Author: Renato Souza
Position: Me
Institution: Médecins Sans Frontières - Geneva
E-mail: renato.souza@geneva.msf.org
Additional Authors: Silvia Yasuda; Susanna Cristofani
Submitted Date: July 25, 2007
Published Date: July 25, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Although DOTS is advocated as the best approach for global tuberculosis control, the variable success of such a strategy should help us in learning which problems we might face while adopting the same strategy for the treatment of schizophrenia in developing countries [1].

Our experience while integrating mental health care into primary health care in developing countries has taught us that some points stated in the 5 pillars of DOTS for TB cannot be totally transferred to the treatment of schizophrenia unless some of its principles and weak points are addressed in advance: [2]
1. In developing countries, we face the challenge of integrating mental health knowledge into the skills of poor qualified and over burned human resources. Therefore, unless strong training and supervision capacity for staff at primary health care level is developed, this obstacle wont be overcome.
2. Passive case finding, for a disease that provokes such high level of disability such as schizophrenia, knowing that patients are facing stigma and human rights abuse, is not appropriate in our view.
3. A standard treatment regimen needs to be seen with caution if implemented for the treatment of schizophrenia due to the need to adjust the dose of the antipsychotic to patients with different patterns of response and side effects.
4. A regular supply of essential psychotropic medication is obligatory but non-existent in most developing countries and when available, does not reach the primary health care level.
5. Monitoring and tracking patients under treatment is a very important issue although of enormous burden to overstretched primary health care systems unless the community is heavily involved.

In Darfur-Sudan, due to the high level of mental health morbidity, Medecins sans Frontieres (MSF) has been implementing a syndromic approach to the diagnosis of mental illnesses. [3]
For the identification of patients with severe mental illness including schizophrenia, community health workers (CHW) are trained to identify patients at the community using a locally developed case definition of severe mental illness based on existing local idiom for those conditions.

During a period of 2 months, we have identified 49 patients that were brought to the health clinic where a medical assistant made the diagnosis and started the treatment. CHWs provide therapeutic education to patients and caretakers and support them to continue the treatment at the community. All professionals are under supervision of a mental health trainer.

Some patients were in a dramatic situation as being chained to their beds or having received several forms of traditional treatments without any success.

We firmly believe that unless a system is built where the community is involved, medical personal receives training and supervision and Ministries of Health commit to deliver a constant supply of drugs at primary health care level, the attempt to use one or another strategy wont bring much relief to patients and families affected by this disease.

It is since 1974 that the WHO postulated that mental health care should be integrated at primary health care level. The management of psychosis was put as one of the priorities. [4]. It is very unfortunate that in most of the places where MSF works, the majority of health actors usually neglect the needs of people with severe mental illness.

References
1. Whalen CC (2006) Failure of directly observed treatment for tuberculosis in Africa: a call for new approaches. Clin Infect Dis 42:1048-1050
2. World Health Organisation (1994). Framework for effective tuberculosis control. WHO document WHO/TB/94.179.
3. Kim G, Torbay R, Lawry L (2007) Basic, women’s health, and mental health among displaced persons in Nyala Province, South Darfur, Sudan. Am J Public Health 97:1-9.doi:10.2105/AJPH.2005.073635
4. World Health Organization (2001) The effectiveness of mental health services in primary care: the view from the developing world. WHO document WHO/MSD/MPS/01.1