Frog. Neuro-Psychophamacol. Vo1.3, pp.5-9, 1979. Pergamon Press Ltd. Printed in Great Britain

WORLD HEALTH ORGANIZATION ACTIVITY IN PSYMOPHARMACOTHRRAPY

F. E. VARTANIAN

Division of Mental Health, World Health Organization Geneva, Switzerland

Abstract

1. The Division of Mental Health of the World Health Organization is developing a series of closely-linked activities concerned with research, information exchange and training in biological psychiatry, including psychopharmacology. One of the main mechanisms utilized in WHO programmes is joint work in a network of Collaborating Centres. These Collaborating Centres of WHO, which carry out projects on clinical psychopharmacology and biological psy- chiatry, are distributed over the different geographical regions of the world.

2. The successful development of these collaborative activities has permitted the rational integration of efforts of Collaborating Centres and the creation of optimal conditions for international collaboration towards rational treatment approaches of mental disorders.

Key words: WHO, psychopharmacology, biological psychiatry, international collaboration.

Introduction

Over the past 25 years, since the discovery of the antipsychotic effects of chlorpromazine, psychiatrists and specialists in other branches of medicine have had the opportunity to study a wide range of psychotropic compounds and to become convinced of their therapeutic effective- ness. There is no necessity to discuss the achievements of chemotherapy of mental disorders because these achievements are well-known and impressive and they are the reason why psycho- pharmacology is of growing interest to the World Health Organization.

In its recently reformulated WHO mental health programme, the Division of Mental Health of the World Health Organization is developing a series of closely-linked activities concerned with research, information exchange and training in biological psychiatry. WHO's functions relating to recommending psychotropic substances for international control also rests within the Division of Mental Health. There is no need to describe in detail all the activities concerned with WHO's programme on biological psychiatry, but to discuss only the problems which are of direct relevance to the subject matter of this symposium.

One of the main mechanisms utilized in WHO programmes is joint work in a network of Colla- boratin Centres. cology, P

These Collaborating Centres of WHO, biological psychiatry*

dealing with problems of psychopharma- and Centres involved in a new project entitled "Effects of

Psychotropic Drugs in Different Populations",3 regions of the world (see Fig. 1).

are distributed over the different geographical

i WHO Collaborating Centres for the Study of Psychotropic Drugs are located in: New South Wales, Australia, Professor L. G. Kiloh; Vienna, Austria, Dr P. Berner; LiBge, Belgium, Professor J. Bobon; Montreal, Canada, Dr H. E. Lehmann; Prague, Czechoslovakia, Professor L. Eaneli&ek; Copenhagen, Denmark, Professor 0. J. Rafaelsen; Cairo, Egypt, Dr F. Loza; Munich, Federal Republic of Germany, Professor H. Hippius; Paris, France, Professor P. Deniker; Accra, Ghana,

(continued at bottom of p..6) 5

6 F. E. Vartanian

Fig. 1. The network of the WHO Collaborating Centres * WHO Collaborating Centres for the Study of Psychotropic Drugs r WHO Collaborating Centres for Research and Training in Biological

Psychiatry A WHO Collaborating Centres taking part in the WHO Project on the

Effects of Psychotropic Drugs in Different Populations

This distribution is uneven and one can see some kind of disproportion. The picture is like a mosaic, but one should consider that the pieces composing this mosaic have inherent and closely-defined interrelationships. Groups of Centres in different combinations are carrying out defined projects. This principle is related to a number of factors such as present experi- ence, resources and location of Centres, the degree to which the presence of all this permits to carry out transcultural studies and experience in multilateral cooperation, etc. At the present stage of the development of biomedical sciences and health practice, we are witnessing a trend towards wider international cooperation where WHO has an important role to play in this development. One of the main objectives is to set up optimal conditions for international collaboration in biomedical research and this requires a number of specific steps to be taken.

