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Mihretu A, Fekadu W, Alemu AA, Amare B, Assefa D, Misganaw E, Ayele A, Esleman O, Assefa Z, Alem A, Thornicroft G, Hanlon C. Impact of the COVID-19 pandemic on mental health care and people with mental health conditions in Ethiopia: the MASC mixed-methods study. Int J Ment Health Syst 2023; 17:47. [PMID: 38057791 PMCID: PMC10699067 DOI: 10.1186/s13033-023-00612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/22/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has had far-reaching effects on the mental health of populations around the world, but there has been limited focus on the impact on people with existing mental health conditions in low-income countries. The aim of this study was to examine impact of the pandemic on mental health care and people with mental health conditions in Ethiopia. METHODS A convergent mixed methods study was conducted. We systematically mapped information from publicly available reports on impacts of the pandemic on mental health care. Monthly service utilisation data were obtained from Amanuel Mental Specialised Hospital, the main psychiatric hospital, and analysed using segmented Poisson regression (2019 vs. 2020). In-depth interviews were conducted with 16 purposively selected key informants. Framework analysis was used for qualitative data. Findings from each data source were integrated. RESULTS In the early stages of the pandemic, participants indicated a minimal response towards the mental health aspects of COVID-19. Mental health-related stigma and discrimination was evident. Scarce mental health service settings were diverted to become COVID-19 treatment centres. Mental health care became narrowly biomedical with poorer quality of care due to infrequent follow-up. Households of people with pre-existing mental health conditions in the community reported worsening poverty and decreased access to care due to restricted movement, decreased availability and fear. Lack of reliable medication supplies increased relapse and the chance of becoming chained at home, abandoned or homeless. Caregiver burden was exacerbated. Within mental health facilities, prisons and residential units, infection control procedures did not adequately safeguard those with mental health conditions. Meanwhile, the needs of people with mental health conditions in COVID-19 quarantine and treatment facilities were systematically neglected. Only late in the day were integrated services developed to address both physical and mental health needs. CONCLUSIONS The COVID-19 pandemic had substantial negative impacts on the lives of people with mental health conditions in Ethiopia. Future emergency response should prioritise the human rights, health, social and economic needs of people with mental health conditions. Integration of mental and physical health care would both expand access to care and increase resilience of the mental health system.
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Affiliation(s)
- Awoke Mihretu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wubalem Fekadu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Azeb Asaminew Alemu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Beakal Amare
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dereje Assefa
- Mental Health Case Team, Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Eleni Misganaw
- Mental Health Service Users Association, Addis Ababa, Ethiopia
| | - Abebaw Ayele
- Mental Health Case Team, Disease Prevention and Control Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Ousman Esleman
- Policy, Plan and Monitoring & Evaluation Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Zewdu Assefa
- Center for Public Health Emergency Management, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Atalay Alem
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Graham Thornicroft
- Centre for Global Mental Health, Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Centre for Global Mental Health, Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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Omigbodun OO, Ryan GK, Fasoranti B, Chibanda D, Esliker R, Sefasi A, Kakuma R, Shakespeare T, Eaton J. Reprioritising global mental health: psychoses in sub-Saharan Africa. Int J Ment Health Syst 2023; 17:6. [PMID: 36978186 PMCID: PMC10043866 DOI: 10.1186/s13033-023-00574-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.
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Affiliation(s)
- O O Omigbodun
- Department of Psychiatry and Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, 200212, Oyo State, Nigeria
| | - G K Ryan
- Department of Population Health, London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, Keppel Street, London, WC1E 7HT, UK.
| | - B Fasoranti
- Department of Psychiatry and Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, 200212, Oyo State, Nigeria
| | - D Chibanda
- Department of Population Health, London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, Keppel Street, London, WC1E 7HT, UK
- Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - R Esliker
- Mental Health Department, University of Makeni, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | - A Sefasi
- Department of Mental Health, Kamuzu University of Health Sciences, P/Bag 360, Blantyre, Malawi
| | - R Kakuma
- Department of Population Health, London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, Keppel Street, London, WC1E 7HT, UK
| | - T Shakespeare
- Department of Population Health, London School of Hygiene and Tropical Medicine, International Centre for Evidence in Disability, Keppel Street, London, WC1E 7HT, UK
| | - J Eaton
- Department of Population Health, London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, Keppel Street, London, WC1E 7HT, UK
- CBM Global Disability Inclusion, Dr.-Werner-Freyberg-Straβe 7, 69514, Laudenbach, Germany
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3
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Yang LH, Phillips MR, Li X, Yu G, Grivel MM, Zhang J, Shi Q, Ding Z, Pang S, Susser E. Determinants of never-treated status in rural versus urban contexts for individuals with schizophrenia in a population-based study in China. BMC Psychiatry 2022; 22:128. [PMID: 35177017 PMCID: PMC8851815 DOI: 10.1186/s12888-021-03651-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/10/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A goal of China's 2012 National Mental Health Law is to improve access to services and decrease urban versus rural disparities in services. However, pre-reform data is needed for objective evaluation of these reforms' effectiveness. Accordingly, this study compares the pre-reform utilization of medical services for the treatment of schizophrenia in rural and urban communities in China. METHODS In a large community-based study in four provinces representing 12% of China's population conducted from 2001 to 2005, we identified 326 individuals with schizophrenia (78 never treated). Comparing those living in urban (n = 86) versus rural (n = 240) contexts, we used adjusted Poisson regression models to assess the relationship of 'never treated' status with family-level factors (marital status, family income, and number of co-resident family members) and illness severity factors (age of onset, symptom severity and functional impairment). RESULTS Despite similar impairments due to symptoms, rural patients were less likely to have received intensive mental health services (i.e., use psychiatric inpatient services), and appeared more likely to be 'never treated' or to only have received outpatient care. Among rural patients, only having more than four co-resident family members was independently associated with 'never-treated' status (RR = 0.34; 95% CI, 0.12-0.94; p = 0.039). Among urban patients, only older age of onset was independently associated with 'never-treated' status (RR = 1.06; 95% CI 1.02-1.10, p = 0.003). CONCLUSIONS Identifying differential drivers of service utilization in urban and rural communities is needed before implementing policies to improve the utilization and equity of services and to define metrics of program success.
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Affiliation(s)
- Lawrence H. Yang
- grid.137628.90000 0004 1936 8753Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY USA ,grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Michael R. Phillips
- grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA ,grid.16821.3c0000 0004 0368 8293Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 3210 Humin Road, Shanghai, 201108 People’s Republic of China ,grid.21729.3f0000000419368729Department of Psychiatry, Columbia University, New York, NY USA ,grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Xianyun Li
- grid.414351.60000 0004 0530 7044Beijing Hui Long Guan Hospital, Beijing, China
| | - Gary Yu
- grid.137628.90000 0004 1936 8753Rory Meyers College of Nursing, New York University, New York, NY USA
| | - Margaux M. Grivel
- grid.137628.90000 0004 1936 8753Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY USA
| | - Jingxuan Zhang
- Shandong Provincial Mental Health, Jinan City, Shandong Province China
| | - Qichang Shi
- Tong De Hospital of Zhejiang Province, Hangzhou City, Zhejiang Province China
| | - Zhijie Ding
- The 3rd People’s Hospital of Tianshui City, Tianshui, Gansu Provice China
| | - Shutao Pang
- Qingdao Blood Center, Qingdao City, Shandong Province China
| | - Ezra Susser
- grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
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Cohen F. Ecologies of care for serious mental illness in Uganda: A scoping review. GLOBAL SOCIAL WELFARE : RESEARCH, POLICY & PRACTICE 2021; 8:301-315. [PMID: 34926127 PMCID: PMC8673741 DOI: 10.1007/s40609-020-00193-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Flora Cohen
- Brown School at Washington University in St. Louis
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5
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Huxley P, Krayer A, Poole R, Prendergast L, Aryal S, Warner R. Schizophrenia outcomes in the 21st century: A systematic review. Brain Behav 2021; 11:e02172. [PMID: 33991072 PMCID: PMC8213926 DOI: 10.1002/brb3.2172] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE We report a review of outcomes in schizophrenia in the twenty-first century, replicating and extending work undertaken by the late Richard Warner in his seminal book, "Recovery from Schizophrenia: Psychiatry and Political Economy" (1985;2004). METHOD Warner's methods were followed as closely as possible. Only observational/naturalistic studies were included. Six scientific databases were searched from 2000 to 2020. 6,640 records were retrieved. 47 met inclusion criteria. RESULTS Overall, complete recovery is higher in this study than in Warner's (37.75% cf 20.4%), especially for first episode psychosis (FEP) (57.1% cf 20.7%). Clinical recovery, annualized remission rate (ARR), and employment outcomes were significantly superior for first episode psychosis compared with multiple episode psychosis (MEP). ARR shows a trend toward reduction over time, from 2.2 before the financial crash of 2008 to 1.6 after (t = 1.85 df 40 p = .07). The decline is statistically significant for the MEP group (t = 2.32 df18 p = .03). There were no differences in outcome by region, sample characteristics, outcome measures used, or quality of studies. Heterogeneity of clinical outcome measures across the literature makes evidence synthesis difficult. Weak and inconsistent reporting of functional and employment outcomes mean that findings lack meaning with respect to lived experience. CONCLUSION Future research strategies should aim to reduce heterogeneity in clinical outcome measures and to increase the emphasis on capture and reporting of more sophisticated measures of social and functional outcome. Outcome domains should be disaggregated rather than conflated into unitary recovery constructs.
