Excessive work hours of physicians in training: maladaptive coping strategies.

PLoS Medicine | www.plosmedicine.org 1550
Correspondence
Treating Schizophrenia with DOTS in
Developing Countries: One Size Does
Not Fit All
Renato Souza, Silvia Yasuda, Susanna Cristofani
Although DOTS is advocated as the best approach for global
tuberculosis control, the variable success of this strategy
[1] should help us in learning which problems we might
face while adopting the same strategy for the treatment of
schizophrenia in developing countries, as Dr. Farooq suggests
[2].
Our experience of integrating mental health into
primary health care in developing countries has taught
us that some points stated in the fi ve pillars of DOTS for
tuberculosis cannot be totally transferred to the treatment
of schizophrenia, unless some of their principles and weak
points are addressed in advance [3]:
1. In developing countries, we face the challenge of
integrating mental health knowledge into the skills of poorly
qualifi ed and over-burdened primary health care staff.
Therefore, unless strong training and supervision capacity for
staff at primary health care levels is developed, this obstacle
won’t be overcome.
2. Passive case fi nding, for a disease that provokes such
high levels of disability, stigma, and human rights abuse as
schizophrenia, is not appropriate in our view.
3. A standard treatment regimen needs to be overseen with
caution if implemented for the treatment of schizophrenia,
due to the need to adjust the dose of the antipsychotic based
on patient response and side effects.
4. A regular supply of essential psychotropic medication is
obligatory but non-existent in most developing countries, and
when available does not extend to the primary health care
level.
5. Monitoring and tracking patients under treatment is
an enormous burden to overstretched primary health care
systems, unless the community is heavily involved.
In Darfur-Sudan, due to the high level of mental health
morbidity, Médecins Sans Frontières has been implementing
a syndromic approach to the diagnosis of mental illnesses [4].
For the identifi cation of patients with severe mental illness
including schizophrenia, community health workers are
trained to identify patients at the community level, using
a locally developed case defi nition of severe mental illness
based on existing local idiom for those conditions.
During a period of two months, we have identifi ed 49
patients that were brought to the health clinic, where
a medical assistant made the diagnosis and started the
treatment. Community health workers provide therapeutic
education to patients and caretakers and support them
to continue the treatment within the community. All
professionals are under the supervision of a mental health
trainer.
Some patients were in such dramatic situations as being
chained to their beds. Some had received several forms of
traditional treatments without any success.
We fi rmly believe that unless a system is built where the
community is involved, medical personnel receive training
and supervision, and Ministries of Health commit to
delivering a constant supply of drugs at the primary health
care level, the attempt to use one or another strategy won’t
bring much relief to patients and families affected by this
disease.
It was in 1974 that the World Health Organization
recommended that mental health care be integrated at the
primary health care level. The management of psychosis was
identifi ed as one of the priorities [5]. It is very unfortunate
that in most of the places where Médecins Sans Frontières
works, the majority of health workers usually neglect the
needs of people with severe mental illness. �
Renato Souza (renato.souza@geneva.msf.org)
Silvia Yasuda
Susanna Cristofani
Médecins Sans Frontières
Geneva, Switzerland
References
1. Whalen CC (2006) Failure of directly observed treatment for tuberculosis in
Africa: a call for new approaches. Clin Infect Dis 42:1048–1050
2. Patel V, Farooq S, Thara R (2007) What is the best approach to treating
schizophrenia in developing countries? PLoS Med 4: e159. doi:10.1371/
journal.pmed.0040159
3. World Health Organization (1994) Framework for effective tuberculosis
control. WHO document WHO/TB/94.179.
4. Kim G, Torbay R, Lawry L (2007) Basic, women’s health, and mental health
among displaced persons in Nyala Province, South Darfur, Sudan. Am J
Public Health 97:1–9. doi:10.2105/AJPH.2005.073635
5. World Health Organization (2001) The effectiveness of mental health
services in primary care: The view from the developing world. WHO
document WHO/MSD/MPS/01.1.
Citation: Souza R, Yasuda S, Cristofani S (2007) Treating schizophrenia with DOTS
in developing countries: One size does not fi t all. PLoS Med 4(9): e281. doi:10.1371/
journal.pmed.0040281
Copyright: © 2007 Souza et al. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Funding: The authors received no specifi c funding for this article.
