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George Joseph R, James FC, Ninan E, Rachana A, Kurian S. Individualized Occupational Therapy in Severe Mental Illness-A Recovery Model Approach from a Tertiary care Centre in South India. Int J Soc Psychiatry 2025:207640251317008. [PMID: 39927398 DOI: 10.1177/00207640251317008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Abstract
BACKGROUND The Recovery Model for mental illness explores a broad range of domains for individuals with severe mental illness (SMI) which is not merely the absence from illness but attaining self-sufficiency. The individualized occupational therapy intervention which is part of the recovery model approach includes any or a combination of trainings like Social Skills training, Vocational training, Assertiveness training, Anger Management training, Life Skills training, Stress Management, Study Skills training, Cognitive retraining and Anxiety management. AIMS The objective of the current study was to evaluate the effectiveness in terms of functioning of individuals with (SMI) who had undergone individualized OT intervention. METHOD Patients who had undergone individualized OT intervention were evaluated at designated time points i.e. at discharge, at 3 months and further at 6 months. The outcome measure of functional capacity was scored using the Global Assessment of Functioning instrument. RESULT A total of 31 patients were sampled. The diagnosis of Schizophrenia was seen in 77.4% (n-24) of the sample, Bipolar Affective Disorder in 12.9% (n-4) and Schizoaffective Disorder 9.7% (n-3). The mean GAF for the sample showed improvement and the increment in GAF was maintained on follow up. CONCLUSIONS In services with limited skilled human resources and where community-based services are not established, culturally adapted interventions with individualized OT interventions can ensure positive gains in terms of socio-occupational functioning.
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Affiliation(s)
| | - Farah Cj James
- Christian Medical College and Hospital Vellore, Vellore, India
| | - Elizabeth Ninan
- Christian Medical College and Hospital Vellore, Vellore, India
| | - Arun Rachana
- Christian Medical College and Hospital Vellore, Vellore, India
| | - Suja Kurian
- Christian Medical College and Hospital Vellore, Vellore, India
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Huppertz M. A response to criticism of the global mental health movement. How polarization can be overcome in theory and in west African social psychiatric practice. Glob Ment Health (Camb) 2025; 11:e135. [PMID: 39811623 PMCID: PMC11729476 DOI: 10.1017/gmh.2024.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/17/2024] [Accepted: 09/24/2024] [Indexed: 01/16/2025] Open
Abstract
Since the turn of the 21st century, we have seen the development of an international movement that works in various ways to ensure that everyone in the world has access to adequate mental health care. There is indeed a great need for action, especially in countries with weak and underfunded health systems. The Movement for Global Mental Health (MGMH) is supported by strong organizations such as the WHO, academic institutions and NGOs. As this movement has gained momentum, however, it has been accompanied by fierce criticism, in particular from scholars of the humanities and social science, who see the global expansion of psychiatry as a medical discipline as a form of power-grabbing, neocolonialism and capitalist expansion. They also consider psychiatry to be a biologistic discipline, the justification of which they question, in continuation of a long anti-psychiatric tradition. This criticism prompted several adaptations of the MGMH and various efforts towards integration, but these have not been widely accepted by the critics. The following text primarily summarizes, classifies and critically engages with the basic arguments of the aforementioned critique. Theoretical misconceptions regarding the practice of psychiatry are clarified. Subsequently a specific project in Côte d'Ivoire is presented that demonstrates how contextual psychiatry can proceed and how unnecessary dichotomies and polarizations can be overcome in the interests of the persons concerned.
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Affiliation(s)
- Michael Huppertz
- Psychiatrist and Psychotherapist, Sociologist, Kreuz 10A, D 85625Glonn, Germany
- Executive Board, Mindful Change Foundation, Darmstadt, Germany
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van der Ven E, Yang X, Mascayano F, Weinreich KJ, Chen EYH, Tang CYZ, Kim SW, Burns JK, Chiliza B, Mohan G, Iyer SN, Rangawsamy T, de Vries R, Susser ES. Early intervention in psychosis programs in Africa, Asia and Latin America; challenges and recommendations. Glob Ment Health (Camb) 2025; 12:e3. [PMID: 39781337 PMCID: PMC11704378 DOI: 10.1017/gmh.2024.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/30/2024] [Accepted: 06/25/2024] [Indexed: 01/12/2025] Open
Abstract
Background While early intervention in psychosis (EIP) programs have been increasingly implemented across the globe, many initiatives from Africa, Asia and Latin America are not widely known. The aims of the current review are (a) to describe population-based and small-scale, single-site EIP programs in Africa, Asia and Latin America, (b) to examine the variability between programs located in low-and-middle income (LMIC) and high-income countries in similar regions and (c) to outline some of the challenges and provide recommendations to overcome existing obstacles. Methods EIP programs in Africa, Asia and Latin America were identified through experts from the different target regions. We performed a systematic search in Medline, Embase, APA PsycInfo, Web of Science and Scopus up to February 6, 2024. Results Most EIP programs in these continents are small-scale, single-site programs that serve a limited section of the population. Population-based programs with widespread coverage and programs integrated into primary health care are rare. In Africa, EIP programs are virtually absent. Mainland China is one of the only LMICs that has begun to take steps toward developing a population-based EIP program. High-income Asian countries (e.g. Hong Kong and Singapore) have well-developed, comprehensive programs for individuals with early psychosis, while others with similar economies (e.g. South Korea and Japan) do not. In Latin America, Chile is the only country in the process of providing population-based EIP care. Conclusions Financial resources and integration in mental health care, as well as the availability of epidemiological data on psychosis, impact the implementation of EIP programs. Given the major treatment gap of early psychosis in Africa, Latin America and large parts of Asia, publicly funded, locally-led and accessible community-based EIP care provision is urgently needed.
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Affiliation(s)
- Els van der Ven
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Xinyu Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Franco Mascayano
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Karl J Weinreich
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Eric YH Chen
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
- Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Hong Kong
| | | | - Sung-Wan Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Korea
- Mindlink, Gwangju Bukgu Mental Health Center, Gwangju, Korea
| | - Jonathan K Burns
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Bonginkosi Chiliza
- Department of Psychiatry, Nelson R Mandela School of Medicine, University of Kwazulu-Natal, South Africa
| | - Greeshma Mohan
- Schizophrenia Research Foundation (SCARF), Chennai, India
| | - Srividya N Iyer
- Department of Psychiatry, McGill University, Montreal, Canada
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Canada
| | | | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ezra S Susser
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
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Martinez A, Baumgartner JN, Kaaya S, Swai P, Lawala PS, Thedai B, Minja A, Headley J, Egger JR. Hopefulness among individuals living with schizophrenia and their caregivers in Tanzania: an actor-partner interdependence model. BMC Psychiatry 2023; 23:508. [PMID: 37442999 PMCID: PMC10339619 DOI: 10.1186/s12888-023-04990-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment of mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS attending outpatient psychiatric clinics and their caregivers in Tanzania. METHODS This study utilized baseline and immediate post-intervention data collected as part of a randomized controlled trial testing a culturally tailored model of Family Psychoeducation, KUPAA, in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS (n = 33) and their caregivers (n = 33) at baseline and immediate post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among and between PLWS and their caregivers. RESULTS Better family functioning was associated with higher levels of hopefulness in PLWS and their caregivers. Lower levels of stigma, lower symptom severity, and lower disability were associated with higher levels of hopefulness in PLWS. For PLWS and their caregivers, actor effects from the APIM model were less than one (PLWS, [Formula: see text]; caregivers, [Formula: see text]), indicating stability (within each person) in hopefulness over time. Regarding partner effects, a caregiver's baseline hopefulness had a positive effect on the hopefulness of their PLWS at follow-up ([Formula: see text]). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregivers' hopefulness at follow-up ([Formula: see text]). This suggests that higher hopefulness among PLWS at baseline is associated with lower levels of hope in caregivers at follow-up. CONCLUSION Hopefulness is important to consider in family or caregiver-based treatments for PLWS because caregiver hopefulness may influence improvements in hopefulness among PLWS over time. Future studies should further explore the longitudinal dyadic relationship of hopefulness for these populations, as hope is a non-pharmacological and modifiable mechanism of change that is underutilized in care and treatment plans for PLWS globally. TRIAL REGISTRATION Clinical Trials #NCT04013932, July 10, 2019.
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Affiliation(s)
- Alyssa Martinez
- Harvard Medical School, Department of Global Health & Social Medicine, Boston, MA, USA
| | - Joy Noel Baumgartner
- Duke Global Health Institute, Duke University, Durham, NC, USA
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sylvia Kaaya
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Praxeda Swai
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Paul S Lawala
- Mirembe National Mental Health Hospital, Dodoma, Tanzania
| | | | - Anna Minja
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | | | - Joseph R Egger
- Duke Global Health Institute, Duke University, Durham, NC, USA.
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Renwick L, Susanti H, Brooks H, Keliat BA, Bradshaw T, Bee P, Lovell K. Culturally adapted family intervention for people with schizophrenia in Indonesia (FUSION): a development and feasibility study protocol. Pilot Feasibility Stud 2023; 9:53. [PMID: 36998003 DOI: 10.1186/s40814-023-01280-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Abstract
Background
Mental illnesses comprise the single largest source of health-related economic burden globally, and low- and middle-income countries are disproportionately affected. The majority of people with schizophrenia who need treatment do not receive it and are often wholly reliant on family caregivers for daily care and support. Family interventions have an exceptionally robust evidence base for their efficacy in high-resource settings, but it is unknown whether they can produce equivalent effects in some low-resource settings where cultural beliefs, explanatory models of illness and contextual socio-economic issues differ.
