Muzammil S, Lopes G (2020) Community Mental Health Services in Developing Countries, Time to Think Outside the Box. J Fam Med Dis Prev 6:117.

Review Article | OPEN ACCESS DOI: 10.23937/2469-5793/1510117

Community Mental Health Services in Developing Countries, Time to Think Outside the Box

Sadat Muzammil, MBBS, MRCGP, FRCP (Glasg), CCFP1* and Georgina Lopes, MSc2

1Follylane Medical Center, UK

2Bethany Medical Centre, UK


Developing countries are struggling to provide adequate mental health care to its citizens. One of the main reasons is the serious shortage of psychiatrists and trained Mental Health Nurses (MHNs). In many countries the quality of mental health nursing is less than satisfactory. Some Western countries have devised nurse led care models under the supervision of psychiatrists, which have shown improvement in patient waiting times and care delivery as compared to low-income countries. Nurses with prescribing privileges have received mixed opinions but it has been shown to have benefits to a certain level. In this article a potential solution is suggested on the foundation of a recent literature review for developing countries to empower MHNs under the supervision of psychiatrists, so that patients can have improved access to services and receive enhanced and more timely care delivery.


Psychiatrists, Prescribing, Mental health nursing, Developing countries, Care model


MHNs: Mental Health Nurse


Unfortunately, mental health has a huge stigma in developing countries and therefore does not get the lime light like other medical conditions. This stigma makes early and effective treatment for mental conditions a significant challenge for the patient and relatives. There has been an increase in new cases of depression, anxiety, low mood, stress, illicit substance abuse and mental illness reported in health institutes of low-income countries. Contributory factors include; a globally un-predictable socio-economic climate; terrorism; poverty; literacy; diseases and natural disasters in developing countries, to name but a few [1].


Globally, about 25% of the population will develop mental illness at some stage in their lives, and 12% of the global burden of disease originates from the low-income countries [2]. Furthermore, 10-20% of children and adolescents suffer from mental disorders, with half of all them starting by the age of 14 and three-quarters before the age of 25 [3]. In young adults, mental health conditions can present as lack of confidence, body image issues, social isolation, poor performance in academia, internet addiction and poor quality of life [4]. Self-harm and suicidal behaviour in adolescence are markers of mental health disorders and represent unfavourable social outcomes in young adulthood, mostly accounted for by adolescent psychosocial problems [5]. In addition, there is a significant shortage of psychiatrists especially in developing countries and the concept of nurses specialised in mental health is not well developed. This makes the management of mental health cases significantly challenging. Due to the severe shortage of psychiatrists, patients in developing countries choose to go to non- medical 'healers' who sometimes makes the condition even worse. There is a huge stigma attached to mental health conditions which is a barrier for prompt treatment [6]. On the other hand, the population is growing older and its mental health needs are getting complex and there are not enough resources to cater everyone's' needs [7]. These factors are more pronounced in southern Asia and Western Africa which accounts for almost 26% of the world's population [8]. Cultural issues could perhaps explain why women tend to get neglected in low income countries where lack of health funding makes matters even worse [9,10]. The shortage of psychiatrists is multifactorial, but the lack of teaching time given to psychiatry in medical schools in most developing countries needs to be highlighted. The in majority of countries haven't reached the targeted number of psychiatrists which is 10 in 100000 except Japan and the teaching of mental health at undergraduate level represents around twenty hours a year in some colleges [11].

