Sandra Zaeh writes on the the mental health challenges in Sierra Leone. 

By any Western account, the mental health system in Sierra Leone is struggling.

With one trained government psychiatrist, little funding for psychiatric drugs and mental health facilities, and few opportunities for mental health care outside the capital of Freetown, the majority of mentally ill patients are beyond the reach of biomedical care for mental disorders.

To fill the void, Sierra Leoneans turn to alternatives like traditional healing and spiritual practices to address their mental health needs, options that even Western-trained experts consider crucial to maintaining the country’s mental health. And yet, the balance is tenuous - and, without an infusion of financial and human resources, may not be sustainable. (more…)

Joshua Schulman-Marcus reports on the anthropological and psychological impact of chronic diseases in developing countries.

A Personal Reflection

Over the past year, I have written several articles for the Lancet Student on the growing prevalence of chronic noncommunicable diseases (CNDs) in developing countries. Major studies have indicated that diseases and risk factors such as hypertension, diabetes, tobacco use, and asthma are increasing in low- and middle-income countries in all regions of the world (1,2). Recognizing these trends, the World Health Organization (WHO) has recently begun to address this new global health priority (3,4). Researchers and advocates have pointed out that more investment in prevention, screening, and treatment will be needed to avert the resulting unnecessary disability and mortality (5,6). These reports indicate that CNDs will be a major item on the global health agenda for the duration of our careers.

Most of the research, including the recent series published by The Lancet (7), has been predicated on epidemiology, economic impact, health systems, and potential interventions. Less has been said about the non-technical implications of a transition to chronic disease in the developing world. This is unfortunate as “health” extends far beyond the biomedical realm; it is intertwined with sociological structures and culture. A shift from acute infections and traumas to chronic, often asymptomatic ailments, thus presents a paradigm shift in the notion of what it means to be a healthy person. This is a serious adjustment that deserves careful consideration. For how can we expect people to take medicines or alter lifestyles if they don’t believe that they are ill?

I personally saw the anthropological and cultural challenges of the epidemiologic transition when I worked with the Ethiopian Israeli community in 2005. Arriving in urban Israel from rural Ethiopia in the 1980s, the immigrants had a conception of health that largely revolved around the acute infections and malnutrition endemic to poor countries. Within ten years, though, the prevalence of Type 2 diabetes rose from 0.5% to 17% in some cities. Similarly, asthma, blood cholesterol levels, blood pressure, and red meat consumption soared.

The Ethiopian immigrants had no word in their common language for diabetes. I spoke with a man with longstanding diabetes who had never heard of the pancreas. He didn’t believe he was sick. As the deleterious elevation of blood glucose is often asymptomatic early in the disease course, it was exceedingly difficult to convince patients to adhere to therapy. Even worse, the language used to explain diabetes can be very confusing, as the notion of “high sugar” led some patients to believe that sugary foods were the cause of the condition. Miscommunication between the Israeli primary care providers and the Ethiopian patients, compounded by poverty and power disparities, led to distrust and very poor quality of care. And this was in a country with a well-financed health system designed to address chronic noncommunicable diseases.

Indeed, the entire notion of chronic disease resulted in confusion and frustration for some Ethiopian immigrants. “Why can’t the doctor cure me? Why doesn’t he give me a shot?” asked one. “He must just be a bad doctor, or maybe he doesn’t treat me because I am Ethiopian.” I heard similar confusion about the concept of lifelong drug therapy. One mother, for example, refused to give her son an asthma inhaler, lest he become “addicted” to it like tobacco. Another, however, wanted constant steroids to treat his mild asthma, because “they make me feel good.”

My discussions with the Ethiopian immigrants and Israeli health workers also hinted at the complexity of advocating lifestyle changes to prevent chronic disease. Lifestyle is the product of thousands of choices, many of which are heavily influenced by economics, sociocultural norms, and status. People in developing countries may aspire to eat Western foods high in saturated fats and may choose to smoke American cigarettes to indicate their wealth. Being overweight or obese, even having some diabetes, may be lauded as a sign of success. These attitudes can be deeply ingrained, and modifying them will require interventions informed by a nuanced understanding of local culture and health beliefs. If chronic diseases are not presented in terms that make them believable, most people will be hesitant to significantly alter their lifestyles in order to “prevent” an abstraction.