Methods
This protocol describes the methods for a randomised controlled trial to determine the feasibility of testing culturally adapt and refine an evidence-based, family intervention for relatives and caregivers of people with schizophrenia in Indonesia. The feasibility and acceptability of implementing our adapted, co-produced intervention via task shifting in primary care settings will be evaluated using the Medical Research Council framework for complex interventions. We will recruit 60 carer-service-user dyads and randomise them in a 1:1 ratio either to receive our manualised intervention or continue to receive treatment as usual. Healthcare workers in primary care settings will be trained to deliver family interventions using our manualised intervention by a family intervention specialist. Participants will complete the ECI, IEQ, KAST and GHQ. Service-user symptom level and relapse status will be measured using the PANSS at baseline, post-intervention and 3 months later by trained researchers. Fidelity to the intervention model will be measured using the FIPAS. Qualitative evaluation will further assist with refining the intervention, evaluating trial processes and evaluating acceptability.
Discussion
National healthcare policy in Indonesia supports the delivery of mental health services in a complex network of primary care centres. This study will provide important information on the feasibility of delivering family interventions for people with schizophrenia via task shifting in primary care settings in Indonesia and allow further refinement of the intervention and trial processes.
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Vancampfort D, Kimbowa S, Ward PB, Onekalit K, Lukwata H, Mugisha J. A 10-hours workshop improves physical activity prescription for mental illness knowledge and confidence in health care professionals: a nation-wide multicentre study from Uganda. Disabil Rehabil 2023; 45:170-175. [PMID: 34779314 DOI: 10.1080/09638288.2021.2003448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Lack of knowledge about and confidence in physical activity (PA) prescription for people with mental illness are important barriers for clinical practice in low-income countries. The aim of this study was to evaluate whether a 10-hour workshop improved the knowledge and confidence in PA prescription among health care professionals in 13 regional referral hospitals across Uganda. MATERIAL AND METHODS 260 health care professionals (age = 40.4 ± 10.8 years; 48% women; 63.8% nurses, 10% social workers, 8.1% psychologists, 7.3% medical doctors, 5.8% psychiatrists, 5% physical or occupational therapists) completed the Exercise in Mental Illness Questionnaire - Health Professionals Version (EMIQ-HP) pre- and post-workshop. RESULTS The EMIQ-HP PA knowledge score (3.1 ± 0.7 versus 1.3 ± 1.3, p < 0.001, Cohen's d = 1.28, 95% confidence interval, CI = 1.04-1.52, i.e., large effect) and EMIQ-HP confidence in PA prescription score (3.0 ± 0.8 versus 1.2 ± 1.2, p < 0.001, Cohen's d = 1.14, 95% CI = 0.91-1.36, i.e., large effect) improved significantly following training. Significantly more benefits and fewer barriers to prescribing PA in busy low-resourced settings were reported. CONCLUSIONS Training in PA counselling improved the knowledge and confidence in PA prescription in Ugandan health care professionals. Future research should investigate whether PA uptake in people with mental illness can be improved via additional training of health care professionals.IMPLICATIONS FOR REHABILITATIONThe majority of mental health professionals never recommend physical activity to their patients in low-resourced settings and increased awareness is needed to improve rehabilitation programs.Training in prescribing physical activity using the 5A framework improves knowledge about physical activity prescription in mental health professionals at all levels of care.Training in prescribing physical activity using motivational interviewing improves confidence in physical activity prescription in rehabilitation programs.Training in prescribing physical activity reduces perceived barriers for prescribing in rehabilitation programs in low-resourced settings.
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Affiliation(s)
- Davy Vancampfort
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.,University Psychiatric Centre, KU Leuven, Kortenberg, Belgium
| | - Samuel Kimbowa
- Butabika National Referral Mental Health Hospital, Kampala, Uganda
| | - Philip B Ward
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Schizophrenia Research Unit, Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Keneth Onekalit
- Faculty of Arts and Social Sciences, Kyambogo University, Kampala, Uganda
| | - Hafsa Lukwata
- Division of Mental Health, Ministry of Health, Kampala, Uganda
| | - James Mugisha
- Faculty of Arts and Social Sciences, Kyambogo University, Kampala, Uganda
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Mabunda D, Oliveira D, Sidat M, Cournos F, Wainberg M, Mari JDJ. Perceptions of Community Health Workers (CHW) on barriers and enablers to care for people with psychosis in rural Mozambique: findings of a focus group discussion study using the Capability, Opportunity, Motivation and Behaviour framework (COM-B framework). HUMAN RESOURCES FOR HEALTH 2022; 20:44. [PMID: 35590423 PMCID: PMC9118750 DOI: 10.1186/s12960-022-00741-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/11/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND Psychotic disorders contribute significantly to the global disease burden by causing disability, impaired quality of life, and higher mortality in affected people compared with the general population. In rural settings, where there is limited or no access to healthcare, individuals living with psychotic disorders often seek support from Community Health Workers (CHWs). However, little is known about what CHWs know about psychosis and how they manage such cases. This study aimed to explore the CHWs perception of psychosis and their experiences and beliefs about the factors that might enable or hinder care-taking for patients with psychosis in rural settings in Mozambique. METHODS A qualitative study was conducted in rural districts of Maputo Province, a southern region of Mozambique, using six focus group discussions with participation of 79 CHWs. Thematic analysis was used informed by the Capabilities, Opportunities, Motivation and Behaviour framework (COM-B). RESULTS Nine primary themes were identified. Overall, CHWs perceived psychosis as treatable medical conditions and held a positive attitude about being part of the care-taking process of patients with psychosis in rural settings. Partnerships with key-stakeholders such as traditional healers, health care workers, and families, were perceived by CHWs as enablers to improve access to care in rural areas. However, stigma, myths, and lack of competencies to treat people with psychosis were perceived by CHWs as barriers for appropriate care. CONCLUSION CHWs, with adequate support, could play an important role in the care of patients with psychosis in rural settings, including identifying patients requiring care and referring them to appropriate healthcare professionals, and following up medicated patients with psychosis. Training of CHWs should consider inclusion of basic mental health care competencies.
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Affiliation(s)
- Dirceu Mabunda
- Department of Psychiatry and Psychological Medicine, Universidade Federal de São Paulo, São Paulo, Brazil.
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique.
| | - Déborah Oliveira
- Division of Social Protection and Health, InterAmerican Development Bank, Washington, DC, United States of America
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique
| | - Francine Cournos
- Department of Psychiatry, Columbia University College of Physician and Surgeons, New York, NY, United States of America
| | - Milton Wainberg
- Department of Psychiatry, Columbia University College of Physician and Surgeons, New York, NY, United States of America
| | - Jair de Jesus Mari
- Department of Psychiatry and Psychological Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
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Thela L, Talatala M, Chiliza B. Addressing the Needs of People with Schizophrenia in South Africa During the COVID-19 Pandemic. SCHIZOPHRENIA BULLETIN OPEN 2022; 3:sgac048. [PMID: 35996533 PMCID: PMC9384532 DOI: 10.1093/schizbullopen/sgac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Research indicates that most people with Schizophrenia from low to middle-income countries do not receive adequate healthcare. Inadequate policies, lack of funding, poor service planning and neglect are some barriers to adequate care. Intrinsic barriers to care include stigma, lack of insight, and pathways to care that are often driven by cultural beliefs, and many systemic challenges. South Africa was not spared from the scourge of COVID-19, hosting a third of all reported cases in Africa. In a country with disparities, it would be of interest to get insight into the situation concerning the healthcare needs of people with Schizophrenia during the pandemic. A pandemic such as COVID-19 placed enormous strains on already limited and unequally distributed health care resources. In this paper, we discuss: (1) The South African healthcare system (with respect to Schizophrenia care). (2) COVID-19 policies related to the care of people with Schizophrenia (testing, access to vaccine). (3) Managing people with Schizophrenia amid the COVID-19 pandemic. (4) Recommendations.
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Affiliation(s)
- Lindokuhle Thela
- Discipline of Psychiatry, University of KwaZulu-Natal , Durban , South Africa
| | - Mvuyiso Talatala
- Department of Psychiatry, University of Witwatersrand , Johannesburg , South Africa
| | - Bonginkosi Chiliza
- Discipline of Psychiatry, University of KwaZulu-Natal , Durban , South Africa
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Vancampfort D, Stanton R, Probst M, De Hert M, Van Winkel R, Myin-Germeys I, Kinyanda E, Mugisha J. A quantitative assessment of the views of mental health professionals on exercise for people with mental illness: perspectives from a low-resource setting. Afr Health Sci 2019; 19:2172-2182. [PMID: 31656502 PMCID: PMC6794511 DOI: 10.4314/ahs.v19i2.42] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Exercise is nowadays considered as an evidence-based treatment modality in people with mental illness. Nurses and occupational therapists working in low-resourced mental health settings are well-placed to provide exercise advice for people with mental illness. Objectives We examined the current exercise prescription practices employed by Ugandan health care professionals when working with people with mental illness, and identified perceived barriers to exercise prescription and exercise participation for people with mental illness. Methods In this study, 31 Ugandan health care professionals 20 men; 31.2 ± 7.1 years completed the Exercise in Mental Illness Questionnaire- Health Professionals Version EMIQ-HP. Results The vast majority of the respondents 29/31, 94% reported they prescribed exercise at least “occasionally” to people with mental illness. Exercise-prescription parameters used were consistent with those recommended for people with mental illness. Regarding barriers to exercise participation, coping with side effects of psychotropic medication at the individual level and reducing stigma at community level should be prioritized. Conclusion A health care reform to enable collaboration with exercise professionals, such as exercise physiologists or physiotherapists, might increase exercise uptake for people with mental illness, thereby improving health outcomes for this vulnerable population.
