Outcomes that matter: a qualitative study with persons with schizophrenia and their primary caregivers in India

The role of peer support in recovery among clients with mental illness attending the psychiatric service in a tertiary hospital in Malaysia: a qualitative study

BACKGROUND

The understanding that mental health recovery is a personal and subjective experience informs mental health policies in many countries. However, most of the populations in these studies are from the West, limiting their applicability in Asia. Peer support in mental health refers to helping and mentoring people who have overcome similar obstacles. Despite being proven to be effective in promoting recovery, little is known about its use in Malaysian psychiatric patients. This study aims to explore the participants' perspectives on their concept of recovery and how the peer support group (PSG) aid them to achieve recovery.

METHODOLOGY

This study was conducted on clients with mental illness who attended the PSG provided by the Community Psychiatry and Psychosocial Intervention Unit in National University Malaysia Medical Centre. A qualitative generic inductive approach was employed in this thematic exploratory study. Purposive sampling was the method used to collect the data for this thematic exploratory study. In-depth interviews of 11 study participants were audio recorded and transcribed verbatim. Data were analyzed using Braun and Clarke (2006) descriptive thematic analysis method.

RESULTS

The findings of this study highlighted six key themes; three pertaining to the participants' perspectives on the meaning of recovery (1. Gaining self-reliance and social inclusion, 2. Personal growth and improved life circumstances in recovery, and 3. Symptoms improvement) and another three pertaining to how the peer support group aids recovery (1. Empowerment and growth through peer support, 2. Promoting well-being, 3. Social connection and support).

CONCLUSION

The findings of this study provide valuable insights into the perspectives of psychiatry clinic patients enrolled in PSG on the concept of recovery and the role of such groups in their recovery journey. The findings demonstrated that the PSG complemented the participants' perspectives on recovery, reinforcing the notion that a comprehensive and person-centered approach to mental health services is essential for successful and sustained recovery outcomes.

Vocational rehabilitation in persons with mental illness in India: A scoping review

BACKGROUND

Employment has a therapeutic impact, enhances community integration and improves the quality of life of persons with mental illness (PwMI). Vocational rehabilitation (VR) models must be sensitive to existing needs and resources. Several VR models have been tested in high income countries. Mapping different VR models in India would help both practitioners and policymakers.

AIM

The study aimed to comprehensively review VR models tested among PwMI in India.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews. We included interventional studies, case studies and grey literature carried out for the VR of PwMI in India. The search was done in PubMed, PsychInfo, worldwide science and Web of Science. Google Scholar was used to supplement the search. A Boolean search using MeSH terms was carried out for the period January 2000 to December 2022.

RESULTS

A total of twelve studies (one feasibility study, four case studies, four institute-based intervention studies and two studies reporting NGOs' role) were included in the final synthesis. The studies included in the review were either quasi-experimental studies or case based. Types of VR included supported employment or place and train or train and place models, case management and prevocational skills training.

CONCLUSION

Limited studies exist on VR in PwMI from India. Most studies assessed a restricted set of outcomes. The experiences of NGOs should be published so that practical challenges can be understood. There is a need for public-private partnerships in designing and testing services and should involve all the stakeholders.

People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n  =  647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n  =  649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b  =  -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

Feasibility testing of a peer support programme for prisoners with common mental disorders and substance use

BACKGROUND

The prevalence of mental disorders and substance use among prisoners is high. Convicted prisoners of 'good behaviour' can be part of a peer support system in prisons.

AIM

To evaluate the feasibility of a peer support programme for prisoners with common mental disorders and substance use in prison.

METHOD

The study used a mixed method research design, with a quasi-experimental approach (single group pre-post without control). It was conducted in two phases: Phase I. Thirty-five peers/convicted prisoners were recruited through advertisements on the prisoners' community radio station. Volunteers with good behaviour reports were given training over 5 days to recognise mental and substance use disorders and provide basic peer support in prison; their attitudes and knowledge were tested before and after the training.

PHASE II

Feasibility of the peer support programme was tested by (i) recording the number of cases identified and referred, (ii) pre- and post-evaluation of well-being, coping, and symptom severity of those supported and (iii) evaluating qualitatively the experience of the peer supporters and service users.