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Affiliation(s)
- Peter Huxley
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Anne Krayer
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Rob Poole
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Louise Prendergast
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Sanjaya Aryal
- Department of Sociology, University of Essex, Colchester, UK
| | - Richard Warner
- Clinical Professor of Psychiatry and Adjunct Professor of Anthropology, University of Colorado, Denver, CO, USA
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Mayston R, Kebede D, Fekadu A, Medhin G, Hanlon C, Alem A, Shibre T. The effect of gender on the long-term course and outcome of schizophrenia in rural Ethiopia: a population-based cohort. Soc Psychiatry Psychiatr Epidemiol 2020; 55:1581-1591. [PMID: 32239264 DOI: 10.1007/s00127-020-01865-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although some studies have suggested that women with schizophrenia are more likely to achieve positive outcomes, the evidence-base is fraught with inconsistencies. In this study we compare the long-term course and outcomes for men and women living with schizophrenia in rural Ethiopia. METHODS The Butajira course and outcome study for severe mental disorders is a population-based cohort study. Community ascertainment of cases was undertaken between 1998 and 2001, with diagnostic confirmation by clinicians using the Schedules for Clinical Assessment in Neuropsychiatry. Findings from annual outcome assessments were combined with clinical records, patient and caregiver report, and psychiatric assessments at 10-13 years using the Longitudinal Interval Follow-up Evaluation- LIFE chart. For the sub-group of people with schizophrenia (n = 358), we compared course of illness and treatment, co-morbidity, recovery, social outcomes and mortality between men and women. Multivariable analyses were conducted for modelling associations identified in bivariate analyses according to blocks shaped by our a priori conceptual framework of the biological and social pathways through which gender might influence the course and outcome of schizophrenia. RESULTS Looking into over 10-13 years of follow-up data, there was no difference in the functioning or recovery in women compared to men (AOR = 1.79, 95% CI = 0.91, 3.57). Women were less likely to report overall life satisfaction (AOR = 0.22, 95% CI = 0.09, 0.53) or good quality of spousal relationships (AOR = 0.09, 95% CI = 0.01-1.04). Men were more likely to have co-morbid substance use and there was a trend towards women being more likely to be prescribed an antidepressant (AOR = 2.38, 95% CI = 0.94, 5.88). There were no gender differences in the course of illness, number of psychotic episodes or adherence to medications. CONCLUSION In this rural African setting, we found little evidence to support the global evidence indicating better course and outcome of schizophrenia in women. Our findings are suggestive of a gendered experience of schizophrenia which varies across contexts. Further investigation is needed due to the important implications for the development of new mental health services in low and middle-income country settings.
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Affiliation(s)
- Rosie Mayston
- Centre for Global Mental Health, Health Service, and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Derege Kebede
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Global Health & Infection, Brighton & Sussex Medical School, Brighton, UK
| | - Girmay Medhin
- Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service, and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.,Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Atalay Alem
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teshome Shibre
- Department of Psychiatry, Horizon Health Network, Fredericton, NB, Canada.
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Tirfessa K, Lund C, Medhin G, Selamu M, Birhane R, Hailemichael Y, Fekadu A, Hanlon C. Impact of integrated mental health care on food insecurity of households of people with severe mental illness in a rural African district: a community-based, controlled before-after study. Trop Med Int Health 2020; 25:414-423. [PMID: 31925844 DOI: 10.1111/tmi.13370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the impact of integrated mental health care upon food insecurity (FI) in households of people with severe mental illness (SMI) in a rural Ethiopian district, and to investigate mediation by improved work impairment and discrimination. METHODS A community-based, controlled before-after study was conducted. People with probable SMI were identified in the community, diagnosed by primary healthcare workers, with diagnostic confirmation from a psychiatric nurse. Households of a person with SMI were matched to control households. District-wide integration of mental health care was implemented. Change in FI status over 12 months of follow-up was measured using the Household Food Insecurity Access Scale. Multivariable models were used to assess improvement in FI. Direct and indirect mediators of change in FI status were modelled using path analysis. RESULTS A total of 239 (81.8%) people with SMI and 273 (96.5%) control households were assessed after 12 months. Maintenance of food security or improvement in food insecurity status was observed in 51.5% of households of a person with SMI vs. 39.7% of control households (adjusted risk ratio 1.41: 95% CI 1.11, 1.80). Reduction in symptom severity was indirectly associated with improved FI status via an impact on reducing work impairment and discrimination (P < 0.001). CONCLUSIONS Improving access to mental health care may reduce food insecurity in households of people with SMI. Optimising engagement in care and adding interventions to improve work functioning and tackle discrimination may further reduce food insecurity.
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Affiliation(s)
- Kebede Tirfessa
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,College of Education and Behavioral Studies, Kotebe Metropolitan University, Addis Ababa, Ethiopia
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.,Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medhin Selamu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rahel Birhane
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Abebaw Fekadu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Global Health & Infection Department, Brighton and Sussex Medical School, Brighton, UK
| | - Charlotte Hanlon
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.,Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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8
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Ghebrehiwet S, Baul T, Restivo JL, Kelkile TS, Stevenson A, Gelaye B, Fekadu A, Hailemariam M, Girma E, Teferra S, Canelos V, Henderson DC, Borba CPC. Gender-specific experiences of serious mental illness in rural Ethiopia: A qualitative study. Glob Public Health 2019; 15:185-199. [PMID: 31630624 DOI: 10.1080/17441692.2019.1680723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Considerable variation in the gender-specific prevalence of serious mental illness (SMI) has been reported in low- and middle-income countries (LMICs). In the rural setting of Butajira, Ethiopia, the male-to-female prevalence ratio of schizophrenia was reported to be 5:1. This qualitative study explores gender-specific experiences of SMI and the extent to which sociocultural factors may explain the observed difference in prevalence estimates. Using purposive sampling, 39 in-depth interviews were conducted with community members from Butajira, a rural district in South Central Ethiopia. Transcripts were analysed using thematic analysis to elicit community perspectives on cultural explanatory models of SMI and experiences in this region. Gender-specific experiences were reported to differ due to visibility of symptoms, community responses, and varying levels of family support towards individuals with SMI. Overall, respondents described how various sociocultural factors subject women with SMI to higher levels of physical and social isolation compared to men, greatly affecting community health workers' ability to identify and provide care to women with mental illness. Future case detection methods should involve family members as they interact with women with SMI early on in the development of their symptoms and play an essential role in their path to mental health care.
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Affiliation(s)
| | - Tithi Baul
- Department of Psychiatry, Boston Medical Center, Boston, USA
| | - Juliana L Restivo
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | | | - Anne Stevenson
- Broad Institute, Stanley Center for Psychiatric Research, Cambridge, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Bizu Gelaye
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, USA
| | - Abebaw Fekadu
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.,Global Health & Infection Department, Brighton and Sussex Medical School, Brighton, UK.,Department of Psychological Medicine, Centre for Affective Disorders, King's College London, Institute of Psychiatry, London, UK
| | - Maji Hailemariam
- College of Human Medicine, Division of Public Health, Michigan State University, Flint, USA
| | - Eshetu Girma
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Teferra
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - David C Henderson
- Department of Psychiatry, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
| | - Christina P C Borba
- Department of Psychiatry, Boston Medical Center, Boston, USA.,Boston University School of Medicine, Boston, USA
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9
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Kebede D, Fekadu A, Kelkile TS, Medhin G, Hanlon C, Mayston R, Alem A. The 10-year functional outcome of schizophrenia in Butajira, Ethiopia. Heliyon 2019; 5:e01272. [PMID: 30923757 PMCID: PMC6423701 DOI: 10.1016/j.heliyon.2019.e01272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/11/2018] [Accepted: 02/20/2019] [Indexed: 10/27/2022] Open
Abstract
Background Long-term functional schizophrenia outcomes are not well characterized in low-income environments because of the rarity of prospective studies. Objectives To assess and describe long-term schizophrenia's functional outcomes and potential outcome predictors. Methods Following a baseline assessment, 316 people with schizophrenia were studied for 10 years, on average. Of the total, 79 were incident cases: cases with onset of the illness occurring two years or less from entry into the study. SF-36 scores of physical and social functioning were used to assess functional outcomes. Linear mixed models were employed to evaluate the association of functioning with potential predictors. Results Social and physical functioning scores regarding the cohort were lower than the population's norm for most of the follow-up period. Incident cases had better function than prevalent cases. Fifteen percent of incident and 30% of prevalent cases had reduced social functioning for at least six years. Declining symptom severity during the follow-up period was significantly associated with improvement in social functioning. When baseline functioning was controlled for, the long-term trend in functionality was not associated with demographic or illness characteristics (age and speed of onset, duration of illness and neuroleptic use at entry, substance use, and medication adherence). Conclusion Long-term physical and social functioning of the population with schizophrenia were significantly lower than the population norm. A significant proportion of the cohort had lower functioning for the long-term. Functioning was not associated with demographic or illness characteristics of the study population.
