Chapter 3: Solving Mental health problems: Previous page | 1,2,3,4

Examples of effectiveness

Chapter 3 The shifting paradigm Principles of care Ingredients of care Examples of effectiveness

Interventions for the management of mental and behavioural disorders can be classified in three major categories: prevention, treatment and rehabilitation. These correspond approximately to the concepts of primary, secondary and tertiary prevention (Leavell & Clark 1965).

• Prevention (primary prevention or specific protection) comprises measures applicable to a particular disease or group of diseases in order to intercept their causes before they involve the individual; in other words, to avoid the occurrence of the condition.
• Treatment (secondary prevention) refers to measures to arrest a disease process already initiated, in order to prevent further complications and sequelae, limit disability, and prevent death.
• Rehabilitation (tertiary prevention) involves measures aimed at disabled individuals, restoring their previous situation or maximizing the use of their remaining capacities. It comprises both interventions at the level of the individual and modifications of the environment.

The following examples present a range of effective interventions of public health importance. For some of these disorders, the most effective intervention is preventive action, whereas for others treatment or rehabilitation is the most efficient approach.

Depression

Currently, there is no evidence that interventions proposed for primary prevention of depression are effective except in a few isolated studies. There is, however, evidence of the effectiveness of certain interventions, such as setting up supportive network systems for vulnerable groups, specific event-centred interventions, and interventions that target vulnerable families and individuals, as well as adequate screening and treatment facilities for mental disorders as part of primary care for physical disability (Paykel 1994). A number of screening, education and treatment programmes for mothers have been shown to reduce depression in mothers and prevent adverse health outcomes for their children. These programmes can be delivered in the primary health care setting by, for example, health visitors or community health workers. However, they have not been widely disseminated in primary care, even in industrialized countries (Cooper & Murray 1998).

The goals of therapy are reduction of symptoms, prevention of relapses and, ultimately, complete remission. The first-line treatment for most people with depression today consists of antidepressant medication, psychotherapy, or a combination of the two.

Antidepressant drugs are effective across the full range of severity of major depressive episodes. With mild depressive episodes, the overall response rate is about 70%. With severe depressive episodes, the overall response rate is lower, and medication is more effective than the placebo. Studies have shown that the older antidepressants (tricyclics), known as ADTs, are as effective as the newer drugs and less expensive: the cost of ADTs is about US$ 2­3 per month in many developing countries. New antidepressant drugs are effective treatments for severe depressive episodes, with fewer unwanted effects and greater patient acceptance, but their availability remains limited in many developing countries. These drugs may have advantages in older age groups.

The acute phase requires 6 to 8 weeks of medication during which patients are seen every one or two weeks ­ and more frequently in the initial stages ­ for the monitoring of symptoms and side-effects, dosage adjustments, and support.

The successful acute phase of antidepressant drug treatment or psychotherapy should almost always be followed by at least 6 months of continued treatment. Patients are seen once or twice a month. The primary goal of this continuation phase is to prevent relapse; it can cut the relapse rate from 40­60% to 10­20%. The ultimate goal is complete remission and subsequent recovery. There is some evidence, albeit weak, that relapse is less common following successful treatment with cognitive behavioural therapy than with antidepressants (see Table 3.2).

Table 3.2 Effectiveness of interventions for depression

The phase known as maintenance pharmacotherapy is intended to prevent future recurrences of mood disorders, and is typically recommended for individuals with a history of three or more depressive episodes, chronic depression, or persistent depressive symptoms. This phase may extend for years, and typically requires monthly or quarterly visits.

Some people prefer psychotherapy or counselling to medication for the treatment of depression. Twenty years of research have found several forms of time-limited psychotherapy as effective as drugs in mild-to-moderate depressions. These depression-specific therapies include cognitive behavioural therapy and interpersonal psychotherapy, and emphasize active collaboration and patient education. A number of studies from Afghanistan, India, Pakistan, the Netherlands, Sri Lanka, Sweden, the United Kingdom and the United States show the feasibility of training general practitioners to provide this care and its cost-effectiveness (Sriram et al. 1990; Mubbashar 1999; Mohit et al. 1999; Tansella & Thornicroft 1999; Ward et al. 2000; Bower et al. 2000).

