Paper short abstract:

This paper draws on ethnography of Peruvian peasant communities to discuss obstacles to community provision for severe mental disorders. Psychiatry must reckon with rival healers, ethnic divisions and resource-poor services, if it is to fill the 'treatment gap' between urban and rural mentally ill.

Paper long abstract:

In recent years, the 'global mental health' (GMH) movement has provided an impetus towards the scale-up of mental health care provision in developing countries, based on evidence-based practice. The tenets of the programme have not gone unchallenged, with criticisms of its tendencies towards medicalisation and question marks over its cross-cultural efficacy. Even some of GMH's harshest critics, however, have largely accepted the value of its input for disorders such as psychosis (Summerfield 2008). Yet even its proponents accept that the evidence base for the implementation of interventions with marginalised, rural populations is sparse.

This paper draws on ethnographic research in the peasant communities of a southern Peruvian province to discuss the possibilities and obstacles that confront efforts to extend the provision of services for severe mental disorders to this historically neglected population. Although psychiatric input is now available, it must compete with traditional healers and the evangelical churches for the loyalties of its patients, and deal with the legacy of historic tensions between health services and the largely indigenous residents. Patients often do not persist with it and it is by no means dominant. The GMH 'package of care' for psychosis relies heavily on the input of family, community figures and primary health workers for referral and monitoring; based on the Peruvian context, I explore how psychiatry will need to approach such social environments if it is to successfully fill the 'treatment gap' between the urban and rural mentally ill.