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Affiliation(s)
- Derege Kebede
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
| | | | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Health Service, and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK
| | - Rosie Mayston
- Centre for Global Mental Health, Health Service, and Population Research Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, UK
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Agenagnew L, Mamaru A, Hailesilassie H, Mekuriaw B, Dawud B, Abdisa E, Tolosa D, Abera M, Soboka M, Kerebih H, Yeshigeta E, Tesfaye E. Disability among patients with mental illness in Jimma Town, Southwest Ethiopia, 2017, communitybased crosssectional studyquestionnaire. JOURNAL OF MENTAL HEALTH AND HUMAN BEHAVIOUR 2019. [DOI: 10.4103/jmhhb.jmhhb_42_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Souraya S, Hanlon C, Asher L. Involvement of people with schizophrenia in decision-making in rural Ethiopia: a qualitative study. Global Health 2018; 14:85. [PMID: 30134989 PMCID: PMC6103856 DOI: 10.1186/s12992-018-0403-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/01/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The involvement of people with psychosocial disabilities in decision-making is a fundamental component of a person-centred and recovery-oriented model of care, but there has been little investigation of this approach in low- and middle-income countries. The aim of this study was to explore the involvement of people with schizophrenia in decision-making relating to their care in rural Ethiopia. METHODS A qualitative study was conducted in rural Ethiopia as part of the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) project, involving two focus group discussions (n = 10) with community-based rehabilitation workers, and 18 in-depth interviews with people with schizophrenia, caregivers, health officers, supervisors and a community-based rehabilitation worker. Thematic analysis was used to examine major themes related to involvement in decision-making in this specific setting. RESULTS Involvement of people with schizophrenia in decision-making in this rural Ethiopian setting was limited and coercive practices were evident. People with schizophrenia tended to be consulted about their care only when they were considered clinically 'recovered'. Caregivers typically had a prominent role in decision-making, but they also acquiesced to the views of health care professionals. People with schizophrenia and caregivers were often unable to execute their desired choice due to inaccessible and unaffordable treatment. CONCLUSIONS Community-based rehabilitation, as a model of care, may give opportunities for involvement of people with schizophrenia in decision-making. In order to increase involvement of people with schizophrenia in rural Ethiopia there needs to be greater empowerment of service users, wider availability of treatment choices and a facilitating policy environment. Further studies are needed to explore concepts of person-centred care and recovery across cultural settings.
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Affiliation(s)
- Sally Souraya
- Department of Population Health, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK. .,Health Services and Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Charlotte Hanlon
- Health Services and Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.,Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Laura Asher
- Department of Population Health, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
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Asher L, Hanlon C, Birhane R, Habtamu A, Eaton J, Weiss HA, Patel V, Fekadu A, De Silva M. Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): a 12 month mixed methods pilot study. BMC Psychiatry 2018; 18:250. [PMID: 30075715 PMCID: PMC6091097 DOI: 10.1186/s12888-018-1818-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based rehabilitation (CBR), or community-based inclusive development, is an approach to address the complex health, social and economic needs of people with schizophrenia in low and middle-income countries. Formative work was undertaken previously to design a culturally appropriate CBR intervention for people with schizophrenia in Ethiopia. The current study explored the acceptability and feasibility of CBR in practice, as well as how CBR may improve functioning among people with schizophrenia. METHODS This mixed methods pilot study took place in rural Ethiopia between December 2014 and December 2015. Ten people with schizophrenia who were unresponsive to treatment with medication alone, and their caregivers, participated in CBR. CBR was led by lay workers with five weeks training and involved home visits (education, family intervention and support returning to work) and community mobilisation. Theory of change was used to guide the pilot evaluation. Qualitative and quantitative data were collected at baseline, six months and 12 months. Forty in-depth interviews and two focus group discussions were conducted with 31 individuals comprising people with schizophrenia, caregivers, CBR workers, supervisors, health officers and community members. RESULTS The RISE CBR intervention may have a positive impact on functioning through the pathways of enhanced family support, improved access to health care, increased income and improved self-esteem. CBR was acceptable to CBR workers, community leaders and health officers. Some CBR workers found it challenging to accept the choices of people with schizophrenia. These concerns were felt to be resolvable with supplementary training for CBR workers. The intervention was feasible but further evaluation is needed on a larger scale. CONCLUSION In low and middle-income countries, CBR may be an acceptable and feasible adjuvant approach to facility-based care for people with schizophrenia. However, contextual factors, including poverty and inaccessible anti-psychotic medication, remain substantial challenges. There were indications that CBR can impact on functioning but the RISE trial will determine effectiveness.
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Affiliation(s)
- Laura Asher
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, NG5 1PB UK
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rahel Birhane
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alehegn Habtamu
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Julian Eaton
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
- CBM International, Cambridge, UK
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Abebaw Fekadu
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Habtamu K, Alem A, Medhin G, Fekadu A, Hanlon C. Functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 2018; 53:803-814. [PMID: 29947862 DOI: 10.1007/s00127-018-1546-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/06/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low- and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting. METHODS A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing community-ascertained cohort of people with SMD (n = 218), and attendees at the Butajira General Hospital psychiatric clinic (n = 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding 2 years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS) were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment. RESULTS Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects, and internalized stigma were associated with functional impairment across self-reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment. CONCLUSION To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects, and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted.
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Affiliation(s)
- Kassahun Habtamu
- School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O.BOX: 1176, Addis Ababa, Ethiopia. .,Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Psychological Medicine, Centre for Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Health Services and Population Research Department, Centre for Global Mental Health, Kings College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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14
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Abstract
PURPOSE OF REVIEW The aim was to synthesize recent evidence on schizophrenia illness experience and outcomes and models of care in low and middle-income countries (LMICs). RECENT FINDINGS There is a plurality of explanatory models for psychosis and increasing evidence that context influences experiences of stigma. People with schizophrenia in LMICs are vulnerable to food insecurity, violence and physical health problems, in addition to unmet needs for mental healthcare. Family support may help to improve outcomes if present, but caregivers may be overwhelmed by the challenges faced. Despite efforts to increase availability, evidence-based care remains inaccessible to many people with schizophrenia. Non-randomized evaluations in South Africa and Mexico indicate that psychosocial support groups for people with schizophrenia and caregivers may be acceptable and useful. Randomized controlled trials in Pakistan and China show that culturally adapted cognitive-behavioural therapy can reduce symptom severity. There is emerging evidence that alternative medicine, such as Tai Chi, may be beneficial, but to date most studies are of low quality. The challenges of biomedical-traditional provider collaborations have been highlighted. Evaluations of integrated mental healthcare in primary care are underway and promise to provide vital information about how to scale-up quality care. SUMMARY Acceptable and effective responses to schizophrenia in LMICs should be cognisant of both cultural context and universal concerns. Efforts to enhance the quality of family support should be central to models of care.
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15
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Ayano G. Significance of mental health legislation for successful primary care for mental health and community mental health services: A review. Afr J Prim Health Care Fam Med 2018; 10:e1-e4. [PMID: 29781692 PMCID: PMC5913777 DOI: 10.4102/phcfm.v10i1.1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 06/11/2017] [Accepted: 06/20/2017] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Mental health legislation (MHL) is required to ensure a regulatory framework for mental health services and other providers of treatment and care, and to ensure that the public and people with a mental illness are afforded protection from the often-devastating consequences of mental illness. AIMS To provide an overview of evidence on the significance of MHL for successful primary care for mental health and community mental health servicesMethod: A qualitative review of the literature on the significance of MHL for successful primary care for mental health and community mental health services was conducted. RESULTS In many countries, especially in those who have no MHL, people do not have access to basic mental health care and treatment they require. One of the major aims of MHL is that all people with mental disorders should be provided with treatment based on the integration of mental health care services into the primary healthcare (PHC). In addition, MHL plays a crucial role in community integration of persons with mental disorders, the provision of care of high quality, the improvement of access to care at community level. Community-based mental health care further improves access to mental healthcare within the city, to have better health and mental health outcomes, and better quality of life, increase acceptability, reduce associated social stigma and human rights abuse, prevent chronicity and physical health comorbidity will likely to be detected early and managed. CONCLUSION Mental health legislation plays a crucial role in community integration of persons with mental disorders, integration of mental health at primary health care, the provision of care of high quality and the improvement of access to care at community level. It is vital and essential to have MHL for every country.
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Affiliation(s)
- Getinet Ayano
- Research and Training Department, Amanuel Mental Specialized Hospital, Addis Ababa.
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16
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Abstract
BackgroundOutcome of schizophrenia has been described as favourable in low-and middle-income countries. Recently, researchers have questioned these findingsAimsTo examine the outcome studies carried out in different countries specifically looking atthose from low-and middle-income countriesMethodsLong-term course and outcome studies in schizophrenia were reviewedResultsA wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/ occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low-and middle-income countriesConclusionsThe outcome of schizophrenia appears to be better in low-and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes
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Kretchy IA, Osafo J, Agyemang SA, Appiah B, Nonvignon J. Psychological burden and caregiver-reported non-adherence to psychotropic medications among patients with schizophrenia. Psychiatry Res 2018; 259:289-294. [PMID: 29091831 DOI: 10.1016/j.psychres.2017.10.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 10/09/2017] [Accepted: 10/22/2017] [Indexed: 11/18/2022]
Abstract
The study examined the association between psychological distress, caregiving burden and caregiver-reported medication adherence in 444 informal family caregivers of patients with schizophrenia. Participants were assessed on the Depression, Anxiety Stress Scale, Zarit Burden Interview and the Medication Adherence Report Scale. Caregivers reported a non-adherence rate of 54.5% among patients with schizophrenia. Poor adherence to antipsychotics was significantly associated with caregiver burden (p < 0.01) and experience of anxiety (p < 0.0001). The burden of caregiving should be considered during the assessment of adherence. The findings suggest a need for culturally appropriate interventions that improve antipsychotic adherence of outpatients with schizophrenia with specific attention to the burden of the caregiver.