Even in industrialized countries, only a minority of people suffering from depression seek or receive treatment. Part of the explanation lies in the symptoms themselves. Feelings of worthlessness, excessive guilt and lack of motivation deter individuals from seeking help. In addition, such individuals are unlikely to appreciate the potential benefits of treatment. Financial difficulties and the fear of stigmatization are also deterrents. Beyond the individuals themselves, health care providers may fail to recognize symptoms and to follow best practice recommendations, because they may not have the time or the resources to provide evidence-based treatment in primary care settings.

Alcohol dependence

The prevention of alcohol dependence needs to be seen within the context of the broader goal of preventing and reducing alcohol-related problems at the population level (alcohol-related accidents, injuries, suicide, violence, etc). This comprehensive approach is discussed in Chapter 4. Cultural and religious values are associated with low levels of alcohol use.

The goals of therapy are the reduction of alcohol-related morbidity and mortality, and the reduction of other social and economic problems related to chronic and excessive alcohol consumption.

Early recognition of problem drinking, early intervention for problem drinking, psychological interventions, treatment of the harmful effects of alcohol (including withdrawal and other medical consequences), teaching new coping skills in situations associated with a risk of drinking and relapse, family education and rehabilitation are the main strategies proven to be effective for the treatment of alcohol-related problems and dependence.

Epidemiological research has shown that most problems arise among those who are not significantly dependent, such as individuals who get intoxicated and drive or engage in risky behaviours , or those who are drinking at risk levels but continue to have jobs or go to school, and maintain relationships and relatively stable lifestyles. Among patients attending primary health care clinics and drinking at hazardous levels, only 25% are alcohol dependent.

Brief interventions comprise a variety of activities directed at persons who engage in hazardous drinking, but who are not alcohol dependent. These interventions are of low intensity and short duration, typically consisting of 5­60 minutes of counselling and education, usually with no more than three to five sessions. They are intended to prevent the onset of alcohol-related problems. The content of such brief interventions varies, but most are instructional and motivational, designed to address the specific behaviour of drinking, with feedback from screening, education, skill-building, encouragement and practical advice, rather than intensive psychological analysis or extended treatment techniques (Gomel et al. 1995).

For early drinking problems, the effectiveness of brief interventions by primary care professionals has been demonstrated in numerous studies (WHO 1996; Wilk et al. 1997). Such interventions have reduced up to 30% of alcohol consumption and heavy drinking, over periods of 6­12 months or longer. Studies have also demonstrated that these interventions are cost-effective (Gomel et al. 1995).

For patients with more severe alcohol dependence, both outpatient and inpatient treatment options are available and have been shown to be effective, although outpatient treatment is substantially less costly. Several psychological treatments have proved to be equally effective: these include cognitive behavioural treatment, motivational interviewing, and "Twelve Steps" approaches associated with professional treatment. Community reinforcement approaches, such as that of Alcoholics Anonymous, during and following professional treatment are consistently associated with better outcomes than treatment alone. Therapy for spouses and family members, or simply their involvement, have benefits for both initiation and maintenance of alcohol treatment.

Detoxification (treatment of alcohol withdrawal) within the community is preferable, except for those with severe dependence, a history of delirium tremens or withdrawal seizures, an unsupportive home environment, or previous failed attempts at detoxification (Edwards et al. 1997). Inpatient care remains a choice for patients with serious comorbid medical or psychiatric conditions. Psychosocial ancillary and family interventions are also important elements in the recovery process, particularly when other problems occur along with alcohol dependence.

No evidence indicates that coercive treatment is effective. It is unlikely that such treatment (whether it follows civil commitment, a decision of the criminal justice system, or any other intervention) will be beneficial (Heather 1995).

Medication cannot replace psychological treatment for people with alcohol dependence, but a few drugs have shown to be effective as a complementary treatment to reduce relapse rates (NIDA 2000).

Drug dependence

The prevention of drug dependence needs to be seen within the context of the broader goal of preventing and reducing drug-related problems at the population level. This broad approach is discussed in Chapter 4.

