Heidi Splete

A 9-year-old girl presented with symptoms of sexual abuse including vulvovaginal maceration and perianal skin tags.

She also had gum hypertrophy, hand eczema, mild clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What's your diagnosis?

Watch our video to find out.

A 9-year-old girl presented with symptoms of sexual abuse including vulvovaginal maceration and perianal skin tags.

She also had gum hypertrophy, hand eczema, mild clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What's your diagnosis?

Watch our video to find out.

A 9-year-old girl presented with symptoms of sexual abuse including vulvovaginal maceration and perianal skin tags.

She also had gum hypertrophy, hand eczema, mild clubbing of the fingers, and diffuse hair loss, as well as depression and apathy. What's your diagnosis?

Watch our video to find out.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

SAN DIEGO – Women with nontoxic goiter were more than twice as likely to have breast cancer, compared with women in the general population, according to a review of data from 789 women with nontoxic, multinodular goiter, uninodular goiter, or simple goiter.

The findings were presented at the annual meeting of the American Association of Clinical Endocrinologists.

Data from previous studies of a potential link between thyroid disorders and breast cancer are inconclusive, said Sarika Patel Sanghvi, D.O., of Robert Wood Johnson Medical School in New Brunswick, N.J.

In this study, Dr. Sanghvi and her colleagues compared breast cancer incidence in women with nontoxic goiter with breast cancer incidence in the general population of New Jersey. Breast cancer history was obtained from each patient’s medical history.

Overall, 28 of 789 women with goiter also had breast cancer, for a prevalence of 3.6%. By contrast, the prevalence of breast cancer in the general population, based on data from the New Jersey Department of Health and Senior Services, was significantly lower at 1.6%.

Two of the 28 patients with breast cancer had low TSH levels, but one had a free T4 within normal limits and the other had a total T4 within normal limits, said Dr. Sanghvi. Four of the 28 patients had serum thyroid peroxidase (TPO) antibodies, only one level of which was elevated, but this patient had normal TSH and free T4 levels, Dr. Sanghvi said.

The association between breast cancer and nontoxic goiter is unclear, she said. Possible mechanisms include the role of iodine, thyroid-stimulating hormone, and estrogen.

"Iodine has been theorized as being a causative factor, because it is utilized by both breast and thyroid tissues," and these are the only two organs in which iodine is stored. Dr. Sanghvi explained. However, epidemiologic studies are needed to explore the association between iodine and breast cancer, she said.

The results were limited by the retrospective nature of the study, and the lack of a standard medical history questionnaire. But they underscore the important of breast cancer screening in women with benign thyroid disease until larger, prospective studies provide additional information, Dr. Sanghvi said.

In the study population as a whole, the average age was 51 years, the average body mass index was 29.2 kg/m², the average TSH was 2.02 mIU/L, and the average free T4 was 1.67 ng/dL. Among the 28 patients with a family history of breast cancer, the average age was 57 years, the average BMI was 29 kg/m², the average TSH was 1.54 mIU/L, and the average free T4 was 1.14 ng/dL

One of the patients with breast cancer had ductal carcinoma in situ; the breast cancer types in the other 27 patients were not specified.

Dr. Sanghvi reported having no financial conflicts to disclose.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

NATIONAL HARBOR, MD. – Fibromyalgia patients who failed to respond to pregabalin showed significant symptom improvement when milnacipran was added to their regimen compared with those who continued taking pregabalin alone, a study involving 332 patients has shown.

The open-label study was the first randomized, controlled trial to show the benefits of adding milnacipran (MLN) to existing pregabalin (PGN) therapy in fibromyalgia patients, according to Dr. Mildred Farmer of Meridien Research in St. Petersburg, Fla., and colleagues. Pregabalin was approved for treating patients with fibromyalgia in 2007; milnacipran was approved for the indication in 2009.

The patients, aged 18-70 years, had baseline Visual Analog Scale (VAS) pain scores of 40 or higher, and they failed to improve on PGN alone during a 4- to 12-week PGN run-in period.

After the run-in period, patients were randomized to 300 or 450 mg/day of PGN (which served as the control group) or a PGN treatment plus 100 mg/day of milnacipran.

After 11 weeks, significantly more patients in the MLN group reported their symptoms were "much improved" or "very much improved" compared with the control group, based on Patients’ Global Impression of Change scale scores. Patients in the MLN group also showed significant improvements in physical and mental function, fatigue, and cognition compared with controls, based on scores on the Multiple Ability Self-Report Questionnaire (–3.69 vs. 1.19).

In addition, "patients receiving MLN added to PGN had significantly greater improvements in VAS 1-week recall pain scores than patients treated with PGN alone," Dr. Farmer said at the annual meeting of the American Academy of Pain Medicine.

The incidence of serious adverse events was not significantly different between the MLN and PGN groups (2.7% vs. 3.4%), nor was the rate of discontinuation significantly different between the two groups (15% vs. 9%). The most common treatment-emergent adverse events in the MLN group were nausea (10%), fatigue (10%), and constipation (10%). Overall, the incidence of adverse events was consistent with, or less than, the adverse events listed in the prescribing information for MLN and PGN, the researchers noted.