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Affiliation(s)
- Irene A Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, University of Ghana, P. O. Box LG 43, Legon, Ghana.
| | - Joseph Osafo
- Department of Psychology, School of Social Studies, College of Humanities, University of Ghana, P.O. Box LG 84, Legon, Ghana.
| | - Samuel Agyei Agyemang
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana.
| | - Bernard Appiah
- Department of Public Health Studies, School of Public Health, Texas A&M Health Science Center, 212 Adriance Lab Rd, 1266 TAMU, College Station, TX, USA.
| | - Justice Nonvignon
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana.
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Humphries S, King R, Dunne MP, Nguyen CH. Early psychosis in central Vietnam: A longitudinal study of short-term functional outcomes and their predictors. Int J Soc Psychiatry 2017; 63:602-613. [PMID: 28817993 DOI: 10.1177/0020764017724589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few longitudinal studies have investigated the functional outcomes of individuals with recent-onset psychotic illness in low- and middle-income countries. AIMS To investigate short-term functional remission and its predictors in a central Vietnamese sample. METHODS A naturalistic 6-month prospective cohort study recruited 79 patients of public health facilities who had experienced a first episode of schizophrenia or related illness in the past 18 months. Individuals and their family members were interviewed using standardised assessments of community functioning, symptoms, treatment, demographics and various psychosocial variables. Rates of functional remission (i.e. no or minimal impairment) were calculated based on rigorous, culturally appropriate criteria. Generalised estimating equations were used to explore predictors of remission. RESULTS Rates of global functional remission were 28% at baseline and 53% at follow-up. In individual functional domains, remission was least common for occupational activities, intermediate for relationships and relatively common for daily living activities. Global functional remission was significantly associated with absence of negative and cognitive symptoms, average or better household economic status and unimpaired premorbid functioning. CONCLUSION Remission rates appeared similar to those seen in many international intervention studies. However, individuals from poor households had markedly unfavourable outcomes, suggesting the need for community-based interventions targeting low-socioeconomic status (SES) groups.
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Affiliation(s)
- Seiji Humphries
- 1 School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD, Australia.,2 Institute for Community Health Research, Hue University of Medicine and Pharmacy, Hue City, Vietnam
| | - Robert King
- 1 School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD, Australia
| | - Michael P Dunne
- 2 Institute for Community Health Research, Hue University of Medicine and Pharmacy, Hue City, Vietnam.,3 School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Cat Huu Nguyen
- 4 Department of Psychiatry, Hue University of Medicine and Pharmacy, Hue City, Vietnam
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Ayano G, Assefa D, Haile K, Chaka A, Haile K, Solomon M, Yohannis K, Awoke A, Jemal K. Mental health training for primary health care workers and implication for success of integration of mental health into primary care: evaluation of effect on knowledge, attitude and practices (KAP). Int J Ment Health Syst 2017; 11:63. [PMID: 29046715 PMCID: PMC5639774 DOI: 10.1186/s13033-017-0169-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/26/2017] [Indexed: 12/04/2022] Open
Abstract
Background Mental disorders are always remained a neglected public health problems in low and middle-income countries (LMICs), most people with mental disorders never receive effective care and there is a large treatment gap. In order to solve the problem integration of mental health into primary health care is recommended and in Ethiopia implementation of the scale of mental health services at primary health care level was started in 2014. For the success of the integration of mental health into primary health care, primary care health professionals are the key personnel who are responsible for the management of mental, neurologic and substance use disorders. However, proper training and education of primary care health professionals is mandatory for an optimal performance and success of integration. This interventional study was conducted to assess the effectiveness of mental health training course for scale up of mental health services at primary health care level in Ethiopia. Methods This quasi-experimental pre- and post-study design was conducted in Ethiopia from October to December 2016 using quantitative data collection methods. A total of 94 primary health care professionals were included in the study. The intervention was conducted by psychiatry professionals using standardized World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) guide prepared for scaling up of mental health care through integration into primary health care (PHC) and general medical services. Pre- and post intervention assessment was done for knowledge, attitude and practice (KAP); and statistically analyzed. A paired sample t test with p values was performed to test the differences between the pre- and post-test. In additions mean and standard deviation of the responses were calculated. Overall the response rate was 100% at the end of the intervention. Results The study resulted in a significant improvement in knowledge, attitude and practice (KAP) of PHC workers about all the four mental, neurologic and substance use disorders during the post intervention survey (p < 0.05). Post intervention the knowledge of health professionals increased by 53.19% for psychosis, 42.56% for depression, 19.25% for epilepsy and 54.22% for alcohol use disorders. Similarly, post intervention attitude increased by 55.32% for psychosis, 40.42% for depression, 36.17% for epilepsy and 43.6% for alcohol use disorders. In addition, post intervention case identification rate increased by 62.78% for psychosis, 55.46% for depression, 21.35% for epilepsy and 41.49% for alcohol use disorders with significant p value (p < 0.05). Conclusions The study results suggest that mental health training could be an effective intervention for improving knowledge, attitudes, and practices among primary health care professionals regarding mental, neurologic and substance use disorders. Training is a prerequisite and vital to enhance the knowledge, attitude, and practice of primary care professionals which plays a significant role for the easy success of integrated care and treatment of mental, neurologic and substance use disorders into the existing general health care services.
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Affiliation(s)
- Getinet Ayano
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Dawit Assefa
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Kibrom Haile
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Asrat Chaka
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Kelemua Haile
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Melat Solomon
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Kalkidan Yohannis
- Research and Training Department, Amanuel Mental Specialized Hospital, PO Box: 1971, Addis Ababa, Ethiopia
| | - Akilew Awoke
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Kemal Jemal
- Academic and Research, College of Health Science, Salale University, Fitche, Ethiopia
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20
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Asher L, Fekadu A, Teferra S, De Silva M, Pathare S, Hanlon C. "I cry every day and night, I have my son tied in chains": physical restraint of people with schizophrenia in community settings in Ethiopia. Global Health 2017; 13:47. [PMID: 28693614 PMCID: PMC5504711 DOI: 10.1186/s12992-017-0273-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 06/28/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mental illness and their families, are rarely heard. The aim of this study was to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions. METHODS A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions (n = 35) with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Thematic analysis was used. RESULTS Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. CONCLUSION Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment. The scale up of accessible and affordable mental health care may go some way to address the issue of restraint. TRIAL REGISTRATION Clinicaltrials.gov NCT02160249 Registered 3rd June 2014.
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Affiliation(s)
- Laura Asher
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Solomon Teferra
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA
| | - Mary De Silva
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Chidarikire S, Cross M, Skinner I, Cleary M. Treatments for people living with schizophrenia in Sub‐Saharan Africa: an adapted realist review. Int Nurs Rev 2017; 65:78-92. [DOI: 10.1111/inr.12391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- S. Chidarikire
- School of Health Sciences University of Tasmania Launceston TAS Australia
| | - M. Cross
- Centre for Rural Health University of Tasmania Launceston TAS Australia
| | - I. Skinner
- Faculty of Engineering, Health Science and the Environment Charles Darwin University Darwin NT Australia
| | - M. Cleary
- Mental Health Nursing School of Health Sciences University of Tasmania Sydney NSW Australia
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Abayneh S, Lempp H, Alem A, Alemayehu D, Eshetu T, Lund C, Semrau M, Thornicroft G, Hanlon C. Service user involvement in mental health system strengthening in a rural African setting: qualitative study. BMC Psychiatry 2017; 17:187. [PMID: 28521749 PMCID: PMC5437561 DOI: 10.1186/s12888-017-1352-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 05/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is essential to involve service users in efforts to expand access to mental health care in integrated primary care settings in low- and middle-income countries (LMICs). However, there is little evidence from LMICs to guide this process. The aim of this study was to explore barriers to, and facilitators of, service user/caregiver involvement in rural Ethiopia to inform the development of a scalable approach. METHODS Thirty nine semi-structured interviews were carried out with purposively selected mental health service users (n = 13), caregivers (n = 10), heads of primary care facilities (n = 8) and policy makers/planners/service developers (n = 8). The interviews were audio-recorded and transcribed in Amharic, and translated into English. Thematic analysis was applied. RESULTS All groups of participants supported service user and caregiver involvement in mental health system strengthening. Potential benefits were identified as (i) improved appropriateness and quality of services, and (ii) greater protection against mistreatment and promotion of respect for service users. However, hardly any respondents had prior experience of service user involvement. Stigma was considered to be a pervasive barrier, operating within the health system, the local community and individuals. Competing priorities of service users included the need to obtain adequate individual care and to work for survival. Low recognition of the potential contribution of service users seemed linked to limited empowerment and mobilization of service users. Potential health system facilitators included a culture of community oversight of primary care services. All groups of respondents identified a need for awareness-raising and training to equip service users, caregivers, service providers and local community for involvement. Empowerment at the level of individual service users (information about mental health conditions, care and rights) and the group level (for advocacy and representation) were considered essential, alongside improved, accessible mental health care and livelihood interventions. CONCLUSION As Ethiopia increases access to mental health care, a fundamental barrier to service user involvement is beginning to be addressed. Our study identified further barriers that need to be tackled, including a supportive political climate, and receptiveness amongst stakeholders. The findings will inform the development of a model of service user involvement, which will be piloted and evaluated.
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Affiliation(s)
- Sisay Abayneh
- Department of Psychiatry, University College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Heidi Lempp
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Academic Rheumatology, Weston Education Centre, 10, Cutcombe Rd., London, SE5 9RJ UK
| | - Atalay Alem
- Department of Psychiatry, University College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Daniel Alemayehu
- Department of Psychiatry, University College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Tigist Eshetu
- Department of Psychiatry, University College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Crick Lund
- 0000 0004 1937 1151grid.7836.aDepartment of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Rondebosch, Cape Town, 7700 South Africa ,0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
| | - Maya Semrau
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Graham Thornicroft
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, University College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia. .,King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK.
