It is almost a month since the International Day for Persons with Disabilities (December 3) passed. Yet, we must pause and consider the importance of novel and innovative solutions that enhance two important outcomes for the people affected, i.e., activities of daily life and quality of life. By calling for “transformative solutions that will lead to inclusive development, leaving no one behind”, the United Nations has shifted the focus back on innovations that reduce disability. In the important medical field of “neuropsychiatry” that straddles the brain-mind interface, there have been several treatment innovations with the potential to enhance outcomes — and the focus of this article.
Neuropsychiatric disorders are, by definition, disabling and present themselves across the lifespan. These range from autism, Attention-deficit/hyperactivity disorder (ADHD) and intellectual disability in childhood (317 million), and to mental health conditions such as anxiety, depression, obsessive compulsive disorder, eating disorder, addictions, schizophrenia, bipolar disorder through adolescence and adult life (167 million adolescents and 970 million people, globally), traumatic brain injury, spinal injury, epilepsy and headache across the lifespan, stroke, neurodegenerative conditions such as Alzheimer’s dementia and Parkinson’s disease that appear in old age (276 million neurologically affected individuals in all).
Revamp rehabilitation services
With such a large burden of people affected around the globe, it is rational to assume that rehabilitation needs are plentiful. According to the World Health Organization’s Global Burden of Disease study, 2019, 2·41 billion individuals had conditions that would benefit from rehabilitation, contributing to 310 million Years of Living with Disabilities (YLD). This number had increased by 63% from 1990 to 2019. However, with rehabilitation often being seen as a disability-specific service, needed by only a few, it has, despite its individual and societal benefits, not been prioritised in countries and is traditionally under-resourced.
With neurology and psychiatry being closely linked, there exists a continuum of needs between these conditions, often with considerable overlap. Rehabilitation services must, therefore, be designed to address the wide spectrum of neurological and mental health problems as opposed to being narrow in concept and specialist led. There is a need to build awareness in the community that disablement does not need to be endured and can be treated, even reversed, in a proportion of cases.
There is also a need to encourage medical professionals, medical service providers (government, private and non-profit) as well as public health professionals to consider rehabilitation as an essential service. Beyond doctors and nurses, rehabilitation across the lifespan requires a range of professionals: physical and occupational therapists, speech and language therapists, psychological therapists and professional caregivers. Enhancing these professional profiles, improving training, creating mainstream opportunities for career development and empowering their professional growth is important in order for services to develop and evolve. Further, it is widely understood today that rehabilitation services need to be multidisciplinary, multicomponent and holistic. Developing such service paradigms is crucial.
Tap scientific advances
There are unique paradigms of care that have emerged through scientific advances that we must consider. A host of non-invasive brain stimulation (NIBS) procedures have proved themselves to be very useful in the care and rehabilitation of neurological and mental health conditions. Repetitive Transcranial Magnetic Stimulation (rTMS) as a mainstream treatment for both depression and obsessive compulsive disorder and as an adjuvant treatment for diverse conditions: tremors of Parkinson’s disease, Schizophrenia (hallucinations and other psychotic symptoms), addictions, pain and spasticity management especially that following strokes and traumatic brain injury, adolescent and adult Autism Spectrum Disorder, aggression and so on. An allied technique, Functional (or peripheral) Magnetic Stimulation (FMS), is also available today for pain, spasticity, incontinence and other disabling neurological symptoms.
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Another NIBS technique with great promise is transcranial electrical stimulation (TES) with its many sub-types (direct current, alternate current and random noise). The treatment has shown itself to be successful in improving memory and cognition, mood and behaviour, anxiety, tremors, confusion and delirium, and sleep disorders. It has the advantage of being portable and bedside. In the post-COVID-19 era, another treatment that has assumed importance is transcutaneous auricular vagus nerve stimulation (tA-VNS), vagus nerve abnormalities being responsible for a host of long COVID-19 symptoms. Developed as a treatment for epilepsy, this is currently being investigated for depression, migraine and dysautonomia.
Need for collaboration
With a billion people with disabilities worldwide, 80% in developing countries, the United Nation’s call for disability inclusion being central to the promise of the 2030 Agenda for Sustainable Development to leave no one behind assumes importance. People in vulnerable situations such as persons with disabilities are the most excluded and left behind, especially in times of crisis, as was apparent during the COVID-19 pandemic. Therefore, it is crucial for governments, the public and private sectors to collaborate and find innovative solutions for and with persons with disabilities, to make the world a more accessible and equitable place.
Dr. Ennapadam S. Krishnamoorthy is Founder – Buddhi Clinic, Past President, International Neuropsychiatric Association (INA) and Adjunct Professor, Manipal University and the Public Health Foundation of India