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Baranyi G, Scholl C, Fazel S, Patel V, Priebe S, Mundt AP. Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studies. Lancet Glob Health 2019; 7:e461-e471. [PMID: 30879509 PMCID: PMC6419715 DOI: 10.1016/s2214-109x(18)30539-4] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/08/2018] [Accepted: 11/26/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although more than two thirds of the world's incarcerated individuals are based in low-income and middle-income countries (LMICs), the burden of psychiatric disorders in this population is not known. This review provides estimates for the prevalence of severe mental illness and substance use disorders in incarcerated individuals in LMICs. METHODS For this systematic review and meta-analysis, we searched 17 electronic databases to identify prevalence studies of psychiatric disorders in prison populations in LMICs, published between January, 1987, and May, 2018. We included representative studies from general prison samples, providing information about four major psychiatric diagnoses: psychosis, major depression, alcohol use disorders, and drug use disorders. We pooled data from studies using random-effects meta-analyses and assessed the sources of heterogeneity by meta-regression. We extracted general population estimates from the Global Burden of Diseases 2016 database to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42015020905. FINDINGS We identified 23 publications reporting prevalence estimates of severe mental illness and substance use disorders for 14 527 prisoners from 13 LMICs. In this population, the estimated pooled 1 year prevalence rates for psychosis were 6·2% (95% CI 4·0-8·6), 16·0% (11·7-20·8) for major depression, 3·8% (1·2-7·6) for alcohol use disorders, and 5·1% (2·9-7·8) for drug use disorders. We noted increased prevalence at prison intake and geographic variations for substance use disorders. For alcohol use disorders, prevalence was higher in the southeast Asian region than in the eastern Mediterranean region; and drug use disorders were more prevalent in the eastern Mediterranean region than in Europe. Prevalence ratios indicated substantially higher rates of severe mental illness and substance use disorders among prisoners than in the general population (the prevalence of non-affective psychosis was on average 16 times higher, major depression and illicit drug use disorder prevalence were both six times higher, and prevalence of alcohol use disorders was double that of the general population). INTERPRETATION The prevalence of major psychiatric disorders is high in prisoners in LMIC compared with general populations. As these findings are likely to reflect unmet needs, the development of scalable interventions should be a public health priority in resource-poor settings. FUNDING CONICYT of the Chilean government and the Wellcome Trust.
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Affiliation(s)
- Gergő Baranyi
- Centre for Research on Environment, Society and Health, Department of Geography, School of GeoSciences, The University of Edinburgh, Edinburgh, UK
| | - Carolin Scholl
- School of Informatics, The University of Edinburgh, Edinburgh, UK
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Vikram Patel
- Department of Global Health & Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK
| | - Adrian P Mundt
- Medical Faculty, Universidad Diego Portales, Santiago, Chile; Medical School, Universidad San Sebastián, Puerto Montt, Chile.
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Razzouk D. Accommodation and Health Costs of Deinstitutionalized People with Mental Illness Living in Residential Services in Brazil. PHARMACOECONOMICS - OPEN 2019; 3:31-42. [PMID: 29713951 PMCID: PMC6393275 DOI: 10.1007/s41669-018-0078-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Health costs are the main hindrances for expanding community mental health services. Exploring patient profiles and cost predictors may be useful for optimising financial resources. However, the deinstitutionalisation process may burden health budgets in terms of supporting multiple community services based on varying levels of need. OBJECTIVE This study assessed accommodation and health service costs, quality of life and clinical and psychosocial profiles among individuals receiving mental healthcare through residential services. Specific accommodation cost predictors were also verified. METHODS Health costs were assessed from the perspective of a public health provider using a microcosting bottom-up approach at 20 residential services in São Paulo, Brazil. Instruments used to assess health costs and patient profiles included the Brazilian version of the Client Socio-demographic and Service Receipt Inventory (CSSRI), the Mini International Neuropsychiatric Interview (MINI), the Clinical Global Impression-Severity Scale (CGI-S), the Independent Living Skills Survey (ILLS), the Social Behaviour Scale (SBS) and the Quality of Life Scale (QLS). RESULTS One hundred and forty-seven residents, predominantly experiencing psychotic disorders, were interviewed. The geographical region and length of time spent living in residential services or in a psychiatric hospital predicted 66% of the variance in accommodation costs. The CGI-S and ILLS scores and years of education explained 52.7% of the variance in quality of life. CONCLUSION Accommodation costs were not driven by patient profile variables, while region and time spent in a hospital or in residential services were the main cost predictors. Semi-staffed homes may be an alternative for resource optimisation among individuals with mild impairment, particularly if strategies for psychosocial rehabilitation and improving quality of life are implemented.
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Affiliation(s)
- Denise Razzouk
- Department of Psychiatry, Centro de Economia da Saúde Mental, Universidade Federal de São Paulo, Rua Borges Lagoa 570, Vila Clementino, São Paulo, 04038-000, Brazil.
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Mottaghipour Y, Tabatabaee M. Family and Patient Psychoeducation for Severe Mental Disorder in Iran: A Review. IRANIAN JOURNAL OF PSYCHIATRY 2019; 14:84-108. [PMID: 31114622 PMCID: PMC6505048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: There are evidence-based practices in the field of family and patient psychoeducation for patients suffering from severe mental disorders. However, given the variation in resources and cultural contexts, implementation of these services, especially in low and middle-income countries is faced with challenges. This study aimed to review articles on family and patient psychoeducation of severe mental disorders in Iran and to find the characteristics of the main components necessary for the implementation of such practices in clinical settings. Method : All published studies on family and patient psychoeducation for severe mental disorders (schizophrenia, schizoaffective, and bipolar disorder) conducted in Iran were searched up to May 2018; and key features and findings of each study were extracted and presented. Results: Forty-eight studies were included in this review, of which 27 were randomized controlled trials, and 20 were quasi-experimental. One study was an implementation and service development report. The main findings of these studies were a significant decrease in relapse rate and/or rehospitalization rate and a significant decrease of burden and distress of families. Conclusion: Despite a wide diversity in approaches, this review showed that different psychosocial interventions in which psychoeducation is one of their core and main components have promising results, demonstrating the significance of this intervention in Iranian mental health research. In our opinion, based on evidence, even with limited resources, it is no longer acceptable to deprioritize some forms of psychoeducation for patients and their families in clinical settings.
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Affiliation(s)
- Yasaman Mottaghipour
- Department of Psychiatry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Tabatabaee
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran.,Corresponding Author: Address: Roozbeh Hospital, Tehran University of Medical Sciences, South Kargar Avenue, Tehran, Iran. Postal Code: 1333715914. Tel: 98-2155412222, Fax: 98-2155419113,
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Breuer E, Subba P, Luitel N, Jordans M, De Silva M, Marchal B, Lund C. Using qualitative comparative analysis and theory of change to unravel the effects of a mental health intervention on service utilisation in Nepal. BMJ Glob Health 2018; 3:e001023. [PMID: 30687522 PMCID: PMC6326347 DOI: 10.1136/bmjgh-2018-001023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/20/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022] Open
Abstract
Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme’s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC. Methods We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5. Results The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities. Conclusions Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.
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Affiliation(s)
- Erica Breuer
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | | | - Mark Jordans
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | | | - Bruno Marchal
- Institute of Tropical Medicine, Antwerp, Belgium.,School of Public Health, University of the Western Cape, 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.,Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, King's College London, London, UK
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Baron EC, Rathod SD, Hanlon C, Prince M, Fedaku A, Kigozi F, Jordans M, Luitel NP, Medhin G, Murhar V, Nakku J, Patel V, Petersen I, Selohilwe O, Shidhaye R, Ssebunnya J, Tomlinson M, Lund C, De Silva M. Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol. BMC Psychiatry 2018; 18:61. [PMID: 29510751 PMCID: PMC5840717 DOI: 10.1186/s12888-018-1642-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/26/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts. METHODS One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy). DISCUSSION Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.
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Affiliation(s)
- Emily C. Baron
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road 7700 Rondebosch, Cape Town, South Africa
| | - Sujit D. Rathod
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Hanlon
- College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Services and Population Research Department, King’s College London, London, UK
| | - Martin Prince
- Centre for Global Mental Health, Health Services and Population Research Department, King’s College London, London, UK
| | - Abebaw Fedaku
- Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Global Health and Infection Department, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Fred Kigozi
- Butabika National Referral and Teaching Mental Hospital, Makerere University, Kampala, Uganda
| | - Mark Jordans
- Research and Development Department, HealthNet TPO, Amsterdam, the Netherlands
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nagendra P. Luitel
- Research Department, Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, Kathmandu, Nepal
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Juliet Nakku
- Butabika National Referral and Teaching Mental Hospital, Makerere University, Kampala, Uganda
| | - Vikram Patel
- Sangath, Goa, India
- Harvard Medical School, Boston, USA
- Public Health Foundation of India, New Delhi, India
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health and School of Applied Human Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health and School of Applied Human Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Rahul Shidhaye
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Joshua Ssebunnya
- Butabika National Referral and Teaching Mental Hospital, Makerere University, Kampala, Uganda
| | - Mark Tomlinson
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road 7700 Rondebosch, Cape Town, South Africa
- Alan J Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road 7700 Rondebosch, Cape Town, South Africa
- Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mary De Silva
- Department of Population Health, Wellcome Trust, London, UK
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Vancampfort D, Stubbs B, Probst M, Mugisha J. Physiotherapy for people with mental health problems in Sub-Saharan African countries: a systematic review. Arch Physiother 2018; 8:2. [PMID: 29423279 PMCID: PMC5787323 DOI: 10.1186/s40945-018-0043-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 01/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background There is a need for psychosocial interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Physiotherapists could have a central role in reducing the burden and facilitating recovery within the multidisciplinary care of people with mental health problems. The aim of this systematic review was to explore the role of physiotherapists within the current mental health policies of SSA countries and to explore the current research evidence for physiotherapy to improve functional outcomes in people with mental health problems in SSA. Methods The Mental Health Atlas and MiNDbank of the World Health Organization were screened for the role of physiotherapy in mental health plans. Next, we systematically searched PubMed from inception until August 1st, 2017 for relevant studies on physiotherapy interventions in people with mental health problems in SSA. The following search strategy was used: "physiotherapy" OR "physical therapy" OR "rehabilitation" AND "mental" OR "depression" OR "psychosis" OR "schizophrenia" OR "bipolar" AND the name of the country. Results The current systematic review shows that in 22 screened plans only 2 made reference to the importance of considering physiotherapy within the multidisciplinary treatment. The current evidence (N studies = 3; n participants = 94) shows that aerobic exercise might reduce depression and improve psychological quality of life, self-esteem, body image and emotional stress in people with HIV having mental health problems. In people with depression moderate to high but not light intensity aerobic exercise results in significantly less depressive symptoms (N = 1, n = 30). Finally, there is evidence for reduction in post-traumatic stress symptoms (avoidance and arousal), anxiety and depression following body awareness related exercises (N = 1, n = 26). Conclusions Our review demonstrated that physiotherapy is still largely neglected in the mental health care systems of SSA. This is probably due to poor knowledge of the benefits of physiotherapy within mental health care by policymakers, training institutes, and other mental health care professionals in SSA. Based on the current scientific evidence, this paper recommends the adoption of physiotherapy within mental health care services and investment in research and in training of professionals in SSA.
