Main content

Across the globe, people with psychotic disorders remain at high risk of being untreated, neglected and stigmatised. Worldwide, around 21 million people are affected with schizophrenia, the most severe psychotic disorder.[1] The illness has an average global lifetime prevalence of 0.7%.[2] The global burden of schizophrenia alone accounts for 1.7% of all years lived with disabilities.[1] People with a diagnosis of schizophrenia live on average fifteen years less than the background population.[3] The highest burden is found in low- and middle-income countries (LMICs),[1] where less than a third of people with schizophrenia can access mental health care and their life expectancy is shortest.[4] The course of psychotic disorders is strongly determined by the social, cultural and geographical context. Due to non-medical explanations of mental health problems such as supernatural causes and lack of resources – including limited number of psychiatrists, poor infrastructure, and poor accessibility to the formal health care system – many people with a psychotic disorder in LMICS remain undetected and untreated. It is a key challenge to improve the lives of people with psychotic disorders in low-resource settings and improve adverse social, political and economic conditions. One way to move forward may be to establish collaboration between formal mental health care and the traditional systems of medicine that are in place in most countries.

Collaborative care

Over the past years, the collaboration in mental health between traditional health practitioners (THPs) and the formal health care system has been given attention.[5] Many patients with severe mental health problems, such as psychosis, receive care from THPs. The majority of patients with schizophrenia perceive traditional medicine treatment to be effective for their condition, and high adherence rates to traditional methods have been reported.[6] Recently, a randomized controlled trial was published by Gureje et al. (2020) showing the effectiveness and cost-effectiveness of collaboration between traditional and faith healers and primary health care providers in treating patients with psychotic disorders in Ghana and Nigeria. In a collaborative care model, skills and advantages of THPs are fully acknowledged, and cooperation between traditional health practitioners and the formal health care system exists. Prior to the study, both the primary health care providers and THPs were trained in psychosis, the collaborative care model, and roles and responsibilities. Primary health care providers were involved in medication prescription and psychoeducation, while THPs applied traditional practices such as herbs or rituals. People who received the intervention consisting of collaborative care had better health outcomes than those who received care as usual; they reported less disabilities, a better course of illness, and increased capabilities to adjust to work.[7]

We describe two of our own experiences exploring the role of traditional health practitioners in care for people with psychotic disorders.

Experiences in Suriname

In Suriname, we explored how patients and their family members seek health care and the views and practices of THPs with regard to psychosis. In our first study, we found that the majority of patients with a psychotic disorder and their family members consult a THP, mainly as first line care.[8; unpublished data] Most of the patients and family members reported a supernatural explanation for the cause of psychosis and mentioned it was caused by a spell or the devil. The supernatural causes indicated varied widely and were aligned with patients’ culture or religion.[8; unpublished data]

Suriname has a highly centralised health care sector with one psychiatric hospital located in the capital, Paramaribo, and one smaller outpatient clinic in the district Nickerie. THPs in the country include herbalists, Winti healers, Javanese healers, and religious healers such as pandits or imams; they have various ethnocultural backgrounds.[9] As healers, they take on a special communal role as persons of trust and respect – a crucial feature for the detection and follow-up of psychotic episodes. THPs align with the cultural and spiritual ideas people have on the origin and treatment of psychosis, are often located in nearby settings, and are easy to access and consult. By visiting traditional healers as first line care, patients may experience a delay in seeking health care in the formal health care system.[8; unpublished data]

We also explored the potential of strengthening collaborative efforts between formal mental health care and THPs by interviewing traditional health practitioners.[10] Some of the traditional healers said they had a positive attitude towards collaboration, while some were sceptical. The reasons for being sceptical were mainly related to certain thoughts about the biomedical management, different attitudes and explanatory models on psychosis, and the lack of acknowledgement of THPs by medical and governmental bodies in Suriname. Interestingly, some form of referral system to general practitioners existed, although not formalised. This feedback as given by THPs should be transferred to the formal health care system, providing a perspective on traditional practices, and a possible basis for collaboration. In designing our qualitative study and conducting these interviews, we discovered that health care professionals in the formal system also need to become acquainted with traditional practices and to overcome certain barriers towards the non-formal system.

Experiences in South Africa

In rural South Africa, traditional health practitioners and faith healers provide a major part of first line care for health problems. In a resource-limited setting in KwaZulu-Natal, we started building a collaboration with traditional healers. The THPs were educated with case vignettes to identify and refer patients with psychosis to our study team investigating the incidence, early course, and treatment pathways of psychotic disorders in this context.[11] The collaboration was optimised by applying a culturally sensitive approach with support from local traditional as well as professional authorities.