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Habtamu K, Alem A, Medhin G, Fekadu A, Dewey M, Prince M, Hanlon C. Validation of the World Health Organization Disability Assessment Schedule in people with severe mental disorders in rural Ethiopia. Health Qual Life Outcomes 2017; 15:64. [PMID: 28381230 PMCID: PMC5382515 DOI: 10.1186/s12955-017-0647-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 03/31/2017] [Indexed: 11/26/2022] Open
Abstract
Background The World Health Organization Disability Assessment Schedule (WHODAS-2.0) has been adapted and validated in several cultures, but data on performance in the African context are lacking. The aim of the study was to evaluate the validity and psychometric properties of the WHODAS-2.0 among people with severe mental disorders (SMD) and their caregivers in a rural African setting. Methods The content validity of the 36 item WHODAS was assessed using free listing and pile sorting in 36 community members. Cognitive interviewing was conducted with 20 people with SMD and 20 caregivers to assess comprehensibility. Convergent validity and sensitivity to change were evaluated in a facility-based cohort study of new or acutely relapsed cases of people with SMD (n = 150) and their caregivers (n = 150) consecutively recruited from a psychiatric clinic. A repeat assessment was conducted in a sub-sample (n = 84) after 6 weeks. Confirmatory factor analysis was used to evaluate construct validity in people with SMD (n = 250) and their caregivers (n = 250). Results Internal consistency of the items of the overall scale and each domain ranged from very good (alpha = 0.82) to excellent (alpha = 0.98). Scores on the WHODAS-2.0 correlated highly with a locally developed measure of functioning (r = 0.88) and moderately with clinical symptom severity (r = 0.52). The WHODAS- 2.0 was sensitive to treatment changes (effect size = 0.50). As hypothesized, the six sub-scales loaded highly onto the general disability factor and each item loaded significantly onto their respective domains. The factor loadings of each item in the one factor model of the brief version of WHODAS (12 item) were also high. For both 12- and 36-item scales the goodness of fit indices, were close to, but outside of, recommended ranges. The caregiver data of both the 36 and 12 item versions had similar psychometric properties, but higher mean values and better responsiveness to change. Conclusions Our study showed that both the 12 and 36 item versions of the WHODAS 2.0 have acceptable validity and psychometric properties and can be used as a cross-cultural measure; however, careful and rigorous adaptation is required for rural African settings. Electronic supplementary material The online version of this article (doi:10.1186/s12955-017-0647-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kassahun Habtamu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. .,School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O.BOX: 1176, Addis Ababa, Ethiopia.
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - Michael Dewey
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Martin Prince
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
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Habtamu K, Alem A, Medhin G, Fekadu A, Prince M, Hanlon C. Development and validation of a contextual measure of functioning for people living with severe mental disorders in rural Africa. BMC Psychiatry 2016; 16:311. [PMID: 27604273 PMCID: PMC5015207 DOI: 10.1186/s12888-016-1022-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/29/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Most measures of functioning in people with severe mental disorders (SMD) have been developed in Western societies. Many of the questions in these scales are culture-bound, fail to capture differentiation of tasks by gender and are difficult to adapt to other contexts. The aim of this study was to develop a measure of functioning for people with SMD which is contextually appropriate for a rural African setting. METHODS A review of existing scales, a qualitative study, free listing and pile sorting exercises, and expert consensus were used to establish a pool of items. Cognitive interviewing guided initial item reduction and refinement. The resulting scale was pilot-tested in people with SMD (n = 200) and their caregivers (n = 200) to inform further item reduction based on psychometric properties. The final Butajira Functioning Scale (BFS) comprised 33 items that were common to both men and women, and an additional eight items for women only, covering the following domains: self-care, work, and family and community participation. Psychometric properties of the finalized BFS were examined in a facility-based sample of 150 people with SMD and their caregivers (n = 150), with longitudinal follow-up of n = 84. RESULTS The BFS in people with SMD had excellent internal consistency (Cronbach's α = 0.99), acceptable convergent validity (r = 0.88 with the World Health Organization Disability Assessment Schedule [WHODAS-2.0] and r = 0.32 with the Brief Psychiatric Rating Scale [BPRS-E]) and was sensitive to change following treatment (effect size =0.50). Addition of the items specific to women did not improve the psychometric properties. The caregiver version had similar psychometric properties but higher mean values for each item and better responsiveness to change. Exploratory factor analysis of the BFS provided evidence of construct validity, with four underlying dimensions. CONCLUSIONS We have developed a measure of functioning for people with SMD in a rural, low income country setting with acceptable psychometric properties. The BFS is easy to administer, sensitive to changes following treatment and has content, construct and convergent validity. The BFS includes domains from existing measures, but has more emphasis on social and occupational domains, which reflects priorities in the setting.
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Affiliation(s)
- Kassahun Habtamu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O.BOX: 1176, Ethiopia. .,School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O.BOX: 1176 Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O.BOX: 1176 Ethiopia ,Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Martin Prince
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O.BOX: 1176 Ethiopia ,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
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Social correlates of mental, neurological, and substance use disorders in China and India: a review. Lancet Psychiatry 2016; 3:882-99. [PMID: 27528098 DOI: 10.1016/s2215-0366(16)30166-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/18/2016] [Accepted: 06/20/2016] [Indexed: 01/10/2023]
Abstract
Understanding the epidemiological profiles of mental, neurological, and substance use disorders provides opportunities for the identification of high-risk population subgroups and for the development of effective country-specific prevention and intervention strategies. Guided by the Conceptual Framework for Action on the Social Determinants of Health by WHO we reviewed the literature to examine the association between a range of social correlates (eg, sex, age, education, income, urbanicity, marital status, and regional differences) and mental, neurological, and substance use disorders in China and India, the most populous countries in the world. We looked for papers on mental, neurological, and substance use disorders with location identifiers and socioeconomic correlates published between 1990 and 2015 and our search found 65 relevant studies from China and 29 from India. Several association patterns between social correlates and mental, neurological, and substance use disorders were not consistent with those reported in high-income countries, including a high concentration of middle-aged men with alcohol use disorders in China and to a lesser extent in India, and a positive association between being married and depression among women in India. Consistent with previous global reports, low education and poverty were associated with higher occurrence of dementia in both China and India, although there is evidence of an interaction between education and income in the risk for dementia in China. Large variations across regions and ethnic groups were consistently documented in China. These unique correlation patterns for mental, neurological, and substance use disorders identified in China and India emphasise the importance of understanding the local social context when planning targeted strategies to reduce the burden of these disorders. High-quality, up-to-date information about the constantly changing pattern of societal factors correlated with mental, neurological, and substance use disorders is urgently needed to help reduce the large and increasing negative social and economic effects that these conditions are having in China, India, and other low-income and middle-income countries.
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Asher L, De Silva M, Hanlon C, Weiss HA, Birhane R, Ejigu DA, Medhin G, Patel V, Fekadu A. Community-based Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE): study protocol for a cluster randomised controlled trial. Trials 2016; 17:299. [PMID: 27342215 PMCID: PMC4919867 DOI: 10.1186/s13063-016-1427-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 06/03/2016] [Indexed: 11/25/2022] Open
Abstract
Background Care for most people with schizophrenia is best delivered in the community and evidence-based guidelines recommend combining both medication and a psychosocial intervention, such as community-based rehabilitation. There is emerging evidence that community-based rehabilitation for schizophrenia is effective at reducing disability in middle-income country settings, yet there is no published evidence on the effectiveness in settings with fewer mental health resources. This paper describes the protocol of a study that aims to evaluate the effectiveness of community-based rehabilitation as an adjunct to health facility-based care in rural Ethiopia. Methods This is a cluster randomised trial set in a rural district in Ethiopia, with sub-district as the unit of randomisation. Participants will be recruited from an existing cohort of people with schizophrenia receiving treatment in primary care. Fifty-four sub-districts will be randomly allocated in a 1:1 ratio to facility-based care plus community-based rehabilitation (intervention arm) or facility-based care alone (control arm). Facility-based care consists of treatment by a nurse or health officer in primary care (antipsychotic medication, basic psychoeducation and follow-up) with referral to a psychiatric nurse-led outpatient clinic or psychiatric hospital when required. Trained community-based rehabilitation workers will deliver a manualised community-based rehabilitation intervention, with regular individual and group supervision. We aim to recruit 182 people with schizophrenia and their caregivers. Potential participants will be screened for eligibility, including enduring or disabling illness. Participants will be recruited after providing informed consent or, for participants without decision-making capacity, after the primary caregiver gives permission on behalf of the participant. The primary outcome is disability measured with the 36-item WHO Disability Assessment Schedule (WHODAS) version 2.0 at 12 months. The sample size will allow us to detect a 20 % difference in WHODAS 2.0 scores between treatment arms with 85 % power. Secondary outcomes include change in symptom severity, economic activity, physical restraint, discrimination and caregiver burden. Discussion This is the first trial of community-based rehabilitation for schizophrenia and will determine, as a proof of concept, the added value of community-based rehabilitation compared to facility-based care alone in a low-income country with scarce mental health resources. Trial registration Clinical Trials.gov Identifier NCT02160249. Registered on 3 June 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1427-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Asher
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK. .,Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Mary De Silva
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Rahel Birhane
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dawit A Ejigu
- Department of Pharmacology, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Vikram Patel
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Public Health Foundation of India, New Delhi, India.,Sangath, Goa, India
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Hanlon C, Alem A, Medhin G, Shibre T, Ejigu DA, Negussie H, Dewey M, Wissow L, Prince M, Susser E, Lund C, Fekadu A. Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial. Trials 2016; 17:76. [PMID: 26865254 PMCID: PMC4750210 DOI: 10.1186/s13063-016-1191-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/21/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Task sharing mental health care through integration into primary health care (PHC) is advocated as a means of narrowing the treatment gap for mental disorders in low-income countries. However, the effectiveness, acceptability, feasibility and sustainability of this service model for people with a severe mental disorder (SMD) have not been evaluated in a low-income country. METHODS/DESIGN A randomised, controlled, non-inferiority trial will be carried out in a predominantly rural area of Ethiopia. A sample of 324 people with SMD (diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder) with an ongoing need for mental health care will be recruited from 1) participants in a population-based cohort study and 2) people attending a psychiatric nurse-led out-patient clinic. The intervention is a task-sharing model of locally delivered mental health care for people with SMD integrated into PHC delivered over 18 months. Participants in the active control arm will receive the established and effective model of specialist mental health care delivered by psychiatric nurses at an out-patient clinic within a centrally located general hospital. The hypothesis is that people with SMD who receive mental health care integrated into PHC will have a non-inferior clinical outcome, defined as a mean symptom score on the Brief Psychiatric Rating Scale, expanded version, of no more than six points higher, compared to participants who receive the psychiatric nurse-led service, after 12 months. The primary outcome is change in symptom severity. Secondary outcomes are functional status, relapse, service use costs, service satisfaction, drop-out and medication adherence, nutritional status, physical health care, quality of care, medication side effects, stigma, adverse events and cost-effectiveness. Sustainability and cost-effectiveness will be further evaluated at 18 months. Randomisation will be stratified by health centre catchment area using random permuted blocks. The outcome assessors and investigators will be masked to allocation status. DISCUSSION Evidence about the effectiveness of task sharing mental health care for people with SMD in a rural, low-income African country will inform the World Health Organisation's mental health Gap Action Programme to scale-up mental health care globally. TRIAL REGISTRATION NCT02308956 (ClinicalTrials.gov). Date of registration: 3 December 2014.