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Affiliation(s)
- Davy Vancampfort
- 1Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium.,2KU Leuven - University of Leuven, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium
| | - Brendon Stubbs
- 3Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.,4Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
| | - Michel Probst
- 1Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium
| | - James Mugisha
- Butabika National Referral and Mental Health Hospital, Kampala, Uganda.,6Kyambogo University, Kampala, Uganda
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Renwick L, Irmansyah, Keliat BA, Lovell K, Yung A. Implementing an innovative intervention to increase research capacity for enhancing early psychosis care in Indonesia. J Psychiatr Ment Health Nurs 2017; 24:671-680. [PMID: 28786548 DOI: 10.1111/jpm.12417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 11/30/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE TOPIC?: In low- and middle-income settings (LMICs) such as Indonesia, the burden from psychotic illness is significant due to large gaps in treatment provision Mental health workers and community nurses are a growing workforce requiring new evidence to support practice and enhanced roles and advanced competencies among UK mental health nurses also requires greater research capacity Research capacity building projects can strengthen research institutions, enhance trial capacity, improve quality standards and improve attitudes towards the importance of health research. WHAT THIS PAPER ADDS?: Delivering innovative, cross-cultural workshops to enhance research capacity to multidisciplinary, early career researchers in Indonesia and the UK are rated highly by attendees Supporting people in this way helps them to gain competitive grant funding to complete their own research which can improve the health of the population To our knowledge, there are no other studies reporting the attainment of grant income as a successful outcome of international research partnerships for mental health nursing so our finding is novel. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This method could be implemented to improve networking and collaboration between UK academics and early career researchers in other lower- and middle-income settings This strategy can also strengthen existing partnerships among early career researchers in the UK to meet the demands for greater research mentorship and leadership among mental health nurses and enhance nurses capabilities to contribute to evidence for practice. ABSTRACT Aim To strengthen research capacity for nurses and early career researchers in Indonesia and the UK to develop a local evidence base in Indonesia to inform policy and improve the nation's health. These strategies can strengthen research institutions, enhance trial capacity, improve quality standards and improve attitudes towards the importance of health research. Methods Four days of workshops were held in Jakarta, Indonesia developing collaborative groups of academic nurses and early career researchers from the UK and Indonesia (30 people including mentors) to produce competitive grant bids to evaluate aspects of early psychosis care. Qualitative and quantitative evaluations were conducted. Results Participants evaluated the workshops positively finding benefit in the structure, content and delivery. Research impact was shown by attaining several successful small and large grants and developing offshoot collaborative relationships. Discussion These novel findings demonstrate that collaborative workshops can strengthen research capacity by developing partnerships and instigating new collaborations and networks. No other studies of international research partnerships among mental health nurses have reported this outcome to our knowledge. Implications for Practice This method could be implemented to improve networking and collaboration between UK academics and early career researchers and also with external colleagues in other LMICs.
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Affiliation(s)
- L Renwick
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Irmansyah
- Marzoeki Mahdi Hospital, Bogor, Indonesia
| | - B A Keliat
- Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - K Lovell
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - A Yung
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
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Asher L, Patel V, De Silva MJ. Community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis. BMC Psychiatry 2017; 17:355. [PMID: 29084529 PMCID: PMC5661919 DOI: 10.1186/s12888-017-1516-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 10/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is consensus that the treatment of schizophrenia should combine anti-psychotic medication and psychosocial interventions in order to address complex social, economic and health needs. It is recommended that family therapy or support; community-based rehabilitation; and/or self-help and support groups should be provided for people with schizophrenia in low and middle-income countries. The effectiveness of community-based psychosocial interventions in these settings is unclear. METHODS Studies evaluating community-based psychosocial interventions for people with schizophrenia were identified through database searching up to April 2016. Randomised controlled trials were included if they compared the intervention group with a control group receiving treatment as usual including medication. Only studies set in low and middle-income countries were included. Random effects meta-analyses were performed separately for each intervention type. RESULTS Eleven randomised controlled trials in five middle-income countries were identified, with a total of 1580 participants. The content of included interventions varied from single-faceted psychoeducational interventions, to multi-component rehabilitation-focused interventions, to case management interventions. A third of the included studies did not incorporate any community involvement in the intervention. The quality of evidence was often low. Amongst the seven studies that reported on symptom severity up to 18 months post intervention, the pooled standardised mean difference (SMD) across all intervention types was 0.95 (95% CI 0.28, 1.61; P 0.005; I 2 = 95%; n = 862), representing a strong effect. A strong effect on symptom severity remained after excluding two studies with a high risk of bias (SMD 0.80; 95% CI 0.07, 1.53; P 0.03; I 2 = 94%; n = 676). Community-based psychosocial interventions may also have beneficial impacts on functioning (SMD 1.12; 95% CI 0.25, 2.00; P 0.01; I 2 = 94%; n = 511) and reducing hospital readmissions (SMD 0.68; 95% CI 0.27, 1.09; P 0.001; I2 = 33%; n = 167). CONCLUSION The limited evidence from low and middle-income countries supports the feasibility and effectiveness of community-based psychosocial interventions for schizophrenia, even in the absence of community mobilisation. Community-based psychosocial interventions should therefore be provided in these settings as an adjuvant service in addition to facility-based care for people with schizophrenia.
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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
| | - Vikram Patel
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Sangath, Porvorim, Goa India
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Stubbs B, Koyanagi A, Schuch F, Firth J, Rosenbaum S, Gaughran F, Mugisha J, Vancampfort D. Physical Activity Levels and Psychosis: A Mediation Analysis of Factors Influencing Physical Activity Target Achievement Among 204 186 People Across 46 Low- and Middle-Income Countries. Schizophr Bull 2017; 43:536-545. [PMID: 27562855 PMCID: PMC5464271 DOI: 10.1093/schbul/sbw111] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Physical activity (PA) can help reduce cardiovascular disease and premature mortality in people with psychosis. However, there is a paucity of representative data on PA in people with psychosis, especially from low- and middle-income countries (LMICs). Moreover, data on subclinical psychosis and PA is absent. This study explored whether complying with PA recommendations of 150 minutes of moderate-vigorous PA per week is related to: (1) psychotic symptoms without a psychosis diagnosis (subclinical psychosis); and (2) clinical psychosis (psychosis diagnosis). A total of 204 186 participants aged 18-64 years from 46 LMICs recruited via the World Health Survey were subdivided into those with (1) no psychosis diagnosis and no psychotic symptoms in the past 12 months (controls); (2) subclinical psychosis; and (3) psychosis diagnosis. People with a psychosis diagnosis had significantly higher odds for low PA in the overall sample (OR = 1.36; 95% CI = 1.04-1.78; P = .024) and among males (OR = 2.29; 95% CI = 1.57-3.34; P < .0001) but not females (OR = 0.93; 95% CI = 0.67-1.30; P = .6712). No difference was found among those with subclinical psychosis vs controls. Mediation analyses demonstrated that mobility difficulties explained the largest amount of low PA among males (18.5%) followed by self-care difficulties (16.3%), depression (16.1%), cognition (11.8%), pain and discomfort (11.4%), interpersonal activities (8.6%), sleep and energy (7.2%), and vision (3.0%). The results from the largest dataset on PA and psychosis and first in LMICs, found that psychosis diagnosis (especially among males) but not subclinical psychosis, is associated with physical inactivity. Population level interventions seeking to increase PA among people with psychosis may help improve health outcomes.
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Affiliation(s)
- Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK;,Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Barcelona, Spain;,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
| | - Felipe Schuch
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil;,Programa de Pós Graduação em Ciências Médicas: Psiquiatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Joseph Firth
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Simon Rosenbaum
- Department of Exercise Physiology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, London, UK
| | - James Mugisha
- Kyambogo University, Kampala, Uganda;,Butabika National Referral and Mental Health Hospital, Kampala, Uganda
| | - Davy Vancampfort
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium;,KU Leuven, University Psychiatric Center KU Leuven, Leuven-Kortenberg, Belgium
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Vancampfort D, Stubbs B, De Hert M, du Plessis C, Gbiri CAO, Kibet J, Wanyonyi N, Mugisha J. A systematic review of physical activity policy recommendations and interventions for people with mental health problems in Sub-Saharan African countries. Pan Afr Med J 2017; 26:104. [PMID: 28491235 PMCID: PMC5409986 DOI: 10.11604/pamj.2017.26.104.10051] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/28/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction There is a need for interventions to address the escalating mental health burden in Sub-Saharan Africa (SSA). Implementation of physical activity (PA) within the rehabilitation of people with mental health problems (PMHP) could reduce the burden and facilitate recovery. The objective of the current review was to explore (1) the role of PA within mental health policies of SSA countries, and (2) the current research evidence for PA to improve mental health in SSA. Methods We screened the Mental Health Atlas and MiNDbank for mental health policies in SSA countries and searched PubMed for relevant studies on PA in PMHP in SSA. Results Sixty-nine percent (=33/48) of SSA countries have a dedicated mental health policy. Two of 22 screened mental health policies included broad physical activity recommendations. There is clear evidence for the role of PA in the prevention and rehabilitation of depression in SSA. Conclusion Despite the existing evidence, PA is largely a neglected rehabilitation modality in the mental health care systems of SSA. Continued education of existing staff, training of specialized professionals and integration of PA for mental health in public health awareness programs are needed to initiate and improve PA programs within the mental health care systems of SSA.