RESULTS

Thirty-five peer supporters identified 49 cases over 3 months. These cases showed significant improvement in well-being (Z -1.962; p < 0.050) and reduction in symptom severity (Z -1.913; 0.056). There was a significant improvement in the peers supporters' self-esteem from pre- to post-training (t -3.31; p < 0.002), improvement in their benevolence (t -4.37; p < 0.001) and a significant reduction in their negative attitudes to mental illness (Z -3.518; p < 0.001). A thematic model of peer support encompassed self-experienced benefits for the peer supporter, wider recognition of peer supporters in the prison, challenges to this kind of support, experience of training and visions for future work.

CONCLUSION

The peer support programme was experienced positively by the peer-supporters and supported. Common mental disorders, substance use and suicidality were recognised and appropriately referred. A full-scale evaluation of this promising programme is warranted.

Exploring the feasibility and public health impact of integrating a community-based recovery-oriented intervention for people living with schizophrenia in partnership with a tertiary care mental hospital in India

Background

There is a priority need to make community-based care widely available for people living with schizophrenia (PLwS) in low- and middle-income countries. An innovative approach for increasing access could be to integrate clinical services available in tertiary care hospitals with community-based care through a task-sharing approach. We describe such an integrated intervention that was implemented at Tezpur in northeast India in collaboration with the Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH).

Method

The objectives of the study were to illustrate the feasibility of integrating and implementing the intervention and to describe its individual, systemic, and public health impacts. Due to the limited resources available, we conducted a pragmatic single-arm longitudinal evaluation of the intervention cohort over 24 months.

Results

Of the 239 PLwS enrolled in the intervention, 198 (83%) were followed up for 24 months, with nearly three-quarters reporting a >70% reduction in disabilities, most notably between 6 and 18 months. There was a marked reduction in unmet needs across multiple domains, and at 24 months, 62% of the cohort was engaged in individual jobs or other market-linked livelihood opportunities. There was greater uptake and retention with outpatient contacts at the LGBRIMH, and PLwS experienced a marked (82%) reduction in inpatient admissions rates, as compared to before enrolment. Over a period of 24 months, primary caregivers reported that their families experienced significantly fewer social difficulties such as unemployment, interpersonal conflicts, and social isolation. The intervention had a significant public health impact, with an estimated 51.8% effective treatment coverage rate for the integrated intervention.

Conclusion

Our findings provide preliminary evidence of the feasibility of implementing the integrated intervention and its effectiveness. We believe that there is merit in further in-depth refinement and exploration of this implementation-related research and cost analysis while replicating the intervention in other tertiary care institutions.

Qualitative Analysis of the Content Validity of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) in Schizophrenia: A Multi-Stakeholder Perspective

The US Food and Drug Agency (FDA) requires clinical trials targeting cognitive impairment associated with schizophrenia (CIAS) to demonstrate the functional relevance of cognitive improvements by employing a functional co-primary measure. Although quantitative evidence supports the suitability of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) for this purpose, FDA guidelines for qualification of clinical outcome assessments require evidence of content validity, defined as qualitative evidence that key stakeholders view the measure as relevant and important. To collect this important qualitative data, semi-structured interviews were conducted with outpatients with schizophrenia (n = 24), caregivers (n = 12), and professional peer support specialists (n = 12) to elicit their views about the definition and importance of functional independence, the importance of the functional domains assessed by the VRFCAT (meal planning, using transportation, handling money, shopping), and the relevance of the VRFCAT tasks to these domains. Qualitative thematic analyses revealed consistent themes across groups in defining functional independence, including performing instrumental self-care, financial, and social tasks; making decisions autonomously; and not depending on others to carry out daily activities. There were, however, notable differences in their views regarding the importance of and barriers to functional independence. All groups viewed the VRFCAT as assessing skill domains that are central to independent functioning and, with some minor differences, the VRFCAT tasks were viewed as relevant and meaningful examples of the domains. These qualitative results provide converging evidence that key stakeholders view the VRFCAT as a content-valid measure.