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Affiliation(s)
- Charlotte Hanlon
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.
- Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King's College, London, UK.
| | - Atalay Alem
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Teshome Shibre
- Horizon Health Network, Dr Everett Chalmers Regional Hospital, Psychiatry, Fredericton, New Brunswick, Canada.
| | - Dawit A Ejigu
- Department of Pharmacology, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Hanna Negussie
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.
| | - Michael Dewey
- Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King's College, London, UK.
| | - Lawrence Wissow
- Department of Health, Behaviour and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | - Martin Prince
- Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King's College, London, UK.
| | - Ezra Susser
- Mailman School of Public Health, Columbia University, New York, USA.
- New York State Psychiatric Institute, New York, USA.
| | - Crick Lund
- Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King's College, London, UK.
- Department of Psychiatry and Mental Health, Alan J. Flisher Centre for Public Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, South Africa.
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, Psychology and Neuroscience, Centre for Affective Disorders, London, UK.
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Asher L, Fekadu A, Hanlon C, Mideksa G, Eaton J, Patel V, De Silva MJ. Development of a Community-Based Rehabilitation Intervention for People with Schizophrenia in Ethiopia. PLoS One 2015; 10:e0143572. [PMID: 26618915 PMCID: PMC4664267 DOI: 10.1371/journal.pone.0143572] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 11/08/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community-based rehabilitation (CBR) is a multi-sectoral strategy to improve the functioning and quality of life of people with disabilities. The RISE (Rehabilitation Intervention for people with Schizophrenia in Ethiopia) trial will evaluate the effectiveness of CBR for people with schizophrenia in Ethiopia. Nevertheless, the components of CBR that are both feasible and likely to prove effective in low and middle-income countries such as Ethiopia are unclear. METHODS In this study intervention development work was undertaken to design a CBR intervention that is acceptable and feasible in the local context. The development work consisted of five phases. 1: Identify potential components of CBR for schizophrenia, 2: Situational analysis, 3: Determine feasibility of CBR (Theory of Change workshops with experts and local stakeholders), 4: Determine acceptability of CBR (16 in-depth interviews and five focus group discussions with people with schizophrenia, caregivers, health workers and community leaders) and 5: Synthesise results to finalise intervention. A Theory of Change map was constructed showing the causal pathway for how we expect CBR to achieve its impact. RESULTS People with schizophrenia in rural Ethiopia experience family conflict, difficulty participating in work and community life, and stigma. Stakeholders perceived CBR to be acceptable and useful to address these problems. The focus of CBR will be on the individual developing the skills and confidence to perform their previous or desired roles and activities. To ensure feasibility, non-health professionals will be trained to deliver CBR and provide supervision, rather than mental health specialists. Novel components of CBR for schizophrenia included family intervention and dealing with distressing symptoms. Microfinance was excluded due to concerns about stress and exploitation. Community mobilisation was viewed as essential to ensure the effectiveness and sustainability of CBR. CONCLUSION Extensive formative research using a variety of methods has enabled the design of a culturally appropriate CBR intervention for people with schizophrenia that is acceptable and feasible.
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Affiliation(s)
- Laura Asher
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Center for Global Mental Health, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Gemechu Mideksa
- RAPID (Rehabilitation And Prevention Initiative against Disabilities) CBR Project, Adama, Ethiopia
| | - Julian Eaton
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- CBM West Africa Regional Office, Lome, Togo
| | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Sangath, Goa, India
| | - Mary J. De Silva
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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de Menil V, Knapp M, McDaid D, Raja S, Kingori J, Waruguru M, Wood SK, Mannarath S, Lund C. Cost-effectiveness of the Mental Health and Development model for schizophrenia-spectrum and bipolar disorders in rural Kenya. Psychol Med 2015; 45:2747-2756. [PMID: 25994212 DOI: 10.1017/s0033291715000719] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The treatment gap for serious mental disorders across low-income countries is estimated to be 89%. The model for Mental Health and Development (MHD) offers community-based care for people with mental disorders in 11 low- and middle-income countries. METHOD In Kenya, using a pre-post design, 117 consecutively enrolled participants with schizophrenia-spectrum and bipolar disorders were followed-up at 10 and 20 months. Comparison outcomes were drawn from the literature. Costs were analysed from societal and health system perspectives. RESULTS From the societal perspective, MHD cost Int$ 594 per person in the first year and Int$ 876 over 2 years. The cost per healthy day gained was Int$ 7.96 in the first year and Int$ 1.03 over 2 years - less than the agricultural minimum wage. The cost per disability-adjusted life year averted over 2 years was Int$ 13.1 and Int$ 727 from the societal and health system perspectives, respectively, on par with antiretrovirals for HIV. CONCLUSIONS MHD achieved increasing returns over time. The model appears cost-effective and equitable, especially over 2 years. Its affordability relies on multi-sectoral participation nationally and internationally.
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Affiliation(s)
- V de Menil
- Department of Social Policy,London School of Economics and Political Science,UK
| | - M Knapp
- Personal Social Services Research Unit,London School of Economics and Political Science,UK
| | - D McDaid
- Personal Social Services Research Unit,London School of Economics and Political Science,UK
| | - S Raja
- Policy and Practice Directorate,BasicNeeds,India
| | | | | | - S K Wood
- Policy and Practice Directorate,BasicNeeds,India
| | - S Mannarath
- Policy and Practice Directorate,BasicNeeds,India
| | - C Lund
- Alan J. Flisher Centre for Public Mental Health,Department of Psychiatry and Mental Health,University of Cape Town,South Africa
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30
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Selamu M, Asher L, Hanlon C, Medhin G, Hailemariam M, Patel V, Thornicroft G, Fekadu A. Beyond the biomedical: community resources for mental health care in rural Ethiopia. PLoS One 2015; 10:e0126666. [PMID: 25962075 PMCID: PMC4427185 DOI: 10.1371/journal.pone.0126666] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 04/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources. METHOD We employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered. RESULTS The district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities. DISCUSSION The plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention.
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Affiliation(s)
- Medhin Selamu
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Laura Asher
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Maji Hailemariam
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, King’s College London, London, United Kingdom
| | - Abebaw Fekadu
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders and Affective Disorders Research Group, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, United Kingdom
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Habtamu K, Alem A, Hanlon C. Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study. BMC Psychiatry 2015; 15:34. [PMID: 25885525 PMCID: PMC4354755 DOI: 10.1186/s12888-015-0418-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/19/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The functional outcome of people with severe mental disorders (SMD) is purported to be better in low- and middle-income countries compared to high-income countries; however, cross-cultural measures of functioning may not capture adequately the relevant functional activities in rural, non-Western settings. This study aimed to gain in-depth understanding of day-to-day functioning in a rural Ethiopian setting and the functional impairments associated with SMD. METHOD A qualitative study was carried out in the Butajira area, south Ethiopia. In-depth interviews were conducted with people with SMD (n = 6), religious healers (n = 2) and psychiatric nurses (n = 2). Four focus group discussions were carried out with caregivers of people with SMD (n = 37) and one with project outreach workers (n = 5). A thematic analysis approach was used. RESULTS Participants emphasized that functional impairment in people with SMD arose not only because of the symptoms associated with the illness, but also due to poverty, social exclusion and lack of social support. Within this rural community, the ability to work productively, engage in family life, maintain self-care and fulfill social obligations were the most highly valued domains of functioning. A wide range of farming tasks were elaborated in detail and noted to be of varying levels of difficulty. Although many people with symptomatic SMD were reported to be able to carry out simple farming tasks, this was distinguished from effective farming. Gender differences were most apparent in the domains of work and family life. Impaired functioning was reported to have a critical immediate impact on survival and longer-term impacts on the lifetime opportunities of people with SMD, their caregivers and the younger generation within the family. CONCLUSIONS The study indicates that tackling social exclusion and poverty is needed alongside medical treatment through contextual community based rehabilitation programs. The gendering of functional roles and the complexity of work activities in this subsistence farming community lend support to arguments for locally contextualized measures of functioning in people with SMD.