The goals of therapy are to reduce morbidity and mortality caused by or associated with the use of psychoactive substances, until patients can achieve a drug-free life. Strategies include early diagnosis, identification and management of risk of infectious diseases as well as other medical and social problems, stabilization and maintenance with pharmacotherapy (for opioid dependence), counselling, access to services, and opportunities to achieve social integration.

Persons with drug dependence often have complex needs. They are at risk of HIV and other bloodborne pathogens, comorbid physical and mental disorders, problems with multiple psychoactive substances, involvement in criminal activities, and problems with personal relationships, employment and housing. Their needs demand links between health professionals, social services, the voluntary sector and the criminal justice system.

Shared care and integration of services are examples of good practice in caring for substance dependents. General practitioners can identify and treat acute episodes of intoxication and withdrawal, and provide brief counselling as well as immunization, HIV testing, cervical screening, family planning advice and referral.

Counselling and other behavioural therapies are critical components of effective treatment of dependence, as they can deal with motivation, coping skills, problem-solving abilities, and difficulties in interpersonal relationship. Particularly for opioid dependents, substitution pharmacotherapies are effective adjuncts to counselling. As the majority of drug dependents smoke, tobacco cessation counselling and nicotine replacement therapies must be provided. Self-help groups can also complement and extend the effectiveness of treatment by health professionals.

Medical detoxification is only the first stage of treatment for dependence, and by itself does not change long-term drug use. Long-term care needs to be provided, and comorbid psychiatric disorders treated as well, in order to decrease rates of relapse. Most patients require a minimum of three months of treatment to obtain significant improvement.

Injection of illicit drugs poses a particular threat to public health. Sharing of injection equipment is associated with transmission of bloodborne pathogens (especially HIV and hepatitis B and C) and has been responsible for the spread of HIV in many countries, wherever injecting drug use is widespread.

People who inject drugs and who do not enter treatment are up to six times more likely to become infected with HIV than those who enter and remain in treatment. Treatment services should therefore provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases and, whenever possible, treatment for these conditions and counselling to help patients stop unsafe injecting practices.

Drug dependence treatment is cost-effective in reducing drug use (40-60%), and the associated health and social consequences, such as HIV infection and criminal activity. The effectiveness of drug dependence treatment is comparable to the success rates for the treatment of other chronic diseases such as diabetes, hypertension and asthma (NIDA 2000). Treatment has been shown to be less expensive than other alternatives, such as not treating dependents or simply incarcerating them. For example, in the United States, the average cost for one full year of methadone maintenance treatment is approximately US$ 4700 per patient, whereas one full year of imprisonment costs approximately US$18 400 per person.

Schizophrenia

Currently, primary prevention of schizophrenia is not possible. Recently, however, research efforts have focused on developing ways of detecting people at risk of schizophrenia in the very early stages or even before the onset of the illness. Early detection would increase the chances of early interventions, possibly diminishing the risk for a chronic course or serious residua. The effectiveness of programmes for early detection or early intervention must be evaluated through long-term follow-up (McGorry 2000).

The treatment of schizophrenia has three main components. First, there are medications to relieve symptoms and prevent relapse. Second, education and psychosocial interventions help patients and families cope with the illness and its complications, and help prevent relapse. Third, rehabilitation helps patients reintegrate into the community and regain educational or occupational functioning. The real challenge in the care of people suffering from schizophrenia is the need to organize services that lead seamlessly from early identification to regular treatment and rehabilitation.

The goals of care are to identify the illness as early as possible, treat the symptoms, pro-vide skills to patients and their families, maintain the improvement over a period of time, prevent relapses and reintegrate the ill persons in the community so that they can lead a normal life. There is conclusive evidence to show that treatment decreases the duration of illness and chronicity, along with the control of relapses.

Two groups of drugs are currently used to treat schizophrenia: standard antipsychotics (previously referred to as neuroleptics), and novel antipsychotics (also referred to as second generation or "atypical" antipsychotics). The first standard antipsychotic medicines were introduced 50 years ago and have proved useful in reducing, and sometimes eliminating, such symptoms of schizophrenia as thought disorder, hallucinations and delusions. They can also decrease associated symptoms such as agitation, impulsiveness and aggressiveness. This can be achieved in a matter of days or weeks in about 70% of patients. If taken consistently, these medicines can also reduce the risk of relapses by half. Currently available drugs appear to be less effective in reducing such symptoms as apathy, social withdrawal and poverty of ideas. First generation drugs are inexpensive and do not cost more than US$ 5 per month of treatment in developing countries. Some of them can be given in long-acting injections at 1­4 week intervals.