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Affiliation(s)
- Davy Vancampfort
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium.,KU Leuven - University of Leuven, University Psychiatric Center KU Leuven, Leuven-Kortenberg, Belgium
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
| | - Marc De Hert
- KU Leuven - University of Leuven, University Psychiatric Center KU Leuven, Leuven-Kortenberg, Belgium
| | | | - Caleb Ademola Omuwa Gbiri
- College of Medicine, University of Lagos, Nigeria.,Department of Psychiatry, Faculty of Health Sciences, University of Pretoria, South Africa
| | | | - Nancy Wanyonyi
- Department of Orthopaedics and Rehabilitation, Moi University College of Health Sciences, Eldoret, Kenya
| | - James Mugisha
- Kyambogo University, Kampala, Uganda.,Butabika National Referral and Mental Health Hospital, Kampala, Uganda
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Gowda GS, Hegde A, Shanbhag V, Narayanaswamy JC, Jaisoorya TS. Kerato-lenticular ocular deposits and visual impairment with prolonged chlorpromazine use: A case series. Asian J Psychiatr 2017; 25:188-190. [PMID: 28262147 DOI: 10.1016/j.ajp.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/26/2016] [Accepted: 11/06/2016] [Indexed: 11/26/2022]
Abstract
Chlorpromazine is a low potency "typical" antipsychotic agent used to treat schizophrenia. It continues to be prescribed frequently in India owing to its lower cost. There have been previous reports of ocular adverse effects with prolonged use of chlorpromazine. We report three patients who developed corneal and lenticular opacities secondary to prolonged chlorpromazine use leading to visual impairment. Early detection of ocular deposits and switching over to risperidone from chlorpromazine helped in the reversal of chlorpromazine- induced ocular side effects in one of them. The case series further adds evidence to the causative relationship between chlorpromazine and ocular side effects.
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Affiliation(s)
- Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India.
| | | | - Vandita Shanbhag
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
| | - Janardhanan C Narayanaswamy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
| | - T S Jaisoorya
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 560029, India
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Poltorak M. Anthropology, brokerage, and collaboration in the development of a Tongan public psychiatry: Local lessons for global mental health. Transcult Psychiatry 2016; 53:743-765. [PMID: 28317470 DOI: 10.1177/1363461516679072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Global Mental Health (GMH) movement has raised questions of the translatability of psychiatric concepts and the challenges of community engagement. In Tonga, the local psychiatrist Dr Puloka successfully established a publicly accessible psychiatry that has improved admission rates for serious mental illnesses and addressed some of the stigma attached to diagnosis. On the basis of historical analysis and ethnographic fieldwork with healers, doctors, and patients since 1998, this article offers an ethnographic contextualization of the development and reception of Puloka's three key interventions during the 1990s: (a) collaboration with traditional healers; (b) translation of psychiatric diagnoses into local cultural concepts; and (c) encouraging freedom of movement and legal appeal to involuntary admission. Dr Puloka's use of medical anthropological and transcultural psychiatry research informed a community-engaged brokerage between the implications of psychiatric nosologies and local needs that can address some of the challenges of the Global Mental Health movement.
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Carrà G, Crocamo C, Bartoli F, Lax A, Tremolada M, Lucii C, Martinotti G, Nosè M, Bighelli I, Ostuzzi G, Castellazzi M, Clerici M, Barbui C. First-generation antipsychotics and QTc: any role for mediating variables? Hum Psychopharmacol 2016; 31:313-318. [PMID: 27245736 DOI: 10.1002/hup.2540] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/31/2016] [Accepted: 04/21/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Corrected QT (QTc) interval prolongation is often associated with use of first-generation antipsychotics (FGAs). However, other factors require appropriate consideration, including age and gender, the role of other known medications associated with QTc prolongation, and severe comorbid conditions, such as co-occurring alcohol abuse/dependence. We aimed to study potential mediating roles of different, related, candidate variables on QTc. METHODS We capitalized on data from a large (N = 2366), cross-sectional, national survey, the STAR Network QTc study, using a representative sample of people taking FGAs, and recruited from mental health services across Italy. RESULTS About one-third of the sample was treated with FGAs, and almost one-tenth of the subjects took a different, additional, drug known to cause QTc prolongation. Our findings confirmed that there is an impact from FGAs, age, gender, alcohol misuse, and concurrent risky drugs on QTc. However, comorbid alcohol abuse/dependence and concurrent risky drugs did not mediate the effect of FGAs on QTc. CONCLUSIONS Our findings showed that FGAs, concurrent risky drugs, and alcohol use disorders prolonged QTc. FGAs had a direct effect on QTc, confirming the need for clinicians to monitor a risk that could lead to sudden unexplained death. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Giuseppe Carrà
- Division of Psychiatry, University College London, London, UK
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | - Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | - Annamaria Lax
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | - Martina Tremolada
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | | | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, Chieti, Italy
| | - Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Irene Bighelli
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Mariasole Castellazzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Monza (MB), Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
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Abstract
The growing momentum towards a global consensus on universal health coverage, alongside an acknowledgment of the urgency and importance of a comprehensive mental health action plan, offers a unique opportunity for a substantial scale-up of evidence-based interventions and packages of care for a range of mental disorders in all countries. There is a robust evidence base testifying to the effectiveness of drug and psychosocial interventions for people with schizophrenia and to the feasibility, acceptability and cost-effectiveness of the delivery of these interventions through a collaborative care model in low resource settings. While there are a number of barriers to scaling up this evidence, for eg, the finances needed to train and deploy community based workers and the lack of agency for people with schizophrenia, the experiences of some upper middle income countries show that sustained political commitment, allocation of transitional financial resources to develop community services, a commitment to an integrated approach with a strong role for community based institutions and providers, and a progressive realization of coverage are the key ingredients for scale up of services for schizophrenia.
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Affiliation(s)
- Vikram Patel
- London School of Hygiene & Tropical Medicine, the Public Health Foundation of India and Sangath, Goa, India
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Chua WLLC, Grigorov HS, Hiley J. Oestrogen (adjunct) versus placebo for women with schizophrenia. Hippokratia 2016. [DOI: 10.1002/14651858.cd012220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Wan Lian LC Chua
- Bradford District Care Trust; City Community Mental Health Team; Horton Park Centre 99 Horton Park Avenue Bradford West Yorkshire UK BD7 9EG
| | - Hristo S Grigorov
- Nottinghamshire Healthcare NHS Trust; Stonebridge Centre; Cardiff Street Nottingham Nottinghamshire UK NG3 2FH
| | - John Hiley
- Bradford District Care Trust; Research & Development; Lynfield Mount Hospital, Heights Lane Bradford UK BD9 6DP
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Farooq S, Burns J, Sumathipala A, Naeem F. A global mental health fund for serious mental illness in low-income and middle-income countries. Lancet Psychiatry 2016; 3:495-7. [PMID: 27262038 DOI: 10.1016/s2215-0366(16)00105-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Saeed Farooq
- Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK; South Staffordshire and Shropshire NHS Foundation Trust, Staffordshire, UK.
| | - Jonathan Burns
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Athula Sumathipala
- Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK; South Staffordshire and Shropshire NHS Foundation Trust, Staffordshire, UK
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Sweetland AC, Oquendo MA, Sidat M, Santos PF, Vermund SH, Duarte CS, Arbuckle M, Wainberg ML. Closing the mental health gap in low-income settings by building research capacity: perspectives from Mozambique. Ann Glob Health 2016; 80:126-33. [PMID: 24976551 DOI: 10.1016/j.aogh.2014.04.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 03/07/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Neuropsychiatric disorders are the leading cause of disability worldwide, accounting for 22.7% of all years lived with disability. Despite this global burden, fewer than 25% of affected individuals ever access mental health treatment; in low-income settings, access is much lower, although nonallopathic interventions through traditional healers are common in many venues. Three main barriers to reducing the gap between individuals who need mental health treatment and those who have access to it include stigma and lack of awareness, limited material and human resources, and insufficient research capacity. We argue that investment in dissemination and implementation research is critical to face these barriers. Dissemination and implementation research can improve mental health care in low-income settings by facilitating the adaptation of effective treatment interventions to new settings, particularly when adapting specialist-led interventions developed in high-resource countries to settings with few, if any, mental health professionals. Emerging evidence from other low-income settings suggests that lay providers can be trained to detect mental disorders and deliver basic psychotherapeutic and psychopharmacological interventions when supervised by an expert. OBJECTIVES We describe a new North-South and South-South research partnership between Universidade Eduardo Mondlane (Mozambique), Columbia University (United States), Vanderbilt University (United States), and Universidade Federal de São Paulo (Brazil), to build research capacity in Mozambique and other Portuguese-speaking African countries. CONCLUSIONS Mozambique has both the political commitment and available resources for mental health, but inadequate research capacity and workforce limits the country's ability to assess local needs, adapt and test interventions, and identify implementation strategies that can be used to effectively bring evidence-based mental health interventions to scale within the public sector. Global training and research partnerships are critical to building capacity, promoting bilateral learning between and among low- and high-income settings, ultimately reducing the mental health treatment gap worldwide.