Over the past few years, attention has been increasingly paid to the coming epidemic of chronic noncommunicable diseases in the developing world. These diseases can lead to devastating consequences, both physically and economically. It has thus been recognized that many disciplines will need to be rallied in order to adapt health systems for chronic care, re-train workers, ensure access to medicines, and design cities amenable to physical activity (2-7). Yet the barriers to the effective prevention and care of these diseases cannot be lowered through the technical expertise of biomedicine or policy alone. Rather, my experiences have taught me that it will require a more holistic understanding of how individuals adapt to a revolution in the conception of health, illness, and healing. To do so, I think we first will need to learn how to be better and more patient listeners.

Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York, USA

jschumar@gmail.com

(1) Lopez AD, Mathers CD, Ezzati M et al. Global and regional burden of risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57

(2) Jamison D, Breman J, Measham A, Alleyne G, Claeson M, Evans DB et al. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press and the World Bank, 2006.

(3) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002

(4) Preventing chronic diseases: a vital investment. Geneva: WHO, 2005

(5) Leeder S, Raymond S, Greenberg H, Liu H, and Esson K. A Race against Time: The Challenge of Cardiovascular Disease in Developing Countries. New York: Trustees of Columbia University, 2004.

(6) Yach D, Hawkes C, Gould CL, Hofman K. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004; 291:2616-2622.

(7) Horton R. Chronic disease: the case for urgent global action. Lancet 2007; 370:1881-82.

April 7th marked the start of Parkinson’s disease Awareness Week.  Srimathy Vijayan provides an overview of the disease and information on developments in treatment during the past 50 years. 

The week commencing April 7th marked Parkinson’s disease (PD) Awareness Week. It has been 191 years since the publication of ‘An essay on the Shaking palsy’ by Dr James Parkinson, the London doctor who first established the condition. Since, our knowledge has progressed in all aspects of the condition. Predominantly a disease of the elderly, PD is characterized classically by rest tremor, slowness in initiating movements, and rigidity. The pathogenesis involves a selective and progressive loss of the nigrostriatal dopaminergic neurons located in the brain. At present all medications used to treat PD merely provide symptomatic relief. Consequently, PD is a chronic, progressive neurodegenerative movement disorder.  

The WHO estimates PD to have an incidence rate of 4.5-19 per 100 000 population per year (1). This is a relatively large range most likely attributed to the different clinical methodologies used to evaluate and diagnose PD in various epidemiological studies.  Considering this, it is likely that centres fluctuate between over and under diagnosing cases of PD depending on diagnostic experiences/skill. Another logical reason is that studies are likely to have mixed age distributions within their population cohorts; generally, higher rates are found in more elderly populations. Pezzolia suggested rates ranging from 0.6 for those aged 65–69 years and 3.0 in those aged 80–84 years (2). Nonetheless, it is estimated that 8% of cases occur under the age of 40 years (3). Thus, it has been suggested that age-adjusted rates provide a more realistic picture; such rates give a more restricted range of 9.7 to 13.8 per 100 000 population per year (1). 

Given that PD is a chronic condition, it is unsurprising prevalence data are higher than incidence. Prevalence estimates vary from 18 per 100 000 persons in a population survey in Shanghai, China, to 328 per 100 000 in a door-to-door survey of the Parsi community in Bombay, India (1). Such geographic disparity in prevalence may suggest that environmental and genetic factors both play an important role in the development of PD. Certainly a multifactorial aetiology seems most plausible, and prominent genetic links with PD have now been established (4). Likewise, environmental factors are continuously being evaluated, most recently, pesticides (5). Age-adjusted prevalence of 72–258.8 per 100 000 population have been documented (1). 

A particularly neglected area regarding epidemiological studies of PD are the rates in under-developed countries such as Africa. This might be because PD as a medical condition is undermined in comparison to the other significant health problems in these areas such as HIV, tuberculosis and malaria. In addition, the rates of PD in this part of the world are significantly decreased in comparison to wealthier nations, perhaps due to shorter life expectancy and decreased potential for PD manifestation.  As a result, the level of interest regarding PD research is decreased in these countries.  As such there is paucity of data, thus at present, a drive to research in this area - Dotchin et al. are currently door-to-door prevalence study in Tanzania (6).