Antipsychotic drugs can help sufferers to benefit from psychosocial forms of treatment. The latest antipsychotic drugs are less likely to induce some side effects while improving certain symptoms. There is no clear evidence that the newer antipsychotic medications differ appreciably from the older drugs in their effectiveness, although there are differences in their most common side-effects.

The average duration of treatment is 3­6 months. Maintenance treatment continues for at least one year after the first episode of illness, for 2­5 years after the second episode, and for longer periods in patients with multiple episodes. In developing countries, response to treatment is more positive, medicine dosages are lower, and duration of treatment is shorter. In the total care of the patients, the support of the families is important. Some studies have shown that a combination of regular medication, family education and support can reduce relapses from 50% to less than 10% (see Table 3.3) (Leff & Gamble 1995; Dixon et al. 2000; Pharaoh et al. 2000).

Table 3.3 Effectiveness of interventions for schizophrenia

Psychosocial rehabilitation for people with schizophrenia encompasses a variety of measures that range from improving social competence and social support networking to family support. Central to this are consumer empowerment and the reduction of stigma and discrimination, through the enlightenment of public opinion and by introducing pertinent legislation. Respect for human rights is a guiding principle of this strategy.

Currently, few patients with schizophrenia need long-term hospitalization; when they do, the average duration of stay is only 2­4 weeks, compared with a period of years before the introduction of modern therapies. Rehabilitation in day care centres, sheltered workshops and halfway homes improves recovery for patients with long-standing illnesses or residual disabilities of slowness, lack of motivation and social withdrawal.

Epilepsy

Effective actions for the prevention of epilepsy are adequate prenatal and postnatal care, safe delivery, control of fever in children, control of parasitic and infectious diseases, and prevention of brain injury (for example, control of blood pressure and the use of safety belts and helmets).

The goals of therapy are to control fits by preventing them for at least two years, and to reintegrate people with epilepsy into educational and community life. Early diagnosis and the steady provision of maintenance drugs are fundamental for a positive outcome.

Epilepsy is almost always treated using anti-epileptic drugs (AEDs). Recent studies in both developed and developing countries have shown that up to 70% of newly diagnosed cases of children and adults with epilepsy can be successfully treated with AEDs, so that the people concerned will be seizure free, provided they take their medicines regularly (see Table 3.4). After 2­5 years of such successful treatment (cessation of epileptic fits), the treatment can be withdrawn in 60-70% of cases. The remainder have to continue on medication for the rest of their lives, but providing they take the medication regularly, many are likely to remain free of seizures, while in others the frequency or severity of seizures can be much reduced. For some patients with intractable epilepsy, neurosurgical treatment may be successful. Psychological and social support are also valuable (ILAE/IBE/WHO 2000).

Table 3.4 Effectiveness of interventions for epilepsy

Phenobarbitone has become the front-line anti-epileptic drug in developing countries, perhaps because other drugs cost 5­20 times as much. A study in rural India found that 65% of those who received phenobarbitone were successfully treated, with the same proportion responding to phenytoin; adverse events were similar in both groups (Mani et al. 2001). A study in Indonesia concluded that, despite some disadvantages, phenobarbitone should still be used as the first-line drug in epilepsy treatment in developing countries. Studies in Ecuador and Kenya compared phenobarbitone to carbamazepine and found that there were no significant differences between them in terms of efficacy and safety (Scott et al. 2001). In most countries, the cost of treatment with phenobarbitone can be as low as US$ 5 per patient per year.

Alzheimer's disease

Primary prevention of Alzheimer's disease is not possible at present. The goals of care are to maintain the functioning of the individual; reduce disability due to lost mental functions; reorganize routines so as to maximize use of the retained functions; minimize disturbing functions, such as psychotic symptoms (for example, suspiciousness), agitation and depression; and provide support to families.