Understanding needs of stakeholders and outcomes desired from a home-based intervention program for "difficult to treat" schizophrenia and related disorders: A qualitative study

BACKGROUND

We aimed to understand the needs of service users - families and patients with schizophrenia and related disorders, and mental health professionals (MHPs) and expectations from a home-based psychosocial intervention program in Indian setting.

MATERIALS AND METHODS

We conducted four focus group discussions (FGDs) with families, patients with schizophrenia and related disorders and MHPs. Two FGDs were conducted with families and one each with the patients and MHPs. Participants in families and MHP group were asked about their primary concerns in caring for the patients, perceived needs of patients and the areas that can be targeted through a home-based psychosocial intervention program. All FGDs were audio-recorded and verbatim transcribed. Content analysis of the data was done to obtain a final list of needs and expected outcomes from a psychosocial intervention supported by families.

RESULTS

Six key priority needs were identified for intervention: medication adherence, activities of daily living, promoting physical health, engagement in meaningful work, building of social and support networks and information about all aspects of illness. Priority outcomes identified by MHPs were mostly clinical like symptom reduction, fewer rehospitalisation while families and patients focused more on psychosocial outcomes, such as improvement of wellbeing, having relationships, engagement in meaningful activities, better organization of the day, increased self-respect, reduced stress, lesser interference, and critical comments. All groups suggested that book or mobile app or video could be used.

CONCLUSION

This qualitative study shows that while both clinicians and service users consider recovery from schizophrenia and related disorders to be important, they differ on what they prioritise.

The personal recovery movement in Singapore - past, present and future

The personal recovery movement is beginning to gain traction within Singapore's mental healthcare systems. We believe it is timely to give a broad overview of how it developed and provide suggestions on how it can evolve further. From the early custodial care in the 1800s to the community-centric programmes of the 1900s and early 2000s, we now find ourselves at the forefront of yet another paradigm shift towards a more consumer-centric model of care. The following decades will allow personal recovery practitioners and researchers to innovate and identify unique but culturally appropriate care frameworks. We also discuss how the movement can continue to complement existing mental healthcare systems and efforts.

Caregivers' hopes, expectations and concerns surrounding the employment and future of young people with mental health conditions

OBJECTIVE

Informal caregivers are often placed in a better position to understand and advocate for the vocational needs of young persons with mental health conditions. However, their opinions are largely ignored in the planning of vocational outcomes. This qualitative study had two broad aims: to explore (1) the perceptions of caregivers of young adults with mental health conditions on issues of paid employment and (2) their views and expectations of employment support services.

METHODS

A total of 30 semi-structured interviews were conducted. Caregivers were 45 years old on average, the majority were women (73%) and were of Chinese ethnicity (53%). Most participants (60%) were parents of the young persons with psychotic disorders (57%), or affective and mood disorders, such as depression or anxiety disorders (43%).

RESULTS

Thematic analyses of data revealed three superordinate themes: (1) caregiving roles, (2) caregivers' expectations and hopes, and (3) barriers to employmentof young persons with mental health conditions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Caregivers strongly believed that employment support services should prioritise and advocate for recovery while securing employment. Local mental health employment support services should incorporate the views and expectations of caregivers of young persons with mental health conditions to foster better coordination between stakeholders, and enhance support for successful employment, reintegration into the community, and ultimately recovery for these individuals.

Adapting to People With Schizophrenia: A Phenomenological Study on a Rural Society in Indonesia

BACKGROUND

The growing prevalence of schizophrenia in Indonesia requires the consideration of the families, caregivers, health care professionals, and the entire society, to serve as a support and coping resource for the patients. The process of recovery is rather difficult, especially in the absence of a decent place to live. Hence, there is the need to provide a supportive environment that facilitates recuperation from psychotic symptoms, enhances interaction with others, promotes self-expression of thoughts and feelings, and helps deal with daily stress and challenges. There are currently no studies on the framework of societal adaptation for people with schizophrenia (PWS). The aim of this research, therefore, was to explore the experiences of rural society inhabitants in adapting to PWS in Indonesia.

METHODS

The study uses a qualitative research design and implements an interpretive phenomenological approach. A total of ten society members were recruited from the community by purposive sampling, and the in-depth interviews conducted were audio-recorded and transcribed. In addition, thematic analysis was carried out using the interpretive phenomenological analysis method.