Most noteworthy is the implication of an increasing ageing population. As a consequence, a greater proportion of patients are likely to develop PD in the future; one study estimated the number of people with PD over the age 50 will double  worldwide over the next 25 years (7). Therefore, it is important for healthcare providers to acknowledge the imminent increasing burden of PD and plan accordingly.    

The mainstay pharmacological treatment for PD is Levodopa. Since its development in the 1960s to, in effect, replace the diminishing levels of dopamine, the quality of life for patients has improved significantly. Although Levodopa has been and considered the first-line drug treatment of choice, some 50 years later, a number of other pharmaceutical agents have been developed. These, both individually or in conjunction with Levodopa, provide various other treatment regimens, helping to overcome the well known consequences of long term Levodopa treatment (levodopa induced dyskinesias) and to also target the increasingly recognized non-motor symptoms of the condition. Some important classes of these newer drugs are dopamine agonists, COMT inhibitors, MAO-B inhibitors, and glutamate antagonists. Given the extensive list of pharmaceutical agents and the lack of robust clinical evidence present to suggest best treatment strategies for PD, there remains no agreed upon guidelines. Instead, individual physicians have their own preferred regimen, based on personal experiences. This poses two additional problems.  First, treatments are likely to be expensive as physicians may have to experiment with medications in order to find the most beneficial drug for their patient. Secondly, the administration of various medicinal regimens may cause increased and unnecessary side-effects, which in turn will be addressed by prescribing more medication or requiring surgery.  Taken together, this affects the quality of life (QOL) of these patients and poses additional healthcare costs. As such, there remain many uncertainties concerning the most effective (in terms of efficacy and cost) treatment regime for PD and we await the outcome of many on-going clinical trials (8).  

Although Levodopa is relatively cheap, newer pharmaceutical agents are considerably dearer. According to the British National Formulary (BNF) 2008; a pack of Madopar (Levodopa) starts at net price £6.20 for 100 tablet pack. On the other hand, a pack of Cabergoline (a popular dopamine agonist used in conjunction with Levodopa) is net price £53.20 for 20-tablet pack at the minimal dose. Thus, as one may appreciate, drug treatments for PD are expensive. In the UK, the direct cost of treatment to the NHS has been estimated to be approximately £2298 per patient per year (9). In a study conducted in Germany, the authors estimated average parkinsonian drug costs for a 6-month period of 1520 euro +/-1250 euro (18). The costs are likely to reflect the severity of the disease and in particular the presence of motor fluctuations for which a multiple cocktail of drugs are often needed. A group of researchers from USA attempted to evaluate this logic (11), and showed that PD subjects in their first year of diagnosis accounted for $581 cost. But 5 to 10 years later, the same subjects exhibited significantly higher costs at $1146. Thus for physicians treating PD, it is clear they must calculate the initial short term benefits of drugs with that of the long term consequences of such treatments (dyskinesias) and the economic implications of treating these.

As with the expansion of pharmaceutical agents, surgical techniques have been explored and developed. Deep Brain Stimulation (DBS) of the subthalamic nucleus and/or globus pallidus in patients with advanced PD, where all drug treatments have been exhausted, has been shown to alleviate motor symptoms/dyskinesias (12). Despite the relatively recent interest, numerous studies have already looked at long-term outcomes of such patients. In a 4-year follow up, researchers showed a significant therapeutic benefit in 69 patients with severe PD for the whole 4 years (13). In another 5-year follow up of 49 patients, bilateral stimulation of the subthalamic nucleus demonstrated a marked improvement over 5 years in their motor symptoms but worsening of other symptoms (such as akinesia, speech, postural stability, freezing of gait, and cognitive function) which the researchers classified as ‘the natural history of Parkinson’s disease’ (14). However, other studies have also reported variable outcomes following DBS which may be dependant on location and volume of lesions (15). Thus, we are still in the early stages of refining this surgical technique. Currently the National Institute of Clinical Excellence (NICE), states that between 1-10% of all PD patients are likely to benefit from such surgical procedures but the question remains, how do we identify groups of patients that may benefit from this technique? 

The cost of the DBS surgical procedure itself is stated at 18 456 EURO (16). Of course, in addition to this basic surgical expense is the costs acquired as a result of the infrastructure and support team needed to safely carry out and monitor patients. Highly skilled neurosurgeons are essential, and these factors do limit this form of treatment to more affluent societies.   