No patients in either group had clinically significant increases or decreases in systolic blood pressure.

The results were limited by the open-label nature of the study. However, the data suggest that fibromyalgia patients with an incomplete response to PGN alone might benefit from the addition of MLN. "Milnacipran and pregabalin appear to be complementary in their actions in fibromyalgia patients," Dr. Farmer said.

The study was sponsored by Forest Laboratories and Cypress Bioscience. Two of the study coauthors were employed by these companies. Dr. Farmer is the chief principal investigator and medical director of Meridien Research.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

Learn more about the Carter Center’s mental health program.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

Learn more about the Carter Center’s mental health program.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

Learn more about the Carter Center’s mental health program.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.

He spent a month in Liberia last fall and recently returned in March from his second trip.

What were your goals during your first visit?

The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.

I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.

How would you describe the mental health challenges in Liberia?

There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.

The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.

The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.

Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.

This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.

Have people in Liberia been receptive to mental health care?

In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.

I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.

The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.

What did you observe regarding compliance with mental health treatment?

The main barrier to compliance was the availability of the needed medicine. For example, family members would come to a clinic or hospital for epilepsy medication. They would get medicine to treat the patient for a few months. When they ran out of medication, they would come back for more, but the pharmacy and hospital would have run out. Also, a number of medications are sold on the black market, and patients who buy them can end up with medications that are expired or of the incorrect dosage.

What can be done to make more medications available?

The solutions include advocacy and raising awareness. There is a dearth of data about mental illness prevalence. The Liberian Ministry of Health and Social Welfare faces serious challenges when it makes decisions about allocating scarce resources, and these decisions are complicated by the lack of data on disease burden. If you don’t know the prevalence of epilepsy, it is difficult to determine how much medication needs to be ordered for the country. If clinicians don’t know how to recognize depression, they can’t estimate the number of patients needing treatment.

Better epidemiologic data are crucial to ensuring evidence-based decisions. Some helpful data exist; for example, multiple studies of PTSD (posttraumatic stress disorder) have been conducted that involve thousands of participants in Liberia. However, for other conditions such as epilepsy and schizophrenia, very little epidemiologic information is available. We hope to work with other organizations to determine the prevalence of the most debilitating mental illnesses and then raise awareness about the numbers of individuals affected. Through this process, we can work with the government to get treatment to the people who need it.

What are some of the conditions that people had in the places you visited?

Of approximately 20,000 clinic and hospital visits related to neuropsychiatric conditions in 2010, 45% were for epilepsy or seizure disorders, 15% were for schizophrenia, 14% for anxiety and psychosomatic disorders, and 9% were for depression and bipolar disorder. These numbers are just the tip of the iceberg. The actual burden of depression is likely much greater, as most people with depression don’t seek help. And most clinicians don’t know how to screen for it.

Substance abuse is a key concern, and the Carter Center plans to work with the Liberian government to put tools and resources in place to help address this problem.

The Ministry of Health and Social Welfare in Liberia intends to address five major conditions through a national mental health policy: epilepsy, psychosis, schizophrenia, substance abuse, and PTSD. A major issue with PTSD is the difference between the amount of attention it gets on an international scale and the attention that is given to other conditions. The majority of research in Liberia has focused on PTSD, but epilepsy, depression, psychosis, and substance abuse individually all contribute to a much greater portion of neuropsychiatric disability.

Why do you think there was so much epilepsy?

That is a good question. During my visit, we went to a remote area in the center of the country where roads are impassable for most of the year. In that area, we found a high prevalence of epilepsy and many cases in multiple family members. More research is needed to identify why this large burden of epilepsy affects parts of the country. This will help us find the best way to treat it. Is it a genetic condition, does it result from environmental exposure – or a combination? Many of the patients with epilepsy had cerebral malaria as children. Improving infectious disease treatment may be key to reducing later neuropsychiatric sequelae.

We were interested in the local understandings of epilepsy. We found that many people thought it was contagious. This led to health care workers’ stigmatizing patients and refusing them treatment. One belief is that people can transmit epilepsy from one person to another through saliva during a seizure. They compared it with the way rabies is transmitted from one animal to another.

We saw many persons with epilepsy who had significant burns, scars, and poorly healing sores. We found out that if someone with epilepsy falls into a fire, people do not pull them out because they are afraid of contracting epilepsy. Similarly, there are cases of persons drowning during seizures because people are afraid to pull them out of the water. I would argue that none of these is an unchangeable cultural belief. They represent fundamental human attempts to understand experience. These behaviors and stigmatization can be changed through education, combined with improved access to neuropsychiatric care.

What can be done to raise awareness?