RESULTS

The majority of the participants assumed that PWS prompt the feeling of alertness over fear. In addition, the participants revealed a feeling of indecisiveness in related situations and emphasized the value of keeping up traditional beliefs and practices and the effectiveness of a demonstration of indifference. They explained the need to combine traditional and modern health practices as recommended by the spiritual leaders.

CONCLUSION

Societal adaptation to PWS entails the understanding of how to deal with the disease's uncertainty and complexity. It is important to create a supportive environment to promote mental health and wellbeing.

Treatment Goals for Patients with Schizophrenia - A Narrative Review of Physician and Patient Perspectives

INTRODUCTION

There are many possible treatment goals for patients with schizophrenia. Two major perspectives on treatment goals are the patient's and the physician's perspective. Patient-centered treatment mandates that an individual patient's treatment goals are taken into account when treatment is planned. In this narrative review, we address the commonalities and differences of the patient's and physician's perspectives.

METHODS

We searched for literature on treatment goals for patients with schizophrenia from the last 10 years.

RESULTS

Fifty-two relevant records were identified, 4 of which directly compare patient's and physician's perspectives. Two further articles used the same set of goals to ask patients or physicians for their assessment.

DISCUSSION

Agreement between patients and physicians regarding valuation of treatment goals was high. However, physicians tended to put more emphasis on the classical "textbook" goals of symptom resolution and functioning, while patients stressed well-being and quality of life more. Results on treatment goals from patients are difficult to generalize, since recruiting representative patient samples is challenging and patient subgroups may have differing priorities.

Asian perspectives on personal recovery in mental health: a scoping review

BACKGROUND

Personal recovery is a relatively novel concept in many Asian countries, and recovery-oriented interventions are usually adapted from western conceptualizations of recovery.

AIM

To understand what personal recovery in mental health means to people in Asia, what meanings they give to their conditions, and what factors they perceive as hindering or facilitating their recovery.

METHOD

The review focused on peer-reviewed papers published in English between the years 2000 and 2020. Arksey and O'Malley 5-stage method was used to guide the review.

RESULTS

Thirty studies were included. Personal recovery in Asia meant a return to a pre-illness state and involved a transformative process. Mental illness was explained as being biomedically oriented, although religious/culturally bound explanations were also present in some studies. Social support, religion, meaningful activities, supportive professionals, and personalized coping strategies were viewed as supporting recovery. Religious stigma, discrimination, gendered norms, and negative societal perceptions of mental illness hindered recovery.

CONCLUSIONS

The concept of personal recovery in Asia is extremely diverse. Studies exploring personal recovery among people experiencing mental illness in Asia remains in its early stages and more research is needed to better understand how it is conceptualized. Such knowledge could benefit frontline implementation of recovery-oriented services.

Determinants of family independence in caring for hebephrenic schizophrenia patients

Background: Schizophrenic patients are very susceptible to recurrent incidences, therefore the family plays a key role in providing care as a part of the recovery team. This study aimed to determine the relationship between knowledge, perceptions, attitudes and support with family independence in caring for hebephrenic schizophrenic patients. Design and Methods: It was used a correlational analytic design with cross sectional approach, and consecutive sampling technique was used, which attained 57 respondents. The independent variables were knowledge, perceptions, attitudes, and support, while independence was the dependent variable, and both were measured using questionnaires, and Spearman rank test was used for data analysis. Results: The results indicate the presence of a relationship between knowledge, perceptions, attitudes, as well as support and family independence in caring for hebephrenic schizophrenia. In addition, the spearman rank test showed P-values of 0.008, 0.011, 0.032, and 0.027 in family knowledge, perception, attitudes and support, respectively, at <0.05. Conclusions: This study indicates the importance of family support in attempts to improve the self-esteem of schizophrenic patients. Based on this data, the hospital is expected to improve the family-based patient recovery program.