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Affiliation(s)
- Annika C Sweetland
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY.
| | - Maria A Oquendo
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY
| | - Mohsin Sidat
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Palmira F Santos
- Ministry of Health, Mental Health Department, Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Cristiane S Duarte
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY
| | - Melissa Arbuckle
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY
| | - Milton L Wainberg
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, New York, NY
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Guan L, Liu J, Wu XM, Chen D, Wang X, Ma N, Wang Y, Good B, Ma H, Yu X, Good MJ. Unlocking patients with mental disorders who were in restraints at home: a national follow-up study of China's new public mental health initiatives. PLoS One 2015; 10:e0121425. [PMID: 25848800 PMCID: PMC4388503 DOI: 10.1371/journal.pone.0121425] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 02/12/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2005, China implemented a demonstration program known as "686" to scale-up nation-wide basic mental health services designed to improve access to evidence-based care and to promote human rights for people with severe mental disorders. As part of the 686 Program, teams "unlocked" and provided continuous mental health care to people with severe mental disorders who were found in restraints and largely untreated in their family homes. We implemented a nation-wide two-stage follow-up study to measure the effectiveness and sustainability of the "unlocking and treatment" intervention and its impact on the well-being of patients' families. METHODS 266 patients unlocked from 2005 in "686" demonstration sites across China were recruited in Stage One of the study in 2009. In 2012, 230 of the 266 cases were re-interviewed (the Stage Two study). Outcome measures included the patient medication adherence and social functioning, family burden ratings, and relocking rate. We utilized pre-post tests to analyze the changes over time following the unlocking efforts. RESULTS 96% of patients were diagnosed with schizophrenia. Prior to unlocking, their total time locked ranged from two weeks to 28 years, with 32% having been locked multiple times. The number of persons regularly taking medicines increased from one person at the time of unlocking to 74% in 2009 and 76% in 2012. Pre-post tests showed sustained improvement in patient social functioning and significant reductions in family burden. Over 92% of patients remained free of restraints in 2012. CONCLUSION Practice-based evidence from our study suggests an important model for protecting the human rights of people with mental disorders and keeping them free of restraints can be achieved by providing accessible, community based mental health services with continuity of care. China's "686" Program can inform similar efforts in low-resource settings where community locking of patients is practiced.
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Affiliation(s)
- Lili Guan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Jin Liu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Xia Min Wu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Dafang Chen
- School of Public Health, Peking University, Beijing, China
| | - Xun Wang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Ning Ma
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Yan Wang
- School of Public Health, Peking University, Beijing, China
| | - Byron Good
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hong Ma
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Mary-Jo Good
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Brooke-Sumner C, Petersen I, Asher L, Mall S, Egbe CO, Lund C. Systematic review of feasibility and acceptability of psychosocial interventions for schizophrenia in low and middle income countries. BMC Psychiatry 2015; 15:19. [PMID: 25886524 PMCID: PMC4382830 DOI: 10.1186/s12888-015-0400-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low and middle income countries there is evidence to suggest effectiveness of community-based psychosocial interventions for schizophrenia. Many psychosocial interventions have however been conceptualized in high income countries and assessing their feasibility and acceptability in low and middle income countries is pertinent and the objective of this review. METHODS Six databases were searched using search terms (i) "Schizophrenia"; (ii) "Low and middle income or developing countries" and (iii) "Psychosocial interventions". Abstracts identified were extracted to an EndNote Database. Two authors independently reviewed abstracts according to defined inclusion and exclusion criteria. Full papers were accessed of studies meeting these criteria, or for which more information was needed to include or exclude them. Data were extracted from included studies using a predesigned data extraction form. Qualitative synthesis of qualitative and quantitative data was conducted. RESULTS 14 037 abstracts were identified through searches. 196 full articles were reviewed with 17 articles meeting the inclusion criteria. Little data emerged on feasibility. Barriers to feasibility were noted including low education levels of participants, unavailability of caregivers, and logistical issues such as difficulty in follow up of participants. Evidence of acceptability was noted in high participation rates and levels of satisfaction with interventions. CONCLUSIONS While there is preliminary evidence to suggest acceptability of community-based psychosocial interventions for schizophrenia in low and middle income countries, evidence for overall feasibility is currently lacking. Well-designed intervention studies incorporating specific measures of acceptability and feasibility are needed.
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Affiliation(s)
- Carrie Brooke-Sumner
- School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, Durban, South Africa.
| | - Inge Petersen
- School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, Durban, South Africa.
| | - Laura Asher
- Department for Population Health, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.
- Department of Psychiatry, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Sumaya Mall
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Catherine O Egbe
- School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, Durban, South Africa.
| | - Crick Lund
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa.
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Horvitz-Lennon M, Iyer N, Minoletti A. Do Low- and Middle-Income Countries Learn from the Experience of High-Income Countries? INTERNATIONAL JOURNAL OF MENTAL HEALTH 2014. [DOI: 10.2753/imh0020-7411420103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brooke-Sumner C, Lund C, Petersen I. Perceptions of psychosocial disability amongst psychiatric service users and caregivers in South Africa. Afr J Disabil 2014; 3:146. [PMID: 28730007 PMCID: PMC5443050 DOI: 10.4102/ajod.v3i1.146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/19/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In many parts of South Africa there is little support for people with psychosocial disability caused by schizophrenia, beyond provision of psychotropic medications. Appropriate community-based psychosocial rehabilitation interventions are a crucial element of mental health service development. OBJECTIVES This study aimed to use an explanatory model of illness framework to document experiences of illness, disability and recovery amongst service users with schizophrenia and their caregivers in a poorly resourced area in the North West Province. Data were used to provide recommendations for a contextually appropriate non-specialist facilitated group psychosocial rehabilitation intervention. METHOD Eighteen in-depth individual interviews were conducted: nine with schizophrenia service users and nine with caregivers. Interviews were conducted by two trained field researchers; both clinical psychologists fluent in the first language of participants. All interviews were recorded, translated and transcribed. Data were thematically analysed using NVivo 9. RESULTS Participants linked the illness to witchcraft, poverty and stress. Family conflict was recognised in the course of the illness, causing stress and challenges for emotional well-being. Knowledge of diagnosis and biomedical treatment was minimal. Key factors recognised by service users as promoting recovery were the ability to work, and the support of traditional healers and religious structures. CONCLUSION Based on the findings of this study, a group psychosocial rehabilitation intervention emerged as a recommendation, with the incorporation of psycho-education, adherence support, coping skills, and opportunities for income generation and productive activity. The importance of also enlisting the support of religious leaders and traditional healers in supporting recovery is emphasised.
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Affiliation(s)
- Carrie Brooke-Sumner
- School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, South Africa
| | - Crick Lund
- Alan J. Flisher Centre for Public Mental Health Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Inge Petersen
- School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, South Africa
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Abstract
Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.
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Affiliation(s)
| | - David B Menkes
- Waikato Clinical Campus, University of Auckland, Hamilton 3240, New Zealand
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Adeosun II, Adegbohun AA, Adewumi TA, Jeje OO. The Pathways to the First Contact with Mental Health Services among Patients with Schizophrenia in Lagos, Nigeria. SCHIZOPHRENIA RESEARCH AND TREATMENT 2013; 2013:769161. [PMID: 24490072 PMCID: PMC3893872 DOI: 10.1155/2013/769161] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 11/06/2013] [Accepted: 11/14/2013] [Indexed: 11/13/2022]
Abstract
There is increasing evidence that delay in the commencement of treatment, following the onset of schizophrenia, may be related to the pathways patients navigate before accessing mental health care. Therefore, insight into the pattern and correlates of pathways to mental care of patients with schizophrenia may inform interventions that could fast track their contact with mental health professionals and reduce the duration of untreated psychosis. This study assessed the pathways to mental health care among patients with schizophrenia (n = 138), at their first contact with mental health services at the Federal Neuro-Psychiatric Hospital Yaba Lagos, Nigeria. Traditional and religious healers were the first contact for the majority (69%) of the patients. Service users who first contacted nonorthodox healers made a greater number of contacts in the course of seeking help, eventuating in a longer duration of untreated psychosis (P < 0.001). However, the delay between the onset of psychosis and contact with the first point of care was shorter in patients who patronized nonorthodox practitioners. The findings suggest that collaboration between orthodox and nonorthodox health services could facilitate the contact of patients with schizophrenia with appropriate treatment, thereby reducing the duration of untreated psychosis. The need for public mental health education is also indicated.
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Affiliation(s)
| | | | | | - Oyetayo O. Jeje
- Federal Neuro-Psychiatric Hospital Yaba, 8 Harvey Road, PMB, Lagos 2008, Nigeria
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de Jesus Mari J, Tófoli LF, Noto C, Li LM, Diehl A, Claudino AM, Juruena MF. Pharmacological and psychosocial management of mental, neurological and substance use disorders in low- and middle-income countries: issues and current strategies. Drugs 2013; 73:1549-1568. [PMID: 24000001 DOI: 10.1007/s40265-013-0113-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Mental, neurological, and substance use disorders (MNS) are among the largest sources of medical disability in the world, surpassing both cardiovascular disease and cancer. The picture is not different in low- and middle-income countries (LAMIC) where the relative morbidity associated with MNS is increasing, as a consequence of improvement in general health indicators and longevity. However, 80 % of individuals with MNS live in LAMIC but only close to 20 % of cases receive some sort of treatment. The main aim of this article is to provide non-specialist health workers in LAMIC with an accessible guide to the affordable essential psychotropics and psychosocial interventions which are proven to be cost effective for treating the main MNS. The MNS discussed in this article were selected on the basis of burden, following the key priority conditions selected by the Mental Health Action Programme (mhGAP) developed by the World Health Organization (WHO) (anxiety, stress-related and bodily distress disorders; depression and bipolar disorder; schizophrenia; alcohol and drug addiction; and epilepsy), with the addition of eating disorders, because of their emergent trend in middle-income countries. We review best evidence-based clinical practice in these areas, with a focus on drugs from the WHO Model List of Essential Medicines and the psychosocial interventions available in LAMIC for the management of these conditions in primary care. We do this by reviewing guidelines developed by prestigious professional associations and government agencies, clinical trials conducted in LAMIC and systematic reviews (including Cochrane reviews) identified from the main international literature databases (MEDLINE, EMBASE and PsycINFO). In summary, it can be concluded that the availability and use of the psychotropics on the WHO Model List of Essential Medicines in LAMIC, plus an array of psychosocial interventions, can represent a cost-effective way to expand treatment of most MNS. The translation of these findings into policies can be achieved by relatively low supplementary funding, and limited effort engendered by governments and policy makers in LAMIC.