Despite the obvious costs associated directly with treating the condition, there are other dimensions. PD is a progressively disabling condition, and as the disease progresses the QOL of patients declines.  As a result, patients require additional home care/support. In fact, in a recent study conducted by Findley, it was discovered that the largest component of cost is inpatient and nursing home care (17). Such findings are further supported by other economic analyses; French researchers estimated costs in a cohort of PD patients and concluded hospital stays were the most expensive component of care (39% of costs), followed by ancillary care (30% of costs) (18). 

Treating the accompanying medical problems commonly associated with PD, such as depression and dementia are paramount. These disorders occur in about 50% and 40% of subjects respectively (19, 20). The diagnosis of depression is often complicated by the fact that the anti-parkinsonism drug pramipexole (dopamine receptor agonist) has been shown to cause depression itself (21). Furthermore, the clinical features suggestive of depression often overlap with the motor features of PD, so it may be overlooked. Regardless of these difficulties, cognitive behavioural therapy and anti-depressants are commonly used to treat depression in PD. Although cholinesterase inhibitors have been used successfully in individuals with PD dementia, it is still not clear exactly which patients benefit from this treatment, thus treating dementia is often surrounded by much ambiguity.  

Regarding treatment, a multi disciplinary approach for patients is often implemented.  Such a regimen often requires the participation of PD nurse specialists, physiotherapists, occupational therapists, speech and language therapists, as well as dieticians. Initially most patients do not require these services, however as the disease progresses, and many of the clinical symptoms worsen, a proportion of patients may turn to these options. Remarkably, there are very few clinical trials addressing the utilization / cost of such services by PD patients, possibly because of the ethical hurdles faced when dealing with late stage PD patients as a target population.  

Clearly, overall costs to treat PD vary from country to country. This is likely to reflect individual countries demographic trends, healthcare systems, delivery/availability of services and access to treatment (both pharmaceutical and surgical). This most likely reflects the demographic trends of individual countries, including healthcare setups, delivery/availability of services and access to treatment (both pharmaceutical and surgical). The total annual cost of care including NHS, social services, and private expenditure per patient in the UK has been estimated near £5993 per patient (9). In America total annual direct costs were estimated at 23,101 US Dollars per patient (22). Undoubtedly, in comparison with the demographic trends of the global population, regardless of present day costs, it is apparent that PD will constitute a greater proportion of all healthcare spending in the future.    

Despite these major advances, the fundamental and crucial question about what causes PD is still yet to be answered. A greater understanding of the genetics involved is proving to provide some information. ‘Neuro-protection’ whereby a pharmaceutical agent that has the potential to, in the least part, slow the disease process or better still, halt it, looks promising.  Further down the line, the prospect of ‘Neuro-restoration’ where parts of the brain could be implanted with appropriate nerves/cells to restore function is another key area of research (23). Thus it seems that the disease once thought of as a ‘progressive, chronic neurodegenerative disease with no cure’ will no longer be. Innovative treatment options such as the expanding choices of pharmaceutical agents and potential surgical techniques, is further evidence that PD should be on the agenda of all healthcare providers. 

Srimathy Vijayan

5th year medical student

University of East AngliaNorwich 

s.vijayan@uea.ac.uk 

(1) Neurological Disorders: public health challenges. World Health Organization. 2006.  

(2) G. Pezzolia, M. Canesia, C. Galli. An overview of parkinsonian syndromes: data from the literature and from an Italian data-base. Sleep Medicine 5 (2004) 181–187.   

(3) Bandolier (2003) Incidence of Parkinson’s disease. Bandolier. http://www.jr2.ox.ac.uk/bandolier  

(4) Klein C, Lohmann-Hedrich K. Impact of recent genetic findings in Parkinson’s disease. Curr Opin Neurol. 2007 Aug;20(4):453-64. 

(5) Hancock DB, Martin ER, Mayhew GM, et al. Pesticide exposure and risk of Parkinson’s disease: a family-based case-control study. BMC Neurology 2008, 8:6.    

(6) Dotchin CL, Msuya O, Walker RW. The challenge of Parkinson’s disease management in Africa. Age Ageing. 2007 Mar;36(2):122-7.    

(7) Dorsey, E.R., Constantinescu, R., Thompson, J.P. et al. Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030. Neurology 2006: 68(5), 384-386.  

