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Men at work. Schizophrenia patients in Chennai spend most of the day in organized activities.

vania, and a former president of the American Psychiatric Association. Despite decades of research indicating that mentally ill patients respond best to a combination of drugs and social programs, Fink and others see few signs that U.S. psychiatric institutions are moving to integrate more social interventions into treatment regimens.

Family ties Narendran, a handsome, animated man in his 30s, lives at SCARF’s home for men in Mamallapuram, about 50 kilometers down the coast from Chennai. Sitting at a table in the center’s cafeteria, Narendran, who like many Indians goes by a single name, explains how the activities at SCARF give him a sense A Spoonful of — of purpose. Captaining the center’s cricket team has brought out his competitive side, he says. During the day, Narendran tends the gar- And a Steady Diet of Normality dens at a nearby office complex. He’s proud Private hospitals in India are showing that the best treatment for mentally ill patients to be able to spend part of his earnings on political biographies for a niece. At SCARF, is to lend purpose to their lives finding a job is viewed as essential to a patient’s recovery; family members are on December 5, 2010 CHENNAI, INDIA—Incense wafts around (WHO) in Geneva. advised to bribe employers—typically friends two dozen men standing in a circle stomp- Some Western psychiatrists argue that or relatives—if necessary. ing, clapping, and chanting to the rhythm of social activities such as those employed at SCARF’s philosophy taps into an empha- a drum. This ceremony for the Hindu god SCARF and other Indian nongovernmental sis on family and community long flagged as Krishna wouldn’t seem out of place in a organizations (NGOs) are too often shunned an explanation for evidence that schizophre- temple, but this evening the venue is a in the pursuit of pharmacological solutions. nia patients fare better in developing coun- rehab clinic, and the men are patients with “One of the great disgraces of American psy- tries than in wealthier countries. These find- schizophrenia. chiatry is that we’re very, very invested in ings are especially remarkable because most Earlier, the men were hard at work here medications,” says Paul Fink, a psychiatrist at people with a severe mental illness in India, www.sciencemag.org at the Schizophrenia Research Foundation Temple University in Philadelphia, Pennsyl- for example, receive little if any specialized (SCARF), making chalk sticks or fashion- care; extremely few are lucky ing sturdy shopping bags from old news- enough to get into a program such papers. The clinic sells the items, along with as SCARF’s. The country has dolls and candles made by female patients, only 25,000 psychiatric hospital to local shops in Chennai, a sweltering city beds—a third of which are in a of 6 million on India’s southeast coast, and single state, Maharashtra—for Downloaded from shares the proceeds with the patients. The 15 million people sick enough to buzz of activity makes SCARF feel more need them, including about 3 mil- like a summer camp than a psychiatric lion with schizophrenia. ward. About 40 patients live at SCARF’s Yet a long string of studies, Chennai headquarters, and several dozen beginning with WHO’s Interna- others spend their days here and return tional Pilot Study of Schizophre- home at night. nia, launched in 1967, have Although the patients take antipsychotic reported that patients in India and drugs, it’s the healing power of social inter- other developing countries are ventions that has given SCARF an interna- more likely to have long-term tional reputation as a leader in schizophre- remission of symptoms and fewer nia treatment. The clinic’s success at reha- relapses than patients in the bilitating patients—many of whom recover developed world. Subsequent enough to hold down a full-time job, marry, studies with refined methodolo- and otherwise lead fairly normal lives— gies have concluded the same, offers a powerful lesson on the benefits of says Assen Jablensky, a psychi- going beyond the standard biomedical atric epidemiologist at Western approach. “If I become psychotic, I’d rather Australia University in Perth who be in India than in Switzerland,” confesses led one of the largest follow-ups, Shekhar Saxena, director of Relative peace. Mentally ill patients live with family members at a a 10-country project that wrapped

research at the World Health Organization private hospital in Vellore. up in the early 1990s. He chalks THARYAN CREDITS (TOP TO BOTTOM): SCARF; PRATHAP