These WHO Centres, located in different parts of the world, are taking part in a number of studies dealing with the treatment of mental disorders and with the biological basis of psychia- tric illnesses. An important aim of this work is the definition of rational therapeutic approaches adapted to conditions in a wide range of climatic and various social settings (WHO, 1976). The transcultural psychopharmacological project on "Effects of Psychotropic Drugs in Different Populations" includes three interrelated studies - dose effects of antipsychotic

Dr E. F. B. Forster; Athens, Greece, Professor C. N. Stefanis; Budapest, Hungary, Professor I. Tariska; Bombay, India, Professor V. N. Bagadia; Milan, Italy, Professor C. L. Cazzullo; Sapporo, Japan, Professor I. Yamashita; Mexico City, Mexico, Professor D. Nieto; Ibadan, Nigeria, Dr M. Olatawura; Troms8, Norway, Professor 0. Lingaerde; Warsaw, Poland, Dr Wardaszko-Lyskowska; Dakar, S6n6ga1, Professor B. Diop; Basel, Switzerland, Professor P. Kielholz; Groningen, Netherlands, Professor H. M. van Praag; Moscow, USSR, Professor R. Nadzarov; Rockville, USA, Dr A. A. Leeds; Zagreb, Yugoslavia, Dr N. Bohacek.

2WH0 Collaborating Centres for Research and Training in Biological Psychiatry are located in: Copenhagen, Denmark, Professor 0. J. Rafaelsen; Munich, Federal Republic of Germany, Professor H. Hippius; Groningen, Netherlands, Professor H. M. van Praag; Basel, Switzerland, Professor P. Kielholz; Moscow, USSR, Professor M. Vartanian; Surrey, United Kingdom, Dr A. J. Coppen; Bethesda, United States of America, Dr W. E. Bunney.

%HO Collaborating Centres involved in the WHO Project on Effects of Psychotropic Drugs in Different Populations: Cali, Colombia, Professor C. Leon; Copenhagen, Denmark, Professor 0. J. Rafaelsen; Bombay, India, Professor V. N. Bagadia; Ibadan, Nigeria, Dr M. 0. Olatawura; Stockholm, Sweden, Dr L. Levi; Basel, Switzerland, Professor P. Kielholz.

WHO's activity in psychopharmacotherapy 7

medication; dose effects of antidepressant medication; and effects of benzodiazepines and therapeutic counselling. The project is being carried out by Collaborating Centres situated in different geographical zones - Latin America, Europe, Africa and Asia. It is expected that the results of this study will increase our understanding of the role of climate, culture, nutrition, etc. on the effectiveness of drug treatment in different populations. Of consider- able practical interest would also be the determination of the effectiveness of defined doses and the selection of adequate dosage of drugs for different populations.

In the framework of this project it is also hopedlto clarify certain problems connected with the possible differences of metabolism of psychotropic substances in different populations, a problem whose scientific significance is obvious.

Another group of studies which is related to the project already mentioned includes investi- gation of certain genetic, psychopharmacological and immunological characteristics and factors influencing or underlying mental disorders - relationship between colour blindness and presence of affective disorders; association between plasma amitriptyline and therapeutic response in affective disorder; and investigation of the antithymic factor in schizophrenia (WHO, 1975a, 1977a). These studies are being carried out by WHO Collaborating Centres for Research and Training in Biological Psychiatry and at present preliminary data are available from the immuno- logical and psychopharmacological projects. The successful development of these projects and the advances achieved in the area of methodology of international collaboration in biological psychiatry, permitted a rational integration of effort of the Collaborating Centres, sharing of resources and pooling of knowledge. The results of the work so far lead to the definition of strategies of international collaboration in biological psychiatry. One usually believes that strategy consists of steps suggested by common sense and logic.and this really should be so, but unfortunately this exists only in theory. The history of science, as well as its every- day practice, indicates that on many occasions it is precisely the apparently illogical approaches of the investigators which bring about success. Unfortunately, we do not know how to programme such "illogical" approaches and therefore have to base our work on experience from successful collaborative projects. Several such projects have been carried out by the Division of Mental Health on two conditions of major public health importance - schizophrenia and affective dis- orders.

Table 1 indicates the main directions of research related to these two groups of disorders, the multidisciplinary approach is a priority in the work of WRO. Some of these studies have already been completed or are nearing completion, and the results have been published; others are in progress or in their early beginning (WHO, 1973, 1977b). This illustrates the step-wise approach to major scientific problems, based on the principle of movement from the simple to