The next step is creating antistigma messages in partnership with the Ministry of Health and other local groups. The Carter Center will work to raise awareness and educate people about epilepsy, psychosis, and depression. The campaigns will be in the form of radio dramas and street performances, which are ideal ways to get people engaged in the issue and get them to ask questions. Interactive narrative approaches are crucial to teach basic lessons about mental health care and support for individuals with mental illness

The Carter Center also is developing a mental health training module for family psychoeducation and support. This will complement the government’s ongoing work in standardizing psychosocial care in the country. This summer, the center will be piloting the module to see how it can improve quality of life for persons with mental illness and their families.

Do you have any tips about mental health care for clinicians who are working overseas?

Any clinician – regardless of specialty – who is working in underserved communities can have a dramatic impact in mental health care. There are two powerful things you can do: First, providing general health care for a person with mental illness sets an important example. In Liberia, as in most low- and high-income countries, mental health care often is a lower priority than are other kinds of medical care. In Liberia, persons with mental illness were often not given the same access to hospital care as were other patients because health care workers were uninformed about mental illnesses, thought that mental illnesses were contagious, and were afraid of psychiatric patients. As a clinical provider working overseas, you have the opportunity to demonstrate equality of care.

Second, clinicians in any specialty can take time to provide basic teaching on neuropsychiatric conditions. Any health care worker – from an ophthalmologist to a pediatric nurse – can use such opportunities to teach the basics about epilepsy, depression, or substance abuse.

Even the most basic lessons in mental health would be a tremendous benefit to local health professionals and people in areas with little exposure to information. To promote mental health around the globe, we need to communicate only three basic messages: Mental illness is treatable, it is not contagious, and it is just as important to people’s well-being as treating physical illnesses.

For more information about the Carter Center’s mental health program, visit http://www.cartercenter.org/health/mental_health/index.html.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.

SAN DIEGO – Type 2 diabetes patients achieved greater blood sugar control with once-daily liraglutide injections than with other standard type 2 diabetes medications, according to the findings from a meta-analysis of seven phase III studies. The findings were presented April 14 at the annual meeting of the American Association of Clinical Endocrinologists.

"The progressive nature of type 2 diabetes makes it difficult for any single therapy to be effective long-term," said Dr. Robert Henry of the University of California, San Diego.

Liraglutide (Victoza) was approved by the Food and Drug Administration in January 2010 to treat type 2 diabetes in adults as an adjunct therapy to a healthy diet and exercise.

To further evaluate the impact of liraglutide on blood sugar control, Dr. Henry and his colleagues consolidated data from seven phase III clinical trials and divided the patients into five categories based on their baseline hemoglobin A_1c level: 7.5% or less (651 patients), 7.6%-8.0% (601 patients), 8.1%-8.5% (538 patients), 8.6%-9.0% (432 patients), and greater than 9.0% (607 patients).

The researchers reviewed the mean changes in HbA_1c from baseline to 26 weeks of treatment. Overall, mean hemoglobin A_1c reductions with a once-daily, 1.8-mg dose of liraglutide were greater than the reductions achieved with standard regimens involving exenatide, insulin glargine, glimepiride, rosiglitazone, or sitagliptin.

In particular, HbA_1c levels were significantly reduced in patients with a baseline HbA_1c of 7.5% or less in the liraglutide group compared with all other groups. The mean reductions in HbA_1c for patients on liraglutide ranged from 0.7% in the 7.5% or less category to 1.8% in the greater than 9.0% category. The next best mean reduction in HbA_1c was seen among patients taking two other injectable therapies: insulin glargine and exenatide. Reductions in HbA_1c in patients taking insulin glargine ranged from 0.3% to 1.5%, and HbA_1c reductions in those taking exenatide ranged from 0.4% to 1.3%.

Patients taking sulfonylureas, sitagliptin, or thiazolidinediones showed less improvement from baseline than did patients taking the injectables. The average reduction in patients taking sitagliptin ranged from 0.0% to 1.1%. The average reduction with sulfonylureas ranged from 0.4% to 1.4%, and the average reduction with thiazolidinediones ranged from 0.4% to 0.8%.

Among 348 patients in the liraglutide group with baseline HbA_1c levels of 7.5% or less, 216 (63%) reached the AACE-recommended HbA_1c target of 6.5% or less, compared with less than half (20%-49%) of patients with a baseline HbA_1c of 7.5% or less in the other groups, Dr. Henry noted.

Among 333 patients in the liraglutide group with HbA_1c levels greater than 9.0%, 33 (10%) reached the 6.5% or less target, compared with 4 (12%) of 34 patients in the insulin glargine group and 0%-5% of patients in the other groups.

The study was limited by the use of mean data, which does not account for individual variability, but the results suggest that liraglutide was effective at reducing HbA_1c throughout the baseline HbA_1c spectrum, Dr. Henry said.

The study was sponsored by Novo Nordisk, which manufactures liraglutide. Dr. Henry has received research support from multiple pharmaceutical companies, including Amylin Pharmaceuticals, AstraZeneca, and Novartis. He has served as an adviser or consultant for, and has received consulting fees from, several companies, including Amylin, Eli Lilly, and Novo Nordisk.