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Affiliation(s)
- Kassahun Habtamu
- School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O. BOX: 1176, Addis Ababa, Ethiopia. .,PhD students, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. .,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK.
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Shibre T, Medhin G, Alem A, Kebede D, Teferra S, Jacobsson L, Kullgren G, Hanlon C, Fekadu A. Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population-based cohort. Schizophr Res 2015; 161:414-20. [PMID: 25468171 DOI: 10.1016/j.schres.2014.10.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 10/27/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far. METHODS A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome. RESULT About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia. CONCLUSION This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.
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Affiliation(s)
- Teshome Shibre
- Addis Ababa University, Ethiopia; University of Toronto, Ontario Shores Centre for Mental Health Sciences, Canada.
| | - Girmay Medhin
- Addis Ababa University, Aklilu-Lemma Institute of Pathobiology, Ethiopia
| | | | - Derege Kebede
- Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia; WHO Regional Office for Africa, Brazzaville, Congo
| | | | | | | | - Charlotte Hanlon
- Addis Ababa University, Ethiopia; King's College London, Institute of Psychiatry, Health Services and Population Research Department, Centre for Global Mental Health, London, UK
| | - Abebaw Fekadu
- Addis Ababa University, Ethiopia; King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK
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Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, Ssebunnya J, Fekadu A, Shidhaye R, Petersen I, Jordans M, Kigozi F, Thornicroft G, Patel V, Tomlinson M, Lund C, Breuer E, De Silva M, Prince M. Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries. PLoS One 2014; 9:e88437. [PMID: 24558389 PMCID: PMC3928234 DOI: 10.1371/journal.pone.0088437] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 01/12/2014] [Indexed: 01/24/2023] Open
Abstract
Background Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
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Affiliation(s)
- Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom
- * E-mail:
| | | | - Tasneem Kathree
- School of Psychology, University of KwaZulu-Natal, Durban, South Africa
| | - Vaibhav Murhar
- PRIME India team, Sangath Non-Governmental Organisation, Goa, India
| | - Sanjay Shrivasta
- PRIME India team, Sangath Non-Governmental Organisation, Goa, India
| | - Girmay Medhin
- Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rahul Shidhaye
- Centre for Mental Health, Public Health Foundation of India, New Delhi, India
| | - Inge Petersen
- School of Psychology, University of KwaZulu-Natal, Durban, South Africa
| | - Mark Jordans
- Department of Research and Development, HealthNet Transcultural Psychosocial Organisation, Amsterdam, The Netherlands
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fred Kigozi
- Butabika National Mental Hospital, Kampala, Uganda
| | - Graham Thornicroft
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Vikram Patel
- Sangath Non-Governmental Organisation, Goa, India
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mark Tomlinson
- Centre for Public Mental Health, Department of Psychology, Stellenbosch University and Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Erica Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Mary De Silva
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Martin Prince
- Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom
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Yang LH, Phillips MR, Li X, Yu G, Zhang J, Shi Q, Song Z, Ding Z, Pang S, Susser E. Employment outcome for people with schizophrenia in rural v. urban China: population-based study. Br J Psychiatry 2013; 203:272-9. [PMID: 23258768 PMCID: PMC3796368 DOI: 10.1192/bjp.bp.112.118927] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although outcomes among people with schizophrenia differ by social context, this has rarely been examined across rural v. urban settings. For individuals with schizophrenia, employment is widely recognised as a critical ingredient of social integration. AIMS To compare employment for people with schizophrenia in rural v. urban settings in China. METHOD In a large community-based study in four provinces representing 12% of China's population, we identified 393 people with schizophrenia (112 never treated). We used adjusted Poisson regression models to compare employment for those living in rural (n = 297) v. urban (n = 96) settings. RESULTS Although rural and urban residents had similar impairments due to symptoms, rural residents were three times more likely to be employed (adjusted relative risk 3.27, 95% CI 2.11-5.07, P<0.001). CONCLUSIONS People with schizophrenia have greater opportunities to use their capacities for productive work in rural than urban settings in China. Contextual mechanisms that may explain this result offer a useful focus for future research.
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Affiliation(s)
- Lawrence H. Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Michael R. Phillips
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, China, Departments of Psychiatry and Global Health, Emory University, Atlanta, USA, and WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing Hui Long Guan Hospital, Beijing, China
| | - Xianyun Li
- WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing Hui Long Guan Hospital, Beijing, China
| | - Gary Yu
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, USA
| | - Jingxuan Zhang
- Shandong Provincial Mental Health Center, Jinan City, Shandong Province, China
| | - Qichang Shi
- Tong De Hospital of Zhejiang Province, Hangzhou City, Zhejiang Province, China
| | - Zhiqiang Song
- The 3rd People’s Hospital of Qinghai Province, Xining City, Qinghai Province, China
| | - Zhijie Ding
- Tianshui City Mental Hospital, Tianshui City, Gansu Province, China
| | - Shutao Pang
- Qingdao Mental Health Centre, Qingdao City, Shandong Province, China
| | - Ezra Susser
- Global Mental Health Program at Mailman School of Public Health, Columbia University and New York State Psychiatric Institute, New York, USA
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Burns JK. The Social Determinants of Schizophrenia: An African Journey in Social Epidemiology. Public Health Rev 2012. [DOI: 10.1007/bf03391676] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
BACKGROUND Stigma and disability are two important consequences of schizophrenia that individuals afflicted with it experience. Sociocultural milieu can influence these. We review the literature on stigma and disability experienced by individuals with schizophrenia in the developing countries. METHOD We searched English-language literature from developing countries on stigma and disability in schizophrenia using PubMed and Scopus databases. As individual studies adopted widely varying methodologies, the retrieved papers did not yield themselves for a systematic review. We present a narrative review. RESULTS Much of the literature on stigma and disability in schizophrenia has come from India and only a few other developing countries. Stigma associated with schizophrenia is highly prevalent across regions and across patients themselves, families, communities and professionals. Research is scanty with regard to determinants of stigma and interventions against stigma. A number of tools have been developed for assessment of disability. Preliminary evidence suggests that initiation and continuation of antipsychotic medications is associated with lesser disability. Psychosocial interventions may reduce disability further. CONCLUSIONS Comprehensive, prospective studies evaluating the determinants of stigma and disability need to be conducted in the developing countries. Models of interventions to minimize these adverse consequences, developed based on their results, need to be tested.
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Affiliation(s)
- Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India.
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Abstract
This paper does not provide an exhaustive review of all outcome studies in the developing world. It raises some issues that relate to research on course and outcome such as gender differences, changes over time, untreated states, homelessness and mortality. An overview of the debate over the nature of better outcome in developing countries is also provided. Areas critical for future research have also been discussed.
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Odenwald M, Lingenfelder B, Peschel W, Haibe FA, Warsame AM, Omer A, Stöckel J, Maedl A, Elbert T. A pilot study on community-based outpatient treatment for patients with chronic psychotic disorders in Somalia: Change in symptoms, functioning and co-morbid khat use. Int J Ment Health Syst 2012; 6:8. [PMID: 22747911 PMCID: PMC3527287 DOI: 10.1186/1752-4458-6-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 06/14/2012] [Indexed: 11/13/2022] Open
Abstract
Background In Low and Middle Income Countries, mental health services are often poorly developed due to the lack of resources and trained personnel. In order to overcome these challenges, new ways of care have been suggested such as a focus on community-based services. In Somalia, the consumption of the natural stimulant khat is highly prevalent, aggravating mental illness. At the same time, mental health care is largely unavailable to the vast majority of the population. In a pilot project, we tested possibilities for effective measures in community-based out-patient mental health care. Methods Thirty-five male patients with chronic psychotic disorders and their carers were involved in a 10-months follow-up study. All of them abused khat. Seventeen outpatients experiencing acute psychotic episodes were recruited from the community and received an intensive six week home-based treatment package. Additionally eighteen patients with chronic psychotic disorders in remission were recruited either following hospital discharge or from the community. In a second phase of the study, both groups received community-based relapse prevention that differed in the degree of the family’s responsibility for the treatment. The treatment package was comprised of psycho-education, low-dose neuroleptic treatment, monthly home visits and counseling. The Brief Psychiatric Rating Scale (BPRS) was applied three times. Additionally, we assessed functioning, khat use and other outcomes. Results Of the 35 patients enrolled in the study, 33 participated in the 10-month follow-up. Outpatients improved significantly in the first six weeks of treatment and did not differ from remitted patients at the start of the second treatment phase. In the preventive treatment phase, we find heterogeneous outcomes that diverge between symptom and functioning domains. With the exception of depressive symptoms, symptoms in all patients tended to worsen. The outpatient group had higher BPRS positive and negative symptom scores compared to the remitted group. Levels of functioning in 20 out of 33 patients significantly improved, with small differences between groups. Most patients experienced improvements in basic functioning, such as communication, self-care etc. Khat use could only be reduced in the group of outpatients. Conclusions Community-based out-patient mental health treatment for chronic psychotic disorders has demonstrated positive effects in Somalia and is both feasible and practical, despite facing formidable challenges, e.g. controlling khat intake.