Table 1. Main approaches of WHO collaborative studies

Depression Standardization of clinical assessment Incidence Depression in general practice Dose effects of antidepressant medication

in different populations Associations between plasma amitriptyline

level and therapeutic response in depressive disorders

Schizophrenia Standardization of clinical assessment

Course and outcome in different cultures Environmental influences on prognosis Dose effects of antipsychotic medication in

different populations Investigation of the antithymic immune factor

in schizophrenia

Relationship between colour blindness and presence of affective disorders

ABO antigens determination in unipolar/ bipolar affective disorders

8 P. E. Vartanian

the more complex phenomena, or from the relatively well-known to the little-known. In this process one of the factors of success is, and will continue to be, the capability of the collaborating investigators to develop a common language in the assessment of clinical pheno- mena. This has been achieved by the development of a number of standardized clinical hnstru- ments which have facilitated integration of efforts and led to a relatively rapid yield of data at a lower cost because of avoidance of duplication of efforts. Another factor is the expressed interest of numerous research institutions in different parts of the world in joining this collaborative network coordinated by WHO. One of the main criteria for effectiveness of such joint projects is that they function and advance with minimum coordination by WHO and, in the long run, become capable of further development without the coordinating role of WHO. When this happens it provides additional proof of the soundness of the design of the study and of its methodology, as well as of the right selection of collaborating units and groups.

The problems of drug treatment of mental disorders are related to a number of factors. New data often require change of treatment strategies, the level of training and skills of the collaborating investigators in different categories must be upheld and financial support made permanently available, etc. Especially difficult problems arise in connection with the treat- ment of mental disorders in developing countries. A large proportion of the urban, but parti- cularly of the rural population, has no access whatsoever to any form of organized health care (WHO, 1975b). It is clear that this situation cannot continue indefinitely. New data, new information, new approaches, taking into account the specific conditions prevailing in develop- ing countries, are needed in order to organize and implement rationally the treatment and management of psychiatic disorders. Attention is given to this and the WHO project on the "Effects of Psychotropic Drugs in Different Populations" should be mentioned here again. It is likely that this project will generate new important data. What are the ways of application of this new knowledge? The possibilities for application of knowledge available now in the area of psychopharmacotherapy of mental disorders are limited. The solution of this problem will depend on an improvement in the socio-economic conditions of developing countries and on the level and extent of technical cooperation with such countries, undertaken by international organizations and through bilateral agreements.

WHO puts a very strong emphasis on the need for effective technical cooperation with develop- ing countries in the area of health care and some progress has already been made in this respect. The high cost of psychotropic drugs, the very limited resources for research and for implementation of the practical results of such research, the sky-rocketing costs of scientific books in the area of psychopharmacology, all these have unfavourable effects on the perspec- tives of psychopharmacotherapy in developing countries. Of course, developed countries cannot remain unaffected by these difficulties. The financing of research in applied and basic pey- chopharmacology is limited and inadequate. There is a discrepancy between the objectives and needs put before psychopharmacological centres and their potential for carrying out the neces- sary steps to achieve such objectives. The development of new, more effective psychopharma- cological compounds requires the efforts of large numbers of workers from different branches and specialties, the access to an industrial base, etc. The solution of these problems depends to a considerable degree on the adequate financing of studies, which would enable the tranai- tion from empirical screening of new chemical compounds to the rational goal-oriented synthesis of psychopharmacological drugs.

Thus the research of psychotropic drugs gradually becomes a more systematic exercise based on theoretical foundations. Psychopharmacology is now one of the important avenues of work parallel to research on the aetiology and pathogenesis of mental disorders, and to operational research on the organization of services and training, leading ultimately to the control and prevention of psychiatric morbidity.

There are reasons to believe that in the coming years new groups of psychotropic compounds will become available and that new possibilities for control and intervention into the func- tional mechanisms of the brain will be provided.

WHO's activity in psychopharmacotherapy 9

References

WORLD HEATLH ORGANIZATION (1976). Report of a Consultation on Drug Treatment for Neuropsychia- tric Disorders in Developing Countries. WHO, Geneva. 18 pp.

WORLD HEALTH ORGANIZATION (1975a). Report on an Exchange of Visits of Investigators. WHO, Geneva. 15 pp.

WORLD HEALTH ORGANIZATION (1977a). Report on the 2nd Exchange of Visits of Investigators. WHO, Geneva. 10 pp.

WORLD HEALTH ORGANIZATION (1973). Report of the International Pilot Study of Schizophrenia, Vol. 1. WHO, Geneva. 427 pp.

WORLD HEALTH ORGANIZATION (1977b). Schedule for a Standardized Assessment of Patients with Depressive Disorders, 5th draft. WHO, Geneva. 12 pp.

WORLD HEALTH ORGANIZATION (1975b). Organization of Mental Health Services in Developing Countries, Technical Report Series 564. WHO, Geneva. 41 pp.

Inquiries and reprint requests should be addressed to:

Dr F. E. Vartanian, Senior Medical Officer Division of Mental Health World Health Organization, 1211 Geneva 27, Switzerland.