Because of this chronic lack of psychiatrists in the developing world and compounding factors in varying patient demographics, the need arises is to think outside the box and empower the Mental Health Nurse (MHN). There is a need to better understand the relationship between the nurses' competencies, the care management activities, the strategies used to implement community mental health nursing and the context-specific factors [12]. The concern is if the psychiatric teaching and training for doctors at undergraduate level is limited, this situation is likely to be worse for mental health nurses [13]. The curriculum for mental health nurses needs to be in line with doctors and to improve their basic training. As in many developing countries, organised nursing lacks many of the management and planning skills needed to deliver optimum care. Some of the Western countries have taken significant steps to professionally develop mental health nursing in the last decade and it can be modified and implemented in low-income countries according to the specific country budget [14]. In several countries nurse training is a 3-year diploma that has seen little change in curriculum which is more targeted for hospital service, primary care, public health program management, patient education, and mental health has often not been stressed [15]. Nurses in low- and middle-income countries are often the primary providers of care for people with mental disorders. The lack of sufficient mental health professionals in these countries creates an environment where nurses without training are often the only providers available to care for people with mental disorders [16]. Due to high demand and lack of adequate training, MHNs are under significant occupational stress levels, therefore affecting the physical and mental health of mental health nurses. They receive little support and the burden of care is shouldered by a spouse/partner followed by colleagues [17]. A solution is to train MHNs to be non-medical prescribers which has the potential to improve patients' access to, and experiences of treatment if the nurse is qualified to complete episodes of care. This model of care has already been implemented in the West and it has shown improvement in patient waiting time and care provision. The nurse needs to be appropriately experienced and qualified in the field of mental health and care pathways implemented to streamline care provision. Prescribing needs to be guided by psychiatrists and be in line with the local prescribing formulary. Nurse training needs to encompass processes and culture that encourages both the faculty and students to collaborate across doctoral programs. Postgraduate scholarships should be awarded and work in collaboration with the Colleges of Psychiatrists [18]. Successful intra-professional collaboration has the potential to positively impact healthcare quality, and outcomes, while advancing the nursing profession simultaneously. This model of care has worked in primary care nursing, and several other nursing specialities [19-21]. It has been proven that well-trained MHNs can be an asset to the community and the local psychiatry department [22].

Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression [23]. In a recent cross-sectional study in Brunei, negative attitudes of primary care nurses were reported towards mental health conditions [24]. In a paper from Hong Kong, it was suggested that if mental health nurses adopt societal beliefs into their practice, this can lead to the misinterpretation of mental illness [25]. In a six low-income country study, emphasis was placed on the strengthening of governance, financing, human resource development, service provision and information systems; knowledge transfer in order to consolidate mental health services [26]. In addition, a recent multi-country systemic review reported that there were specific communication and clinical skills lacking in most studies and the methodology for cultural adaptation of interventions was rarely documented [27].

Implications for Practice

Managing Mental health conditions is challenging even with all the desired resources, but it's an even bigger challenge when there are little or no resources. With a wide range of psychiatric illnesses, it's not easy to manage a growing number of patients. There is a historic shortage of psychiatrists in health specialities and this is of significant concern for low income countries where the population numbers are higher, there is a lack of education, lack of overall government health funding, stigma of mental health conditions and inequality for gender. The worry is if governments and societies are continuing to follow the traditional mental health practices the situation will get worse. Now is the time to utilise all available resources in mental health care, including nurses and allied staff. More MHNs can be trained to a higher level with incentives of personal and professional development. The culture of mental health training needs to be reviewed and revised to broaden the scope and to take a non-judgemental approach. This can be achieved by using a multifaceted approach, involving nursing colleges facilitating changes in the nursing curriculum, enhancing mental health post-graduate nursing training and structured psychiatric supervision. The emphasis should be on core nursing training, effective communication skills, non-judgemental thinking and de-stigmatising mental health illness utilising all available platforms including the media. Although this might be embedded in certain societies, more needs to be done to embed it in all health care settings, fundamentally adapting the curriculum to form the basis of mental health nurse training. This would then be conducive to adopting alternative, dynamic and more collaborate ways of working to meet the growing need for mental health care provision.

Conflict of Interest


Source of Funding



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Muzammil S, Lopes G (2020) Community Mental Health Services in Developing Countries, Time to Think Outside the Box. J Fam Med Dis Prev 6:117.