A central goal in research into treatment for Alzheimer's disease is the identification of agents that defer the onset, slow the progression, or improve the symptoms of the disease. Cholinergic receptor agonists (AChEs) have generally been beneficial in ameliorating global cognitive dysfunction and are most effective in improving attention. Amelioration of learning and memory impairments, the most prominent cognitive deficits in Alzheimer's disease, has been found less consistently. Treatment with these AChE inhibitors also appears to benefit non-cognitive symptoms in Alzheimer's disease, such as delusions and behavioural symptoms.

Treatment of depression in Alzheimer's disease patients has the potential to improve functional ability. Of the behavioural symptoms experienced by patients with Alzheimer's disease, depression and anxiety occur most frequently during the early stages, with psychotic symptoms and aggressive behaviour occurring later. In view of the increasing numbers of elderly people, managing their well-being is a challenge for the future (Box 3.7).

Box 3.7 Caring for tomorrow's grandparents

Psychosocial interventions are extremely important in Alzheimer's disease, both for patients and family caregivers, who themselves are at risk of depression, anxiety and somatic problems. These include psycho-education, support, cognitive behavioural techniques, self-help, and respite care. One psychosocial intervention ­ individual and family counselling plus support group participation ­ aimed at carer spouses has been shown in a study to delay institutionalization of patients with dementia by almost a year (Mittleman et al. 1996).

Mental retardation

Because of the severity of mental retardation, and the heavy burden that it imposes on affected individuals, their families and the health services, prevention is extremely important. In view of the variety of different etiologies of mental retardation, preventive action must be targeted to specific causative factors. Examples include the iodization of water or salt to prevent iodine-deficiency mental retardation (cretinism) (Mubbashar 1999), abstinence from alcohol by pregnant women to avoid fetal alcohol syndrome, dietary control to prevent mental retardation in people with phenylketonuria, genetic counselling to prevent certain forms of mental retardation (such as Down's syndrome), adequate prenatal and postnatal care, and environmental control to prevent mental retardation due to intoxication from heavy metals, such as lead.

The goals of treatment are early recognition and optimal utilization of the intellectual capacities of the individual by training, behaviour modification, family education and support, vocational training and opportunities for work in protected settings.

Early intervention comprises planned efforts to promote development through a series of manipulations of environmental or experimental factors, and is initiated during the first five years of life. The objectives are to accelerate the rate of acquisition and development of new behaviours and skills, to enhance independent functioning, and to minimize the impact of impairment. Typically, a child is given sensory motor training within an infant stimulation programme, along with supportive psychosocial interventions.

The training of parents to act as trainers in the skills of daily living has become central to the care of persons with mental retardation, especially in developing countries. This means that parents have to be aware of learning principles and to be educated in behaviour modification and vocational training techniques. In addition, parents can support each other through self-help groups.

The majority of children with mental retardation experience difficulties in regular school curricula. They need additional help, and some need to attend special schools where the emphasis is on daily activities such as feeding, dressing, social skills, and the concept of numbers and letters. Behaviour modification techniques play an important role in developing many of these skills, as well as in increasing desirable behaviours while reducing undesirable behaviours.

Vocational training in sheltered settings and using behavioural skills has led to a large number of people with mental retardation leading active lives.

Hyperkinetic disorders

The precise etiology of the hyperkinetic disorders ­ hyperactivity in children, often with involuntary muscular spasms ­ is unknown, thus primary prevention is currently not possible. It is possible, however, to prevent the onset of symptoms that are often misdiagnosed as hyperkinetic disorders through preventive interventions with families and schools.

The treatment of hyperkinetic disorders cannot be considered without first addressing the adequacy and appropriateness of diagnosis. All too often, hyperkinetic disorders are diagnosed even though the patient does not meet the objective diagnostic criteria. Failure to make an appropriate diagnosis leads to difficulties in establishing the patient's response to therapeutic interventions. Hyperkinetic symptoms can be seen in a range of disorders for which there are specific treatments that are more appropriate than the treatment for hyperkinetic disorder. For instance, some children and adolescents with symptoms of hyperkinetic disorder are suffering from psychosis, or may be manifesting obsessive­compulsive disorder. Others may have specific learning disorders. Still others may be within the normal range of behaviour but are seen in environments with a reduced tolerance for the behaviours that are reported. Some children manifest hyperkinetic symptoms as a response to acute stress in the school or home. A thorough diagnostic process is thus essential, for which specialist help is often needed.

