services, it has a great opportunity to be a world leader in the provision of care for the severely mentally ill. This will rely on innovation rather than the adoption of technology and international models that have failed to deliver elsewhere.

Dr Justin Thomas is an assistant professor in the Department of Natural Science and Public Health at Zayed University