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up the difference to better social support in than 10% of families receive education and bullet. “The trend is to give a medication for more traditional societies. support. Moreover, U.S. psychiatric facilities each symptom,” says Fink. “You can find Indeed, out of necessity, about 99% of Indi- aren’t designed to reduce social isolation or patients with six or seven psychiatric pills, and ans with schizophrenia live with their families, facilitate reintegration into the outside world, it doesn’t make sense, it’s terrible.” The U.S. says psychiatrist R. Thara, SCARF’s director. says William Carpenter, director of the Mary- system is biased toward short appointments In developed countries, estimates range from land Psychiatric Research Center in Balti- and profuse prescriptions, some psychiatrists 15% to 25%; most patients live alone or in a more. “If you go into a hospital, you get pretty say. Insurance companies are happy to reim- hospital or an assisted-living facility. In the much cut off from other things.” burse for psychiatric drugs, Carpenter adds, United States, about 6% of people with schiz- Ironically, part of the reason may lie in the but getting them to pony up for social inter- ophrenia are homeless, and a similar percent- importance attached to patients’ rights in ventions can be difficult. age are in prison. In one study in Chennai, Western countries, Carpenter and others say. three-quarters of patients got married and held Under the U.S. Health Insurance Portability Paradigm shift? jobs—considerably more than in Western and Accountability Act, privacy restrictions Even in India, institutions such as SCARF and countries, Thara and colleagues reported in the limit communication between clinicians and CMC are far from the norm. Severely ill August 2004 issue of the Canadian Journal of . Thara involves the patients’ social network in their care. “We have a much more global view of the patient,” she says. Other illnesses also appear to respond to this holistic strategy, says Prathap Tharyan, head of psychiatry at Christian Medical College (CMC) in Vellore, about 150 kilome- ters west of Chennai. Tharyan will only admit a patient on the condition that at least one fam- ily member stays in an on-campus apartment with the sick relative. CMC may be the first psychiatric hospital in the world to insist on this arrangement, Tharyan says. “It’s on December 5, 2010 absolutely crucial to have the family involved.” Like many Eastern psychiatrists, Tharyan shares the view of Western medicine that mental illness is a neurobiological problem. “I have no doubt that schizophrenia is caused by something that goes wrong in the brain,” he says. But Western medicine often over- looks how mental illness disrupts social net- works, Tharyan says: “It affects the entire System under stress. Crowded government hospitals deter many Indian patients and their families from www.sciencemag.org function of the family and the individual’s seeking care. role in the family.” patients’families, says Fenton. “If you have an patients who don’t live at home often end up in Drug culture 18-year-old child that’s hospitalized for psy- giant state-run mental hospitals. “All that is That idea is more studied than practiced in the chiatric reasons, the hospital can send you a done in a typical state hospital is to ask, ‘How West, particularly in the United States. bill, but they can’t tell you if the child has been are you doing? Are you still hearing voices?’

Researchers have identified at least half a admitted to the hospital, unless the patient and give them medicine,” Thara says. She Downloaded from dozen interventions—including work training gives permission,” Fenton says. “If patients would like to see hundreds of organizations and placement programs, education and sup- are suspicious or hostile, the hospitals are con- such as SCARF spread across the country. port for families, and programs that teach strained in getting a family’s help.” It’s an idea worth considering, says the social skills—that improve the lives of schizo- Work programs such as those at SCARF World Bank’s Benjamin Loevinsohn. He co- phrenia patients, says Wayne Fenton, director are rare in the United States, in part because of authored a review published in The Lancet last of adult translational research at the U.S. lingering memories of peonage at mental August that concluded that NGOs often pro- National Institute of Mental Health (NIMH) institutes. In the 1930s, long-stay mental hos- vide higher quality service at lower cost than in Bethesda, Maryland. pitals were often little more than sweatshops governments do, and he thinks this would The problem is that these findings don’t in which patients toiled without pay, says apply to mental health NGOs, too. make it into the clinic. A 2001 study in Carpenter. Work programs at long-term care On an annual budget of about $70,000, Schizophrenia Bulletin found that although facilities began dying out around midcentury SCARF provides low-cost care for 140 in- 61% of schizophrenia patients in the United as word of abuses leaked out and advocates patients and up to 100 outpatients a day. Most States want to work, fewer than 20% find insisted that patients receive minimum wage of the 25 permanent staff are psychiatric employment. A 1998 study funded by NIMH for their work, making many programs un- social workers. “SCARF has a truly innova- and the Agency for Health Care Policy and affordable, Carpenter says. tive way of doing social interventions without Research hints at the reason. It found that only Another big impediment to weaving social highly trained people” such as psychiatrists, one in four schizophrenia patients in the interventions into care is unbridled enthusi- who are in short supply in India, says Vikram United States receive employment assistance. asm for drugs. Although Western psychiatrists Patel, a psychiatrist at the London School of In addition, less than 10% of patients partici- agree that drugs are essential for stabilizing Hygiene and Tropical Medicine. It’s a lesson pate in community-based programs that help severely ill patients to give other therapies a worth noting for rich and poor countries alike.

CREDITS: TAUSEEF MUSTAFA/GETTY IMAGES MUSTAFA/GETTY TAUSEEF CREDITS: prevent relapses and hospitalization, and less chance to work, too many see drugs as a magic –GREG MILLER

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