Challenge of neurological and psychosocial problems in developing countries

Burton et al. have completed one of the first populationbased studies of behavioral problems of children with epilepsy in Africa. It provides solid research in an area where data is limited and helps identify both neurological and mental health needs in less developed areas. It also reminds us of the challenges faced by children with neuropsychiatric problems in the developing world. Epilepsy is one of the most common neurological disorders worldwide. The incidence and the mortality are significantly higher in developing countries. Unfortunately, this is accompanied by a large treatment gap. People with epilepsy fail to receive needed care because of an inadequate number of health care providers, the cost of medical care, and a lack of antiepileptic drugs. In Africa there is a shortage of professionals trained in epilepsy and limited access to electroencephalography and neuroimaging. As in the study by Burton et al., the diagnosis of epilepsy is based entirely on clinical description. The treatment gap is even more pronounced in rural areas as most professionals and the technology for diagnosis are concentrated in urban centers. Treatment is limited by availability and cost of antiepileptic drugs. Phenobarbital is the least expensive and most readily available. The behavioural side effects have not been seen in trials conducted in developing countries, but there are concerns about drug interactions with medications for HIV. Phenytoin and carbamazepine are available in some areas. In the study by Burton et al., approximately half the children with seizures were not on antiepileptic drugs and only onethird received daily treatment. Adequate treatment is essential. Burton et al. found that more frequent seizures predicted behavioural problems and noted that 48% of children with seizures were not attending school regularly (compared to 0% of the controls). Other studies have shown that inadequate treatment is associated with an increased risk of unexpected death. A major finding in this study is the high prevalence of behavioural and attention problems in children with epilepsy. Neuropsychiatric disorders contribute to 14% of the global burden of disease and are intricately linked with millennium development goals. For example, depression has been shown to adversely affect adherence rates for antiretrovirals in the treatment of HIV ⁄ AIDS. However, mental health has historically been a lower priority in developing countries. There are a number of obstacles to applying proven, successful interventions of mental health disorders in developing countries. Among these is the fact that individuals in developing countries live in different economic, social, cultural, and diseaseprevalence environments and may have different risk factors and contributing factors to mental health disorders. In particular in Africa, there is a higher burden of disease as well as long-term effects of diseases such as HIV ⁄ AIDS, and greater violence, poverty, and risk of displacement. Despite these obstacles, studies assessing the efficacy of interventions have shown that when compared with interventions for other chronic disorders, treatments for common mental disorders are about as cost-effective as antiretroviral treatment for HIV ⁄ AIDS, secondary prevention of hypertension, or glycemic control for diabetes. Effective, locally feasible, and affordable treatments for depression and schizophrenia in low-income and middle-income countries do exist. Further research is needed on prevalence, risk factors, contributing factors, and outcomes of mental health disorders as well as means of implementing mental health services in developing countries.