While treatment with amphetamine-like stimulants is now common, there is support for the use of behavioural therapy and environmental manipulation to reduce hyperkinetic symptoms. Therapies should be evaluated for their appropriateness as first-line treatments, especially where the diagnosis of hyperkinetic disorder is subject to question. In the absence of universally accepted guidelines for the use of psychostimulants in children and adolescents, it is important to start with low dosages and only gradually increase to an appropriate dose of psychostimulants, under continuous observation. Sustained-action medications are now available, but the same caution regarding appropriate dosage applies. Tricyclic antidepressants and other medications have been reported to be of use, but are not currently seen as first-line medications.

The diagnosis of hyperkinetic disorder is often not made until children reach school age, when they may benefit from an increase in structure in the school environment, or more individualized instruction. In the home environment, parental support and the amelioration of unrealistic expectations or conflicts can facilitate a reduction in hyperkinetic symptoms. Once thought to be a disorder that children outgrew, it is now known that, for some people, hyperkinetic disorder persists into adulthood. Recognition of this by the patient can help him (rarely her) to find life situations that are better adapted to limiting the debilitating effects of the untreated disorder.

Suicide prevention

There is compelling evidence indicating that adequate prevention and treatment of some mental and behavioural disorders can reduce suicide rates, whether such interventions are directed towards individuals, families, schools or other sections of the general community (Box 3.8). The early recognition and treatment of depression, alcohol dependence and schizophrenia are important strategies in the primary prevention of suicide. Educational programmes to train practitioners and primary care personnel in the diagnosis and treatment of depressed patients are particularly important. In one study of such a programme on the island of Gotland, Sweden (Rutz et al. 1995), the suicide rate, particularly of women, dropped significantly in the year after an educational programme for general practitioners was introduced, but increased once the programme was discontinued.

Box 3.8 Two national approaches to suicide prevention

The ingestion of toxic substances, such as pesticides, herbicides or medication, is the preferred method for committing suicide in many places, particularly in rural areas of developing countries. For example, in Western Samoa in 1982, the ingestion of paraquat, a herbicide, had become the predominant method of suicide. Reducing the availability of paraquat to the general population achieved significant reductions in total suicide, without a corresponding increase in suicide by other methods (Bowles 1995). Similar successful examples relate to the control of other toxic substances and the detoxification of domestic gas and of car exhausts. In many places, the lack of easily accessible emergency care makes the ingestion of toxic substances ­ which in most industrialized countries would be a suicide attempt ­ another fatality.

In the Russian Federation, as well as in other neighbouring countries, alcohol consumption has increased precipitously in recent years, and has been linked to an increase in rates of suicide and alcohol poisoning (Vroublevsky & Harwin 1998), and to a decline in male life expectancy (Notzon et al. 1998; Leon & Shkolnikov 1998).

Several studies have shown an association between the possession of handguns at home and suicide rates (Kellerman et al. 1992; Lester & Murrell 1980). Legislation restricting access to handguns may have a beneficial effect. This is suggested by studies in the United States, where the restriction of the selling and purchasing of handguns was associated with lower firearm suicide rates. States with the strictest handgun control laws had the lowest firearm suicide rates, and there was no switching to an alternative method of suicide (Lester 1995).

As well as interventions that involve restricting access to common methods of suicide, school-based interventions involving crisis management, enhancement of self-esteem, and the development of coping skills and healthy decision-making have been shown to lower the risk of suicide among young people (Mishara & Ystgaard 2000).

The media can assist in prevention by limiting graphic and unnecessary depictions of suicide and by deglamorizing news reports of suicides. In a number of countries, a decrease in suicide rates coincided with the media's consent to minimize the reporting of suicides and to follow proposed guidelines. Glamorizing suicide may lead to imitation.

Chapter 3: Solving Mental health problems: 1,2,3,4