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More than half a billion people worldwide suffer from neuropsychiatric disorders. The vast majority of these individuals live in Africa, Asia and Latin America. Most of these persons lack access to appropriate treatment or care, and many are subject to stigma, discrimination and marginalisation. This adds up to a serious psychological, physical, social and economic burden. Neuropsychiatric disorders can lead to chronic disability and therefore represent an important health issue across the globe.[1] Although there are effective and inexpensive treatments for many neuropsychiatric illnesses, most patients in low- and middle-income countries (LMICs) are deprived of treatment and psychosocial rehabilitation. Ultimately, the burden of mental illness, in terms of suffering and monetary costs, is high for patients and their families.[2]

Psychosocial rehabilitation

Psychosocial rehabilitation (PSR) is a process of restoring well-being, and social and occupational functioning affected by mental or emotional disorders. Although PSR was long neglected as an intervention, it has gained wider recognition in the last decades. The establishment of the World Association for Psychosocial Rehabilitation (WAPR) in 1986, with the mission to strengthen rehabilitation worldwide, marked an important milestone. Besides mental health professionals, patients, family members and voluntary organisations are also involved in WAPR activities (www.wapr.org). Over the years, PSR has made its way from institutions into communities, taking account of specific regional, historic, economic, social and cultural factors. Our discussion of rehabilitation in this article will refer primarily to patients with schizophrenia, since this group forms more than half of patients with severe mental illness undergoing long-term hospital care.

Psychosocial rehabilitation in LMICs

In most LMICs, mental illness carries a stigma that is just as debilitating as in developed countries. The labelling of an individual as ‘mentally ill’ is associated with important social consequences within the community and among relatives, friends, neighbours and employers, and this hinders the process of recovery. Because of non-existent or very rudimentary health insurance and social welfare, individuals with mental illness in LMICs are often economically dependent on their families. When doing PSR, one has to be aware of the local system and other conditions, and not necessarily assume support from intact extended families. In many cases, growing urbanisation in developing countries means that the extended family system is fast disappearing.[3] For at least 80% of rural inhabitants in LMICS, traditional healers are the main source of help for people with mental disorders.[2] Based on our own clinical experience and observations in LMICS, patients with severe neuropsychiatric disorders do not improve by resorting only to traditional treatment options; they usually need neuroleptic, antidepressant or antiepileptic medication.

Country-specific examples

The first attempt to establish community-oriented treatment and rehabilitation in Africa was in 1954 by Thomas Adeoye Lambo,[4] who developed the Aro Village system in Nigeria. Briefly, Lambo’s aim was to integrate the traditional village community with traditional healers and modern psychiatry, by offering patients modern psychiatric care locally, within a familiar social environment. Lambo stressed that the strength of this approach was grounded in the resources available in the village community such as flexibility and tolerance. An important element of this approach was recognition of the therapeutic value of the traditional cults, dances and rituals that played (and to a large extent still play) such a large part in the lives of African people. In rural Ethiopia, only 10% of people with schizophrenia have access to biomedical care, a treatment gap largely due to an inadequate number of mental health specialists.[5] The Gefersa Mental Health Rehabilitation Center near Addis Ababa is the only Ethiopian facility that exclusively provides PSR services for individuals with severe mental disorders. This facility is largely inaccessible to most patients who live hundreds of miles away in rural areas, making the establishment of similar facilities for severely affected patients living in different regions essential through large financial investment for infrastructure development and trained manpower. The promising results of a pilot study of a trained lay workers’ community-based rehabilitation intervention for people with schizophrenia present a realistic model of PSR for most patients in LMICS.[6] It is important to note that such models are feasible in LMICs as they do not require expensive infrastructures and can be delivered by trained lay workers.

A successful community-oriented rehabilitation programme for persons with chronic schizophrenia was developed in Malaysia in 1978. It prepares individuals with chronic schizophrenia for gainful employment in the community: in a follow-up analysis seventeen years later, 56% of patients had spent five or more years making their own living in their original community settings.[7]

In India there is a large PSR gap largely due to the shortage of specialist mental health care. Thanks to the involvement of NGOs, there are some outstanding examples of PSR in India such as Jyothi Nivas in Kerala. Besides good PSR, it provides innovative anti-stigma campaigns for the surrounding communities. Another successful PSR programme is Chittadhama, a rehabilitation and residential centre for homeless persons with mental illness, in the state of Karnataka.[8] Many of the issues raised above are not confined to LMICs and may, to some extent, apply to high-income countries as well. In 2017, Drake wrote, ‘The central problem, however, is lack of access to high-quality services, even in the wealthiest countries. In the USA, for example, fewer than 5% of people with serious psychiatric disorders can access evidence-based psychiatric rehabilitation.'[9] Bond observed that ‘while the USA has led the way in developing, researching and disseminating evidence-based psychiatric rehabilitation services around the world, the quality of mental health treatment and rehabilitation services in the USA lags behind services in many other industrialised nations.'[10] Thus, we need to be aware that research itself does not necessarily guarantee implementation of good PSR services. It requires appropriate policies and political will to provide evidence-based PSR to those who need it. In fact, there are many creative PSR programmes throughout the globe, but there is a scarcity of data to support their efficacy; this implies that there is scope for research on the short- and long-term outcomes of such PSR programmes.

Innovative approaches such as ‘supported employment’ for people with severe mental illness are available in Europe. Supported employment is a form of PSR wherein individuals recovered from mental illness are assisted to obtain and maintain a job. Even in Germany, where the unemployment rate is low, the chances of a person who suffers from a severe psychiatric disorder finding suitable employment are slim. This prompted the founding of a social firm, the Irseer Kreis Versand, in 1989 to provide protected job opportunities for persons recovered from mental illness. This mail order company started with a staff of seven, five of whom had recovered from a psychiatric disorder.[11] Today (2020), the company’s success can be measured by the fact that its workforce comprises 66 persons, fifty of whom are individuals recovered from a psychiatric disorder.

Conclusion

Psychosocial rehabilitation aiming at reintegrating persons with chronic mental illness into the community, whether in low-, middle- or high-income countries, is an essential component of mental health care. Any efforts towards improvement of PSR services need to address stigma and discrimination against psychiatric patients since these will influence the implementation, reception and ultimate success of PSR programmes.

Based on the authors’ personal experience, the following conditions must be met for the success of psychosocial rehabilitation in any setting:

  1. A positive attitude towards the chronic patient
  2. Hope that a positive outcome can be achieved
  3. A rehabilitative infrastructure
  4. Rehabilitation that match the wishes and abilities of the individual patient
  5. Acceptance that psychopathology per se does not hinder rehabilitation
  6. Providing neuroleptic medication where necessary and bearing in mind that this in itself in not sufficient for patients’ recovery
  7. Recruitment of an interested and motivated staff
  8. Due consideration of the context including local culture, economy, health care system
  9. Patience and perseverance
  10. Continued efforts to demonstrate to administrators, politicians, and even psychiatrists that psychosocial rehabilitation works effectively to the advantage of patients, their families and community in general

Sadly, the current Covid-19 pandemic adds major challenges for the proper care of people with chronic diseases, including neuropsychiatric illnesses.

Note: Since none of the authors are native English speakers, they are grateful to Osborne Almeida for his suggestions and edits.

References

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  11. Krahl W, Müller W, Stöhr K. The role of social firms in psychosocial rehabilitation: Irseer Kreis Versand: a successful example. VIIth World Congress World Association for Psychosocial Rehabilitation Paris, 7-10 May 2000