One glaring omission is the lack of psychiatric medications included.
Around the world, transitional and developing countries’ main expense is pharmaceuticals, ranging from 15% to 66% of total expenditures.1 In light of this fact, countries need to assess what the best products are for the largest demographic, without sacrificing affordability and quality. Most countries do not have the resources to provide such an analysis. The World Health Organization, therefore, intervenes. The WHO first addressed this issue by creating an “essentials list,” which is updated annually and provides countries with guidelines that can assist in providing “health for all.”2 One disparity, however, is the lack of psychiatric medications on this list.
The WHO Essential Medicines List (EML) was assembled in 1977 in response to the demand for a standard medications list. It was originally created to provide effective treatments for communicable and noncommunicable diseases worldwide. This “model list” is the basis for most national and regional formularies in high-, middle- and low-income countries.1 A review of the 2017 EML updated list included the addition of PReP (a preventative HIV medication), hepatitis C, tuberculosis and cancer medications, as well as new advice for antibiotic use.2 Although these are necessary additions, the counsel only added 1 psychiatric medication to the list: lamotigrine, for epileptic seizures in pediatric patients.3
The single addition of lamotrigdine is a prime example of the EML’s shortcomings regarding psychiatric medications. This psychiatric medication addition itself is questionable, as epilepsy is generally thought to be a neurological disease state. The WHO, however, has formally defined epilepsy as a psychiatric condition, because of its unpredictable nature and association to other mental illnesses, such as depression and anxiety when left untreated, as is the case in many developing-world countries.4 Although these lists have positively evolved, they lack the psychiatric medications required worldwide. As one paper highlights, the EML does not focus on such medications, because they are not seen as essential, despite their effectiveness.5
Psychiatric medications, however, ought to be viewed as essential, because of their impact on society.6 Worldwide, mental health will directly affect 1 in 4 people during their lifetimes. Psychiatric conditions, additionally, have been implicated with the induction of multiple disease states, including suicide, cancer, accidents, liver disease, and septicemia, which have increased premature mortality.7 Also, following natural disasters and emergent situations, mental health disorders double.8 This spike, however, can be controlled and contained through the availability of mental health first aid and psychiatric medications that can significantly reduce the need for additional follow-up care.8,9
Accordingly, minor changes may have drastic impacts on countries that base their assessments on the “model list.” One vital effect would be the ability to provide more psychiatric medications to more patients. The results of a study conducted in Sofala, Mozambique, showed that 67% of the clinics there did not have the adequate supplies to provide care for psychiatric patients. The study results also showed that among all 248 locations studied, no 2 clinics had a single identical medication.10 An additional minor adjustment could be including a psychiatrist or psychiatric pharmacist on the counsel responsible for updating the EML, enabling a thorough assessment of mental health medications. Having a relevant interest group present would assist in effectively identifying the list’s shortcomings.11 Another resource that could be offered is mental health first aid training, allowing for more people to better understand how to assess and appropriately assist in mental health crises.
Because of the diverse range of conditions that psychiatric medications treat including epilepsy, anxiety, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, schizophrenia, and dementia, the above statistics should raise worldwide concern. The data show the extensive need for more psychiatric medications first and foremost on the WHO EML. Additionally, when more weight and encouragement are placed on the need for psychiatric medications, countries will adjust their own formularies, leading to more patients receiving proper care, not only on a regular basis but also after emergency situations. With the help of adjustments to the WHO EML, the goal of accepting psychiatric conditions as any other disease state can become a reality.
Brittany N. Galop is a PharmD Candidate at the University of Kentucky College of Pharmacy in Lexington.
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1. World Health Organization. Essential medicines and health products. who.int/medicines/services/essmedicines_def/en/. Accessed November 21, 2017.
2. WHO updates Essential Medicines List with new advice on use of antibiotics, and adds medicines for hepatitis C, HIV, tuberculosis and cancer. [news release]. Geneva, Switzerland: WHO Department of Communications; June 6, 2017. who.int/mediacentre/news/releases/2017/essential-medicines-list/en/. Accessed November 21, 2017.
3. World Health Organization. Executive summary: the selection and use of essential medicines 2017. who.int/medicines/publications/essentialmedicines/EML_2017_ExecutiveSummary.pdf?ua=1. Accessed November 21, 2017.
4. World Health Organization. Epilepsy. who.int/mediacentre/factsheets/fs999/en/. Accessed November 21, 2017.
5. World Health Organization. Essential medicines for mental disorders. Pharmacological Treatment of Mental Disorders in Primary Health Care. U.S. National Library of Medicine, 2009.
6. World Health Organization. Mental health in emergencies. who.int/mediacentre/factsheets/fs383/en/. Updated March 2017. Accessed November 21, 2017.
7. Piatt E, Munetz MR, Ritter C. An examination of premature mortality among decedents with serious mental illness and those in the general population. Psychiatr Serv. 2010;61(7):663-8. doi: 10.1176/ps.2010.61.7.663.
8. World Health Organization. Essential meds for disasters and emergencies in the Caribbean. who.int/medicinedocs/en/d/Js19938en/. Updated November 7, 2017. Accessed November 21, 2017.
9. Campo J. It’s time to recognize mental health as essential to physical health. STAT. statnews.com/2017/05/31/mental-health-medicine/. Published May 31, 2017. Accessed November 21, 2017.
10. Wagenaar BH, Stergachis A, Rao D, et al. The availability of essential medicines for mental healthcare in Sofala, Mozambique. Glob Health Action. 2015;15;8:27942. doi: 10.3402/gha.v8.27942.
11. World Health Organization. Checklist for evaluating a mental health plan. who.int/mental_health/policy/WHOPlanChecklist_forwebsite.pdf?ua=1. Published June 2007. Accessed November 21, 2017.