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Affiliation(s)
- Michael Odenwald
- Department of Psychology, University of Konstanz, Fach D25, Constance, 78457, Germany.
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Zouari L, Thabet JB, Elloumi Z, Elleuch M, Zouari N, Maâlej M. [Quality of life in patients with schizophrenia: a study of 100 cases]. Encephale 2012; 38:111-7. [PMID: 22516268 DOI: 10.1016/j.encep.2011.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 11/22/2010] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the quality of life (QOL) in outpatients with schizophrenia, and to identify factors correlated to an impaired QOL among them. SUBJECTS AND METHODS A transversal study, in the form of an inquiry, was conducted in 100 outpatients, during seven months, in the psychiatric department of the Hedi Chaker teaching hospital in Sfax - Tunisia. We used the "36 item Short-Form Health Survey" (SF-36) to assess the QOL; this has been considered as impaired when the global medium score was inferior to 66.7. For the global assessment of functioning and the global assessment of the interference by existing side effects with the patient's daily performance, we have used respectively the Global Assessment of Functioning scale (GAF) and the Udvalg of Kliniske Undersogelser (UKU) side effect rating scale. The positive and negative symptoms added to the general psychopathology were assessed using the Positive and Negative syndrome scale (PANSS). RESULTS The QOL was impaired in 34% of the cases. The analysis of the scores of the eight dimensions by the scale SF-36 has shown that the most affected dimensions were, in decreasing order: mental health (MH), general health perceptions (GH), vitality (VT), role limitations due to physical health problems (RP) and role limitations due to emotional problems (RE). The standardization revealed that six dimensions were impaired; these were, in decreasing order: mental health (MH), social functioning (SF), role limitations due to emotional problems (RE), role limitations due to physical health problems (RP), general health perceptions (GH) and physical functioning (PF). The standardization has also revealed an impairment of the psychological component, while the physical component has been conserved. After analysis by multiple linear regression, four factors appeared strongly correlated with the impaired QOL: the professional inactivity, the episodic course with interepisode residual symptoms, the presence of side effects moderately influencing the daily performance, and a general psychopathology score for 26 at least. These four factors affected, in decreasing order of importance, social functioning (SF) (related to two factors), general health perceptions (GH) and role limitations due to emotional problems (RE) (each related to one factor). None of the factors appeared to affect the other dimensions: physical functioning (PF), role limitations due to the physical health problems (RP), bodily pain (BP), mental health (MH) and vitality (VT). The bivariate analysis revealed three other factors correlated, to a lesser degree, to the impairment of the QOL: the disorganized sub-type, a score of (GAF) inferior or equal to 30 and the negative type of schizophrenia. CONCLUSION Management of schizophrenic patients should go beyond the remission of the symptoms; it has also to target the improvement in QOL. This needs an action over the factors that affect the QOL, among which residual symptoms and side effects. The atypical antipsychotics would contribute preciously in this way, due to their efficacy on negative symptoms and their better tolerance than the conventional ones.
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Affiliation(s)
- L Zouari
- Service de psychiatrie « C », CHU Hédi Chaker, route El Aïn km 1, Sfax 3029, Tunisie.
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Alem A, Kebede D, Fekadu A, Shibre T, Fekadu D, Beyero T, Medhin G, Negash A, Kullgren G. Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia. Schizophr Bull 2009; 35:646-54. [PMID: 18448478 PMCID: PMC2669573 DOI: 10.1093/schbul/sbn029] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.
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Affiliation(s)
- Atalay Alem
- Medical Faculty, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Derege Kebede
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Abebaw Fekadu
- Health Service and Population Research Department and Section of Neurobiology of Mood Disorders, Psychological Medicine, Institute of Psychiatry, King's College London, London, United Kingdom,To whom correspondence should be addressed: Health Services Research Department and Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK; tel.: +44(0) 20 7848 0136, fax: +44(0) 20 7277 0283; e-mail:
| | - Teshome Shibre
- Medical Faculty, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Fekadu
- Children's Department, Michael Rutter Centre, Maudsley Hospital, London, London, United Kingdom
| | - Teferra Beyero
- Medical Faculty, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Negash
- Medical Faculty, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gunnar Kullgren
- Division of Psychiatry, Department of Clinical Sciences, Institute of Psychiatry, Umea University, Umea, Sweden
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Abstract
INTRODUCTION That schizophrenia has a better course and outcome in developing countries has become an axiom in international psychiatry. This is based primarily on a series of cross-national studies by the World Health Organization (WHO). However, increasing evidence from other research indicates a far more complex picture. METHODS Literature review and tabulation of data from 23 longitudinal studies of schizophrenia outcomes in 11 low- and middle-income countries. RESULTS We reviewed the evidence about the following domains: clinical outcomes and patterns of course, disability and social outcomes (marital and occupational status, in particular), and untreated samples and duration of untreated psychosis. Outcomes varied across the studies and the evidence suggests a need to reexamine the conclusions of the WHO studies. Additionally, assessments of outcomes should take excess mortality and suicide into account. CONCLUSIONS It is time to reexamine presumed wisdom about schizophrenia outcomes in low- and middle-income countries.
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Affiliation(s)
- Alex Cohen
- Department of Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.
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Abstract
There is a constant stream of information emanating from psychiatric research. The challenge for the clinician to keep abreast of the latest research findings is huge. However, even more daunting is the task of making sense of the sometimes conflicting data. In this paper, we provide some examples of evidence that seemed to have been accepted with relatively little critical examination. We discuss how evidence may look plausible on the surface either because contextual factors have not been considered or because they fit into a pre-determined world view. We argue that, in the end, the process of making sense of evidence is not straightforward and that professional biases and social prejudices often influence decisions.
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Affiliation(s)
- Alex Cohen
- Department of Social Medicine, Harvard Medical School, Boston, MA, USA.
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Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, Hosman C, McGuire H, Rojas G, van Ommeren M. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007; 370:991-1005. [PMID: 17804058 DOI: 10.1016/s0140-6736(07)61240-9] [Citation(s) in RCA: 516] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.
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Affiliation(s)
- Vikram Patel
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
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Abstract
About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.
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Affiliation(s)
- Martin Prince
- King's College London, Centre for Public Mental Health, Health Service and Population Research Department, Institute of Psychiatry, London, UK.
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45
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Abstract
Schizophrenia affects an estimated 25 million people in low- and middle-income countries, with an average lifetime risk of about 1%. The illness is associated with excess mortality from a variety of causes. A 2001 Institute of Medicine report on mental illness in developing countries found that in 1990, over two-thirds of people with schizophrenia in these countries were not receiving any treatment (http://www.nap.edu/catalog/10111.html). The report found no evidence that the proportion of treated people in the developing world had increased since 1990. There is now a debate among mental health professionals in low-income countries over how best to improve patient care. In this article, three psychiatrists give their different viewpoints on the current status of treatment efforts for schizophrenia in the developing world and the measures that can be taken to increase the proportion of patients receiving treatment.
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Affiliation(s)
- Vikram Patel
- International Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Koen L, Uys S, Niehaus DJH, Emsley RA. Negative Symptoms and HIV/AIDS Risk-Behavior Knowledge in Schizophrenia. PSYCHOSOMATICS 2007; 48:128-34. [PMID: 17329606 DOI: 10.1176/appi.psy.48.2.128] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Schizophrenia sufferers have been demonstrated to have relatively poor HIV/AIDS risk-behavior knowledge and, as a group, are found to be particularly vulnerable to contracting HIV. The authors asked whether an association could be demonstrated between specific symptoms and differing levels of knowledge. A structured clinical interview and HIV/AIDS Risk Questionnaires were administered to 102 subjects, and a principal-component analysis was performed for global and individual items, followed by comparisons between factors. Three factors (negative, positive, and global thought-disorder) emerged as significant between poor HIV/AIDS risk-behavior knowledge and higher negative-symptom scores. Findings support the notion that existing educational programs should be adapted to target specific areas of deficit.
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Affiliation(s)
- Liezl Koen
- Ngaphakathi Workgroup, Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa.
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Patel V, Cohen A, Thara R, Gureje O. Is the outcome of schizophrenia really better in developing countries? BRAZILIAN JOURNAL OF PSYCHIATRY 2006; 28:149-52. [PMID: 16810400 DOI: 10.1590/s1516-44462006000200014] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
That schizophrenia has a better prognosis in non-industrialized societies has become an axiom in international psychiatry; the evidence most often cited comes from three World Health Organization (WHO) cross-national studies. Although a host of socio-cultural factors have been considered as contributing to variation in the course of schizophrenia in different settings, we have little evidence from low-income countries that clearly demonstrates the beneficial influence of these variables. In this article, we suggest that the finding of better outcomes in developing countries needs re-examination for five reasons: methodological limitations of the World Health Organization studies; the lack of evidence on the specific socio-cultural factors which apparently contribute to the better outcomes; increasing anecdotal evidence describing the abuse of basic human rights of people with schizophrenia in developing countries; new evidence from cohorts in developing countries depicting a much gloomier picture than originally believed; and, rapid social and economic changes are undermining family care systems for people with schizophrenia in developing countries. We argue that the study of the long-term course of this mental disorder in developing countries is a major research question and believe it is time to thoroughly and systematically explore cross-cultural variation in the course and outcome of schizophrenia.
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