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Affiliation(s)
- Jair de Jesus Mari
- Department of Psychiatry, Universidade Federal de São Paulo, Rua Borges Lagoa 570 - 1° andar, Vila Clementino, São Paulo, SP, 04038-000, Brazil,
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De Silva MJ, Cooper S, Li HL, Lund C, Patel V. Effect of psychosocial interventions on social functioning in depression and schizophrenia: meta-analysis. Br J Psychiatry 2013; 202:253-60. [PMID: 23549941 PMCID: PMC3613719 DOI: 10.1192/bjp.bp.112.118018] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Psychosocial interventions may contribute to reducing the burden of mental disorders in low- and middle-income (LAMI) countries by improving social functioning, but the evidence has not been systematically reviewed. AIMS Systematic review and meta-analysis of the effect of psychosocial interventions on social functioning in people with depression and schizophrenia in LAMI countries. METHOD Studies were identified through database searching up to March 2011. Randomised controlled trials were included if they compared the intervention group with a control group receiving placebo or treatment as usual. Random effects meta-analyses were performed separately for depressive disorders and schizophrenia and for each intervention type. RESULTS Of the studies that met the inclusion criteria (n = 24), 21 had sufficient data to include in the meta-analysis. Eleven depression trials showed good evidence for a moderate positive effect of psychosocial interventions on social functioning (standardised mean difference (SMD) = 0.46, 95% CI 0.24-0.69, n = 4009) and ten schizophrenia trials showed a large positive effect on social functioning (SMD = 0.84, 95% CI 0.49-1.19, n = 1671), although seven of these trials were of low quality. Excluding these did not substantially affect the size or direction of effect, although the precision of the estimate was substantially reduced (SMD = 0.89, 95% CI 0.05-1.72, n = 863). CONCLUSIONS Psychosocial interventions delivered in out-patient and primary care settings are effective at improving social functioning in people with depression and should be incorporated into efforts to scale up services. For schizophrenia there is an absence of evidence from high-quality trials and the generalisabilty of the findings is limited by the over-representation of trials conducted in populations of hospital patients in China. More high-quality trials of psychosocial interventions for schizophrenia delivered in out-patient settings are needed.
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Affiliation(s)
- Mary J De Silva
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.
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Thara R, John S, Chatterjee S. Comprehensive Care for Patients in the Developing World. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2013. [DOI: 10.2753/imh0020-7411420105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- R. Thara
- a Schizophrenia Research Foundation, Chennai, India
| | - Sujit John
- a Schizophrenia Research Foundation, Chennai, India
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Cognitive training for schizophrenia in developing countries: a pilot trial in Brazil. SCHIZOPHRENIA RESEARCH AND TREATMENT 2013; 2013:321725. [PMID: 24288608 PMCID: PMC3833062 DOI: 10.1155/2013/321725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/12/2013] [Accepted: 09/17/2013] [Indexed: 11/18/2022]
Abstract
Cognitive deficits in schizophrenia can massively impact functionality and quality of life, furthering the importance of cognitive training. Despite the development of the field in Europe and in the United States, no programmes have been developed and tested in developing countries. Different cultural backgrounds, budget restrictions, and other difficulties may render treatment packages created in high income countries difficult for adoption by developing nations. We performed a pilot double-blind, randomized, controlled trial in order to investigate the efficacy and feasibility of an attention and memory training programme specially created in a developing nation. The intervention used simple, widely available materials, required minimal infrastructure, and was conducted in groups. The sample included seventeen stable Brazilians with schizophrenia. Sessions were conducted weekly during five months. The cognitive training group showed significant improvements in inhibitory control and set-shifting over time. Both groups showed improvements in symptoms, processing speed, selective attention, executive function, and long-term visual memory. Improvements were found in the control group in long-term verbal memory and concentration. Our findings reinforce the idea that cognitive training in schizophrenia can be constructed using simple resources and infrastructure, facilitating its adoption by developing countries, and it may improve cognition.
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Balaji M, Chatterjee S, Brennan B, Rangaswamy T, Thornicroft G, Patel V. Outcomes that matter: a qualitative study with persons with schizophrenia and their primary caregivers in India. Asian J Psychiatr 2012; 5:258-65. [PMID: 22981055 PMCID: PMC3683944 DOI: 10.1016/j.ajp.2012.06.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 06/03/2012] [Accepted: 06/04/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Involving persons with schizophrenia and their families in designing, implementing and evaluating mental health services is increasingly emphasised. However, there is little information on desired outcomes from the perspectives of these stakeholders from low and middle income countries (LMIC). AIMS To explore and define outcomes desired by persons with schizophrenia and their primary caregivers from their perspectives. METHOD In-depth interviews were held with 32 persons with schizophrenia and 38 primary caregivers presenting for care at one rural and one semi-urban site in India. Participants were asked what changes they desired in the lives of persons affected by the illness and benefits they expected from treatment. Data was analysed using thematic and content analysis. RESULTS Eleven outcomes were desired by both groups: symptom control; employment/education; social functioning; activity; fulfilment of duties and responsibilities; independent functioning; cognitive ability; management without medication; reduced side-effects; self-care; and self-determination. Social functioning, employment/education and activity were the most important outcomes for both groups; symptom control and cognitive ability were more important to persons with schizophrenia while independent functioning and fulfilment of duties were more important to caregivers. CONCLUSIONS Interventions for schizophrenia in India should target both clinical and functional outcomes, addressing the priorities of both affected persons and their caregivers. Their effectiveness needs to be evaluated independently from both perspectives.
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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: 0.8] [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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Read U. "I want the one that will heal me completely so it won't come back again": the limits of antipsychotic medication in rural Ghana. Transcult Psychiatry 2012; 49:438-60. [PMID: 22722982 DOI: 10.1177/1363461512447070] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Campaigns to scale up mental health services in low-income countries emphasise the need to improve access to psychotropic medication as part of effective treatment yet there is little acknowledgement of the limitations of psychotropic drugs as perceived by those who use them. This paper considers responses to treatment with antipsychotics by people with mental illness and their families in rural Ghana, drawing on an anthropological study of family experiences and help seeking for mental illness. Despite a perception among health workers that there was little popular awareness of biomedical treatment for mental disorders, psychiatric services had been used by almost all informants. However, in many cases antipsychotic treatment had been discontinued, even where it had been recognised to have beneficial effects such as controlling aggression or inducing sleep. Unpleasant side effects such as feelings of weakness and prolonged drowsiness conflicted with notions of health as strength and were seen to reduce the ability to work. The reduction of perceptual experiences such as visions was less valued than a return to social functioning. The failure of antipsychotics to achieve a permanent cure also cast doubt on their efficacy and strengthened suspicions of a spiritual illness which would resist medical treatment. These findings suggest that efforts to improve the treatment of mental disorders in low-income countries should take into account the limitations of antipsychotic drugs for those who use them and consider how local resources and concepts of recovery can be used to maximise treatment and support families.
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Affiliation(s)
- Ursula Read
- Department of Anthropology, University College London, 14 Taviton Street, London, UK.
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Balaji M, Chatterjee S, Koschorke M, Rangaswamy T, Chavan A, Dabholkar H, Dakshin L, Kumar P, John S, Thornicroft G, Patel V. The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India. BMC Health Serv Res 2012; 12:42. [PMID: 22340662 PMCID: PMC3312863 DOI: 10.1186/1472-6963-12-42] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 02/16/2012] [Indexed: 11/07/2022] Open
Abstract
Background Care for schizophrenia in low and middle income countries is predominantly facility based and led by specialists, with limited use of non-pharmacological treatments. Although community based psychosocial interventions are emphasised, there is little evidence about their acceptability and feasibility. Furthermore, the shortage of skilled manpower is a major barrier to improving access to these interventions. Our study aimed to develop a lay health worker delivered community based intervention in three sites in India. This paper describes how the intervention was developed systematically, following the MRC framework for the development of complex interventions. Methods We reviewed the lierature on the burden of schizophrenia and the treatment gap in low and middle income countries and the evidence for community based treatments, and identified intervention components. We then evaluated the acceptability and feasibility of this package of care through formative case studies with individuals with schizophrenia and their primary caregivers and piloted its delivery with 30 families. Results Based on the reviews, our intervention comprised five components (psycho-education; adherence management; rehabilitation; referral to community agencies; and health promotion) to be delivered by trained lay health workers supervised by specialists. The intervention underwent a number of changes as a result of formative and pilot work. While all the components were acceptable and most were feasible, experiences of stigma and discrimination were inadequately addressed; some participants feared that delivery of care at home would lead to illness disclosure; some participants and providers did not understand how the intervention related to usual care; some families were unwilling to participate; and there were delivery problems, for example, in meeting the targeted number of sessions. Participants found delivery by health workers acceptable, and expected them to have knowledge about the subject matter. Some had expectations regarding their demographic and personal characteristics, for example, preferring only females or those who are understanding/friendly. New components to address stigma were then added to the intervention, the collaborative nature of service provision was strengthened, a multi-level supervision system was developed, and delivery of components was made more flexible. Criteria were evolved for the selection and training of the health workers based on participants' expectations. Conclusions A multi-component community based intervention, targeting multiple outcomes, and delivered by trained lay health workers, supervised by mental health specialists, is an acceptable and feasible intervention for treating schizophrenia in India.