(8) Kalra P.A. Essential Revision Notes for MRCP. Second Edition 2004. PASTEST  

(9) Findley, L., Aujla, M., Bain, P.G. et al. Direct economic impact of Parkinson’s disease: a research survey in the United Kingdom. Movement Disorders 2003:18(10), 1139-1145.  

(10) Spottke AE, Reuter M, Machat O, et al. Cost of illness and its predictors for Parkinson’s disease in Germany. Pharmacoeconomics. 2005;23(8):817-36.  

(11) Leibson CL, Long KH, Maraganore DM, et al. Direct medical costs associated with Parkinson’s disease: a population-based study. Mov Disord. 2006 Nov;21(11):1864-71.  

(12) Volkmann J. Deep brain stimulation for the treatment of Parkinson’s disease. J Clin Neurophysiol. 2004 Jan-Feb;21(1):6-17.  

(13) Rodriguez-Oroz MC, Obeso JA, Lang AE, et al. Bilateral deep brain stimulation in Parkinson’s disease: a multicentre study with 4 years follow-up. Brain. 2005 Oct;128(Pt 10):2240-9.

(14) Krack P, Batir A, Van Blercom N, et al. Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease.N Engl J Med. 2003 Nov 13;349(20):1925-34. 

  

(15) Limousin P, Martinez-Torres I. Deep brain stimulation for Parkinson’s disease. Neurotherapeutics. 2008 Apr;5(2):309-19.  

(16) Valldeoriola F, Morsi O, Tolosa E, et al. Prospective comparative study on cost-effectiveness of subthalamic stimulation and best medical treatment in advanced Parkinson’s disease. Mov Disord. 2007 Nov 15;22(15):2183-91.  

(17) Findley LJ. The economic impact of Parkinson’s disease. Parkinsonism Relat Disord. 2007 Sep;13 Suppl:S8-S12.

(18) LePen C, Wait S, Moutard-Martin F, et al. Cost of illness and disease severity in a cohort of French patients with Parkinson’s disease. Pharmacoeconomics. 1999 Jul;16(1):59-69. 

(19) Dooneief G, Mirabello E, Bell K et al. (1992) An estimate of the incidence of depression in idiopathic Parkinson’s disease. Arch Neurol, 49, 305–307.   

(20) Emre M. Dementia associated with Parkinson’s disease. Lancet Neurol. 2003 Apr;2(4):229-37.  

(21) Rektorova I, Rektor I, Bares M et al. Pramipexole and pergolide in the treatment of depression in Parkinson’s disease: a national multicentre prospective randomized study. Eur J Neurol 2003:10, 399–406.  

(22) Huse DM, Schulman K, Orsini L, et al. Burden of illness in Parkinson’s disease. Mov Disord. 2005 Nov;20(11):1449-54.  

(23) Davie CA. A review of Parkinson’s disease. Br Med Bull. 2008 Apr 8.

In the third part of our series on the global burden of diabetes, Joshua Schulman-Marcus discusses availability of drug treatment

The rising prevalence of Type 2 diabetes mellitus in developing countries presents a global health challenge that is now garnering attention.  With researchers projecting at least a 31% increase in diabetes prevalence in working age adults (1), there is concern for the potential effects on health, household income, and macroeconomics. (2)  Current trends in nutrition, obesity, urbanization, and economic development in developing countries suggest that societal risk factors for diabetes will increase in the near future (2,3).  Wrongly considered a “disease of affluence,” increasing obesity and other risk factors amongst the poor in developing countries suggest that the burden of disease will fall most heavily on their shoulders. (3,4) (more…)

Srimathy Vijayan discusses the global burden of migraine

We may have all experienced a headache of some nature during our lives; in fact, just less than 2% of the population have never had a headache. (1) Usually self-limiting and short lived, headaches tend to disappear causing few aftermath symptoms. However, Migraine, a primary headache disorder, is a distinct medical entity with characteristic symptomology, resulting in profound effects on the individual. (more…)

Srimathy Vijayan takes an in-depth look at this important, but often neglected topic

In the January 2008 edition of The Lancet Neurology, reviewed Childhood epilepsies. (1) Such reviews are of great importance as they stress the requirement of ensuring that epilepsy occurring in childhood is considered as a different clinical entity to that occurring in adulthood. The word “epilepsy” is derived from the Greek word “epilambanein” which means “to seize or attack”. The seizures associated with epilepsy are the result of sudden, excessive electrical discharges in groups of brain cells. (more…)