Competing Interests: The authors have declared that no competing interests exist.
Treating Schizophrenia with DOTS in
Developing Countries: Author’s Reply
Saeed Farooq
I am grateful to Souza et al. [1] for taking interest in our
article [2] and pointing out some very relevant points. I agree
with the authors that despite the fact that the World Health
Organization and many other agencies have advocated that
mental health care in developing countries be integrated
into primary care, there has been no real progress. We
need to think about the real causes for this failure. Lack of
commitment by governments is only a partial explanation.
We, the mental health professionals practicing in developing
countries, must also accept responsibility. One of the major
reasons is that we have not been able to formulate simple
interventions that can be implemented at the primary care
level as a public health measure. The approach based on
DOTS for treating schizophrenia is one such intervention.
Most of the issues raised by Souza et al. are the problems
that we are likely to face in applying an approach
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developed basically for an infectious disease to a chronic
noncommunicable disease. I would like to stress that,
as mentioned in the article, the approach is based on
the principles of DOTS, not on applying DOTS exactly
as practiced in tuberculosis control to the treatment of
schizophrenia. I agree with the authors that it will need
considerable modifi cations before it can be applied to a
chronic disorder like schizophrenia. They have pointed out
several issues and I would like to address these.
1. Health workers would defi nitely need to be better
trained under the supervision of mental health professionals
to apply this approach in primary care.
2. I very much appreciate the work of the authors and
agree that passive case fi nding is not an option. This will
result in the plight of patients mentioned in their letter. One
of the benefi ts of the approach suggested in our article is that
as a result of an intervention available at the public health
level there will be greater awareness of severe mental illness.
Consequently there will be earlier recognition of these cases
in the community. As mentioned in the article, this should
also result in reduced stigma for the disorder.
3. It should be possible to provide a standard regimen
for treatment of schizophrenia based on the essential
psychotropic drugs. We were able to develop this for our
pilot project and are also using the same approach in our
randomized controlled trial [3].
4. One of the major reasons for advocating this approach
is that it could ensure free supplies of the drugs as a part of
a DOTS program. One of fi ve essential components of the
DOTS strategy is government commitment to providing drugs
free of cost. This is the cornerstone of the strategy suggested
in our article.
5. Monitoring and tracking of patients is important but
need not stretch primary care workers beyond capacity, as
schizophrenia is a low prevalence disorder. As explained
in the article, the implementation of DOTS would be for a
two-year period. The community can only be involved if we
can offer effective interventions for those suffering from this
chronic and disabling disorder.
The approach suggested in our article represents an
attempt to bring mental health into the public health
arena. Schizophrenia is a low prevalence disorder, for which
effective interventions are available and can be implemented
at the community level. It therefore represents an ideal
disorder for intervention based on DOTS. Applying an
approach developed essentially for a disorder which has a
time-limited course and is high on the public health agenda
to a disorder which is noncommunicable and runs a much
protracted course demands a paradigm shift. There are
examples of similar approaches in other noncommunicable
diseases. Insulin Demonstration projects, which have been
initiated to improve access to insulin by the International
Diabetes Foundation Task Force, can provide good models
[4]. Small scale programs based on the model suggested
in our article should be developed locally in developing
countries before we can expect governments to support them.
Organizations such Médecins Sans Frontières are ideally
suited to develop programs like these. One size may not fi t all
but we can make a suitable size for a great majority. �
Saeed Farooq (sfarooqlrh@yahoo.com)
Postgraduate Medical Institute
Peshawar, Pakistan
References
1. Souza R, Yasuda S, Cristofani S (2007) Treating schizophrenia with DOTS
in developing countries: One size does not fi t all. PLoS Med 4: e281.
doi:10.1371/journal.pmed.0040281
2. Patel V, Farooq S, Thara R (2007) What is the best approach to treating
schizophrenia in developing countries? PLoS Med 4: e159. doi:10.1371/
journal.pmed.0040159
3. [No authors listed] (2007) Supervised treatment of schizophrenia:
A randomized controlled trial. ID NCT00392249. Available: http://
clinicaltrials.gov/ct/show/NCT00392249?order=1. Accessed 24 August
2007.
4. International Diabetic Federation (2004) Insulin Demonstration project.
Available: http://www.idf.org/e-atlas/home/index. Accessed 24 August
2007.
