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REPLY: Treating schizophrenia with DOTS in developing countries: One size does not fit all.

Posted by plosmedicine on 31 Mar 2009 at 00:12 GMT

Author: Saeed Farooq
Position: Associate Professor and Head Department of Psychiatry
Institution: Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan
Submitted Date: August 06, 2007
Published Date: August 7, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

I am grateful to Souza et al for interest in our article and pointing out some very relevant points. I agree with the authors that despite the fact that WHO and many other agencies have advocated that the mental health care in developing countries must be integrated in primary care, there has been no real progress. We need to think about the real causes for this failure. Lack of commitment by the governments is only partial explanation. We, the mental health professional practicing in developing countries must also accept responsibility for this. One of the major reason is that we have not been able to formulate simple interventions which can be implemented at the level of primary care as a public health measure. The approach based on DOTS for treating schizophrenia is one such intervention.

Most of the issues raised by Souza et al are the problems which we are likely to face in applying an approach developed basically for an infectious disorder to a chronic non communicable disease. I would like to stress that, as mentioned in the article, the approach is based on the principles of DOTS and not applying DOTS as practiced in TB control to treatment pf schizophrenia. I agree with the authors that it will need considerable modifications before it could be applied to a chronic disorder like schizophrenia. They have pointed out several issues and I would like to address these.

1. The health workers would definitely need to be better trained under the supervision of mental health professionals for applying this approach in primary care.
2. I very much appreciate the work of authors and agree that passive case finding is not an option. This will result in the plight of patients as mentioned in their letter. One of the benefits of the approach suggested in the article is that as a result of an intervention available at public health level there will be greater awareness of the severe mental illness. Consequently there will be earlier recognition of the cases in community. As mentioned in the article, this should also result in reduced stigma for the disorder.
3. It should be possible to provide a standard regimen for treatment of schizophrenia based on the essential psychotropic drugs. We were able to develop this for our pilot project and are also using the same approach in our Randomised Controlled Trial (Please see, trial ID : NCT 00392249.)
4. One of the major reason for advocating this approach is that this can ensure free supply of the drugs as a part of DOTS programme. One of five essential components of DOTS strategy is the commitment of governments to provide drugs free of cost. This is the cornerstone of the strategy suggested in our article.
5. The monitoring and tracking patients is important but need not to stretch the primary care workers as Schizophrenia is a low prevalence disorder. As explained in the article the implementation of DOTS would be for two years period. The community can only be involved if we can offer effective interventions for those suffering from this chronic and disabling disorder.

The approach suggested in this article represents an attempt to bring mental health in the public health arena. Schizophrenia is a low prevalence disorder for which effective interventions are available which can be implemented at the community level. It therefore represents an ideal disorder for intervention based on DOTS. Applying an approach developed essentially for a disorder which has time limited course and is high on the agenda of public health to a disorder which is non communicable and runs much protracted course demands a paradigm shift. There are examples of similar approaches in other non communicable diseases. Insulin Demonstration Projects which has been initiated to improve the access to the Insulin by the IDF Task Force can provide good models for this (International Diabetes Federation, 2004). Small scale programmes based on the model suggested in this article should be developed locally in developing countries before we can expect the governments to support the same. Organizations such Medecins sans Frontieres are ideally suited to develop programme like these. One size may not fit all but we can make a suitable size for a great majority.


1. International Diabetic Federation. Insulin Demonstration project., 2004

Competing interests declared: SF declares that he is involved as principal investigator in a randomized controlled trial (“Supervised Treatment of Outpatient Schizophrenia [STOPS]”) evaluating the approach described in his Viewpoint.