As a first step, meetings were organised with tribal counsellors, followed by a presentation of the study to the senior traditional chief of the region and the traditional council to which THPs are affiliated. As they saw the added value of collaboration for THPs and their communities, a formal memorandum of understanding was signed and contact details of THPs provided. A Community Research Advisory Board was established, providing feedback research procedures in relation to the social and cultural values and beliefs of study participants and the wider community. Finally, semi-structured interviews and multiple focus group meetings with THPs were held. Symptoms of psychosis, help-seeking behaviours of (caregivers of) individuals with symptoms, experience regarding referrals and subsequent treatment outcomes, personal beliefs on causes of mental illness, and treatment practices were extensively discussed. The collaborative approach demanded sufficient time to build mutual trust and acknowledgement of each other’s skills and practices. Whereas the worldview of THPs and their recognition of causes of mental health problems (e.g., displeasure of ancestors) differ from a biomedical psychiatric framework, it was possible to discover common ground during focus group meetings and interviews, which allowed for developing a collaborative project of screening and referral by THPs of individuals with suspected psychosis.

Conclusion

Since 1991, the World Health Organization has been advocating for proper use of traditional medicine to achieve health for all. More recently they stated that traditional and complementary medicine can contribute significantly to achieve universal health coverage in global mental health.[12, 13] Studies like Gureje et al. (2020) and our own initiatives can contribute to this movement. Our experiences in Suriname and South Africa, which have highly decentralised health care systems, make it clear that extra attention is needed to overcome distance between the THPs and formal health care system. The role of THPs in mental health care cannot be ignored, and lessons learned from previous as well as our own studies deserve attention in designing collaborative care models that align with local infrastructure and health care systems.

References

  1. Charlson FJ, Ferrari AJ, Santomauro DF, et al. Global epidemiology and burden of schizophrenia: findings from the Global Burden of Disease Study 2016. Schizoph Bull. 2018 Oct 17:44(6):1195-1203. DOI: 10.1093/schbul/sby058
  2. McGrath J, Saha S, Chant D, et al. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30, 67-76. DOI: 10.1093/epirev/mxnoor
  3. Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry. 2017 Apr;4(4):295-301. DOI:10.1016/ $2215-0366(17)30078-0 [Published correction]
  4. Lora A, Kohn R, Levav I, et al. Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bull World Health Organ. 2012 Jan 1;90(1):47-54B. DOI: 10.2471/BLT.11.089284
  5. World Health Organization. WHO traditional medicine strategy: 2014-2023 [Internet]. Geneva: World Health Organization; 2013. 78 p. Available from: https://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/
  6. Ojagbemi A, Gureje, O. The potential role of traditional medicine in the management of schizophrenia. Curr Psychiatry Rep. 2020 Oct 22;22(12):71. DOI: 10.1007/s11920-020-01196-7
  7. Gureje O, Appiah-Poku J, Bello T, et al. Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial. Lancet. 2020 Aug 29;396(10251):612-22. DOI:10.1016/S0140-6736(20)30634-6
  8. Van Beek A, De Zeeuw J, De Leeuw M, et al. Duration of untreated psychosis and pathways to care in Suriname: a qualitative study among patients, relatives and general practitioners. Unpublished
  9. Van der Meulen R. De schaduw van de winti. University of Amsterdam; 2008.
  10. Osmers A, Patsea M, Djordevic. An explorative study on traditional and complementary medicine practitioners’ profile and their views and practices on psychosis in Suriname. Bachelorproject 2020 under supervision of Janine de Zeeuw, Randhir Nanda, Wim Veling. Unpublished
  11. Veling W, Burns JK, Makhathini EM, et al. Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments. Soc Psychiatry Psychiatr Epidemiol. 2019 Mar;54(3):303-12. DOI: 10.1007/s00127-018-1623-x
  12. World Health Assembly. Traditional medicine and modern health care: progress report by the Director-General. Geneva: World Health Organization; 1991. 44 p. Available from: https://apps.who.int/iris/handle/10665/173745
  13. World Health Organization. WHO global report on traditional and complementary medicine. Geneva: World Health Organization; 2019. 228 p. Available from: https://www.who.int/traditional-complementary-integrative-medicine WhoGlobalReportOnTraditionalAndComplementary Medicine2019.pdf