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Chakrabarti S. Family interventions in schizophrenia: Issues of relevance for Asian countries. World J Psychiatry 2011; 1:4-7. [PMID: 24175161 PMCID: PMC3782168 DOI: 10.5498/wjp.v1.i1.4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 11/04/2011] [Accepted: 12/26/2011] [Indexed: 02/05/2023] Open
Abstract
A growing body of research evidence has confirmed the efficacy of family-interventions as adjuncts to antipsychotics for the treatment of schizophrenia. Much of the recent evidence for such interventions derives from Asian, principally Chinese, studies. These trials have shown that relatively simple forms of family-interventions have wide ranging benefits, and can be implemented successfully in routine clinical settings. With the accumulation of this evidence in their favour, family-interventions for schizophrenia in Asia are poised to take the next critical step, that of wider implementation and improved accessibility for potential users. However, several issues merit consideration. Family-interventions need to be based on a culturally-informed theory, which incorporates cultural variables of relevance in these countries. While the ideal format for conducting family-interventions is still to be determined, it is quite evident that for such interventions to be useful they need to be simple, inexpensive, needs-based, and tailored to suit the socio-cultural realities of mental health systems in Asian countries. The evidence also suggests that delivery by non-specialist personnel is the best way to ensure that such services reach those who stand to benefit most from these treatments. However, there are several existing challenges to the process of dissemination of family-interventions. The major challenges include the achievement of a critical mass of trained professionals capable of delivering these interventions, and finding innovative solutions to make family-interventions more acceptable to families. If these hurdles are overcome, we could look forward to a genuine collaboration with families, who have always been the mainstay of care for the mentally ill in Asia.
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Affiliation(s)
- Subho Chakrabarti
- Subho Chakrabarti, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Farooq S, Nazar Z, Irfan M, Akhter J, Gul E, Irfan U, Naeem F. Schizophrenia medication adherence in a resource-poor setting: randomised controlled trial of supervised treatment in out-patients for schizophrenia (STOPS). Br J Psychiatry 2011; 199:467-72. [PMID: 22130748 DOI: 10.1192/bjp.bp.110.085340] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Most people with schizophrenia in low- and middle-income (LAMI) countries receive minimal formal care, and there are high rates of non-adherence to medication. AIMS To evaluate the effectiveness of an intervention that involves a family member in supervising medication administration - supervised treatment in out-patients for schizophrenia (STOPS) - in improving treatment adherence and clinical outcomes. METHOD Individuals (n = 110) with schizophrenia or schizoaffective disorders were allocated to STOPS or to treatment as usual (TAU) and followed up for 1 year. The primary outcome was adherence to the treatment regimen. Positive and Negative Syndrome Scale for Schizophrenia and Global Assessment of Functioning scores were also assessed. RESULTS Participants in the STOPS group had better adherence (complete adherence: 37 (67.3%) in STOPS v. 25 (45.5%) in TAU; P<0.02) and significant improvement in symptoms and functioning. CONCLUSIONS STOPS may be useful in enhancing adherence to treatment for schizophrenia in LAMI countries.
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Affiliation(s)
- Saeed Farooq
- Centre for Ageing and Mental Health, Staffordshire University and Department of Psychiatry, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan.
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Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378:1592-603. [PMID: 22008429 DOI: 10.1016/s0140-6736(11)60891-x] [Citation(s) in RCA: 405] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally.
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Zhang XY, Yu YQ, Sun S, Zhang X, Li W, Xiu MH, Chen DC, Yang FD, Zhu F, Kosten TA, Kosten TR. Smoking and tardive dyskinesia in male patients with chronic schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:1765-9. [PMID: 21723906 DOI: 10.1016/j.pnpbp.2011.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 06/12/2011] [Accepted: 06/13/2011] [Indexed: 11/16/2022]
Abstract
Interactions between smoking and movement disorders include the contrasting associations of more cigarette smoking with reductions in Parkinson's disease and increases in tardive dyskinesia (TD) symptoms. Here we examine the relationship between smoking and TD in a large sample of inpatients with schizophrenia. We used cross-sectional naturalistic methods to analyze the prevalence and severity of neuroleptic-induced TD in relation to cigarette smoking among 764 male chronic and medicated inpatients meeting DSM-IV criteria for schizophrenia. We administered a detailed questionnaire including general information, medical and psychological conditions, and smoking behaviors. We evaluated TD severity using the abnormal involuntary movement scale (AIMS) and psychopathology using the Positive and Negative Syndrome Scale (PANSS). The main statistical analyses used cross-tabulations for the prevalence of TD by smoking and multivariate regression analyses for continuous measures (AIMS and PANSS). We found that the prevalence of TD did not significantly differ between smokers (41%=237/578) and non-smokers (37%=69/186). Secondary outcomes showed a significant association between the AIMS total score and age, duration of illness and hospitalization times. Thus, smoking was not associated with TD in male Chinese schizophrenics, but consistent with previous reports, older patients with a longer duration of illness and more hospitalizations showed greater severity of TD.
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Affiliation(s)
- Xiang Yang Zhang
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
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Abstract
PURPOSE OF REVIEW Against the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs. RECENT FINDINGS Key strategies and actions are as follows: (i) the adoption of a decentralized stepped care approach embracing task shifting to nonspecialists for those disorders for which it has been shown to be effective; (ii) ensuring adequate numbers of mental health specialists to provide a supportive supervisory framework and referral pathways; (iii) ensuring adequate infrastructure to support decentralized care; (iv) promoting mental health literacy; (v) adoption of a social inclusion and developmental model of disability in caring for people with chronic mental illness; and (vi) embracing a multisectoral community collaborative approach. SUMMARY Optimizing mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions. Studies demonstrating the cost-effectiveness of integrated stepped packages of care embracing a task-shifting approach, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors, can assist this process. Specialist mental health training programmes in LMICs also need to be responsive to the changing demands on service providers, incorporating a public health approach and equipping specialists for diversification of their roles within the task shifting model.
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Phanthunane P, Vos T, Whiteford H, Bertram M. Cost-effectiveness of pharmacological and psychosocial interventions for schizophrenia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2011; 9:6. [PMID: 21569448 PMCID: PMC3120770 DOI: 10.1186/1478-7547-9-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 05/13/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Information on cost-effectiveness of interventions to treat schizophrenia can assist health policy decision making, particularly given the lack of health resources in developing countries like Thailand. This study aims to determine the optimal treatment package, including drug and non-drug interventions, for schizophrenia in Thailand. METHODS A Markov model was used to evaluate the cost-effectiveness of typical antipsychotics, generic risperidone, olanzapine, clozapine and family interventions. Health outcomes were measured in disability adjusted life years. We evaluated intervention benefit by estimating a change in disease severity, taking into account potential side effects. Intervention costs included outpatient treatment costs, hospitalization costs as well as time and travel costs of patients and families. Uncertainty was evaluated using Monte Carlo simulation. A sensitivity analysis of the expected range cost of generic risperidone was undertaken. RESULTS Generic risperidone is more cost-effective than typicals if it can be produced for less than 10 baht per 2 mg tablet. Risperidone was the cheapest treatment with higher drug costs offset by lower hospital costs in comparison to typicals. The most cost-effective combination of treatments was a combination of risperidone (dominant intervention). Adding family intervention has an incremental cost-effectiveness ratio of 1,900 baht/DALY with a 100% probability of a result less than a threshold for very cost-effective interventions of one times GDP or 110,000 baht per DALY. Treating the most severe one third of patients with clozapine instead of risperidone had an incremental cost-effectiveness ratio of 320,000 baht/DALY with just over 50% probability of a result below three times GDP per capita. CONCLUSIONS There are good economic arguments to recommend generic risperidone as first line treatment in combination with family intervention. As the uncertainty interval indicates the addition of clozapine may be dominated and there are serious side effects, treating severe patients with clozapine is advisable only for patients who do not respond to risperidone and only in the presence of a stricter side effect monitoring system than currently exists.
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Affiliation(s)
- Pudtan Phanthunane
- Setting Priorities Using Information on Cost-Effectiveness (SPICE) project, Ministry of Public Health, Nonthaburi, Thailand
- School of Population Health, the University of Queensland, Herston, QLD Australia
- Faculty of Management and Information Sciences, Naresuan University, Phitsanulok, Thailand
| | - Theo Vos
- Setting Priorities Using Information on Cost-Effectiveness (SPICE) project, Ministry of Public Health, Nonthaburi, Thailand
- School of Population Health, the University of Queensland, Herston, QLD Australia
| | - Harvey Whiteford
- School of Population Health, the University of Queensland, Herston, QLD Australia
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Summer Park, QLD Australia
| | - Melanie Bertram
- Setting Priorities Using Information on Cost-Effectiveness (SPICE) project, Ministry of Public Health, Nonthaburi, Thailand
- Faculty of Management and Information Sciences, Naresuan University, Phitsanulok, Thailand
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Cohen A, Eaton J, Radtke B, George C, Manuel BV, De Silva M, Patel V. Three models of community mental health services In low-income countries. Int J Ment Health Syst 2011; 5:3. [PMID: 21266051 PMCID: PMC3040158 DOI: 10.1186/1752-4458-5-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 01/25/2011] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To compare and contrast three models of community mental health services in low-income settings. DATA SOURCES/STUDY SETTING Primary and secondary data collected before, during, and after site visits to mental health programs in Nigeria, the Philippines, and India. STUDY DESIGN Qualitative case study methodology. DATA COLLECTION Data were collected through interviews and observations during site visits to the programs, as well as from reviews of documentary evidence. PRINCIPAL FINDINGS A set of narrative topics and program indicators were used to compare and contrast three community mental health programs in low-income countries. This allowed us to identify a diversity of service delivery models, common challenges, and the strengths and weaknesses of each program. More definitive evaluations will require the establishment of data collection methods and information systems that provide data about the clinical and social outcomes of clients, as well as their use of services. CONCLUSIONS Community mental health programs in low-income countries face a number of challenges. Using a case study methodology developed for this purpose, it is possible to compare programs and begin to assess the effectiveness of diverse service delivery models.
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Affiliation(s)
- Alex Cohen
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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