Citation: Farooq S (2007) Treating schizophrenia with DOTS in developing
countries: Author’s reply. PLoS Med 4(9): e285. doi:10.1371/journal.pmed.0040285
Copyright: © 2007 Saeed Farooq. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Funding: The author received no specifi c funding for this article.
Competing Interests: SF is the principal investigator in a randomized controlled
trial (“Supervised Treatment of Outpatient Schizophrenia [STOPS]”) evaluating the
approach described in his Viewpoint.
Excessive Work Hours of Physicians
in Training: Maladaptive Coping
Strategies
Pashtoon Murtaza Kasi, Masoom Kassi, Talha Khawar
We would like to congratulate Kenneth R. Fernández Taylor
for bringing up such an important but avoided issue in
developing countries like Pakistan [1]. The growing debate
regarding long working hours of postgraduate trainees
has been receiving considerable attention recently [2].
This greater workload contributes to increasing stress and
decreases the overall performance and the quality of life of
the affected individuals [3,4].
In Pakistan, physicians, after having done a fi ve-year
medical degree (MBBS) course, are supposed to do their
“internship”, or “house job” as it is often referred to. The
salaries speak a sorry tale as the typical monthly salary of an
intern starts from 8,000 rupees (US$129); even lower than
what is mentioned by the author in El Salvador.
The author very rightly describes a typical tiring working
week for an intern with little or no time for any educational
activities. Some of the specialties are known for the fact that
their working hours are “killing” for their residents and
interns; unfortunately, some may even pride themselves on
this. This inhumane approach is not often criticized by the
interns working in a hospital; probably because they are too
tired at the end of a day or even two or three continuous
days to do so. We know of two specialties (neurosurgery and
urology) in which the on call team came on Friday and left
on Monday morning (72 hours straight); the reason being no
other team was available to cover for them. And most of the
time what an intern does is merely “clerical” work, with little
satisfaction.
We, as fi nal year medical students, tried to bring attention
to this issue by documenting fi rstly how many hours the
interns and residents worked; and secondly if these hours led
to negative coping strategies or mechanisms, which might
further contribute to the stress of these individuals, rather
than helping them in relieving it.
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We found that long working hours were indeed leading
to negative coping mechanisms such as behavioral
disengagement (“I’ve been giving up trying to deal with it”),
substance use (“I’ve been using alcohol or drugs to make
myself feel better”), denial (“I’ve been saying to myself, ‘this
isn’t real’”), and venting (“I’ve been saying things to let my
unpleasant feelings escape”). The frequency of different
coping strategies employed by the residents in the past two
weeks was determined with the Brief COPE–28 tool [5].
We also found signifi cant levels of mild as well as morbid
stress in the trainees of the hospital, with every second
individual suffering from some degree of stress as well. Action
indeed is needed. �
Pashtoon Murtaza Kasi (pashtoon.kasi@gmail.com)
Masoom Kassi
Talha Khawar
Bolan Medical College
Balochistan, Pakistan
References
1. Fernández Taylor KR (2007) Excessive work hours of physicians in training
in El Salvador: Putting patients at risk. PLoS Med 4: e205. doi:10.1371/
journal.pmed.0040205
2. Howard SK, Gaba DM (2004) Trainee fatigue: Are new limits on work hours
enough? CMAJ 170: 975–976.
3. Howard SK, Gaba DM, Rosekind MR, Zarcone VP (2002) The risks and
implications of excessive daytime sleepiness in resident physicians. Acad
Med 77: 1019–1025.
4. Parshuram CS, Dhanani S, Kirsh JA, Cox PN (2004) Fellowship training,
workload, fatigue and physical stress: A prospective observational study.
CMAJ 170: 965–970.
5. Carver CS (1997) You want to measure coping but your protocol’s too long:
Consider the brief COPE. Int J Behav Med 4: 92–100.
Citation: Kasi PM, Kassi M, Khawar T (2007) Excessive work hours of physicians in
training: Maladaptive coping strategies. PLoS Med 4(9): e279. doi:10.1371/journal.
pmed.0040279
Copyright: © 2007 Kasi et al. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
Funding: The authors received no specifi c funding for this article.
Competing Interests: The authors have declared that no competing interests exist.
September 2007 | Volume 4 | Issue 9 | e279