Psychiatric hospital reform in low-income and middle-income countries Structured Individualised inTervention And Recovery (SITAR): a two-arm pragmatic randomised controlled trial study protocol

INTRODUCTION

Low-income and middle-income settings like India have large treatment gaps in mental healthcare. People with severe mental disorders face impediments to their clinical and functional recovery, and have large unmet needs. The infrastructure and standards of care are poor in colonial period psychiatric hospitals, with no clear pathways to discharge and successfully integrate recovered individuals into the community. Our aim is to study the impact of psychiatric hospital reform on individual patient outcomes in a psychiatric hospital in India.

METHODS AND ANALYSIS

Structured Individualised inTervention And Recovery (SITAR) is a two-arm pragmatic randomised controlled trial, focusing on patients aged 18-60 years with a hospital stay of 12-120 months and a primary diagnosis of psychosis. It tests the effectiveness of structural and process reform with and without an individually tailored recovery plan on patient outcomes of disability (primary outcome WHO Disability Assessment Scale), symptom severity, social and occupational functioning and quality of life. A computer-generated permuted block randomisation schedule will allocate recruited subjects to the two study arms. We aim to recruit 100 people into each trial arm. Baseline and outcome measures will be undertaken by trained researchers independent to the case managers providing the individual intervention. A health economic analysis will determine the costing of implementing the individually tailored recovery plan.

ETHICS AND DISSEMINATION

The study will provide answers to important questions around the nature and process of reforms in institutional care that promote recovery while being cognizant of protecting human rights, and dignity. Ethical approval for SITAR was obtained from a registered ethics committee in India (Institutional Ethics Committee VikasAnvesh Foundation, VAF/2018-19/012 dated 6 December 2018) and the University of Warwick's Biomedical and Scientific Research Ethics Committee (REGO-2019-2332, dated 21 March 2019), and registered on the Central Trial Registry of India (CTRI/2019/01/017267). Trial results will be published in accordance to CONSORT guidelines.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

Perspectives of consumers in India on factors affecting recovery from schizophrenia

BACKGROUND

Identifying patient perspectives about recovery may help the service providers to enhance active participation of patients in their recovery.

AIM

This study aimed to explore patients' perspectives about factors affecting recovery from schizophrenia.

METHODS

A semi-structured interview schedule was used to explore the perceptions of 18 patients diagnosed with schizophrenia. The interviews were recorded, transcribed and analysed. Codes were identified and similar codes were grouped together and main themes were identified.

RESULTS

Nine main themes on facilitators and barriers of recovery from schizophrenia were derived.

CONCLUSION

Deeper understanding of patients' perspectives of recovery from schizophrenia can help mental health professionals to plan appropriate recovery-oriented services.

The effect of palliative care intervention program on the quality of life among Jordanian caregivers of cancer patients

The purpose of this study was to evaluate the effect of palliative care intervention on the quality of life among Jordanian caregivers of cancer patients. Repeated measures design was used in this study. Data were collected from 137 Jordanian caregivers of cancer patients utilizing a self-administered questionnaire. An intervention program called SHARE was implemented to the experimental groups and its effectiveness in improving the overall quality of life for caregivers of cancer patients was evaluated using repeated measure ANOVA test. The results showed a statistically significant effect on the quality of life domains. For workshop experimental group (F = 26.822, p < .001) and for home visit experimental group (F = 10.236, p = .003).

Vocational challenges in severe mental illness: A qualitative study in persons with professional degrees

BACKGROUND

Employment is a significant stepping stone towards recovery for persons with severe mental illness. In the last two decades there has been increasing focus on obtaining professional courses and degrees for employment in India.

AIM

To understand the challenges faced by persons with severe mental illness with professional degrees in obtaining and maintaining employment.

METHODS

We interviewed 31 individuals with severe mental illness, who had professional degrees, using qualitative interviews. These interviews explored factors that facilitated as well as those that hindered the process of obtaining and sustaining jobs.

RESULTS

Factors that were identified as facilitators for obtaining and maintaining employment included personal strengths, social support, accommodative work environment, disclosure, support from mental health professionals and services. Factors that were identified as hindering for obtaining and maintaining employment included symptoms of the illness, side effects of medications, stigma, poor social support, academic underachievement, disjointed work history, poor workplace environment and specific cultural, gender issues.

CONCLUSION

Factors such as workplace accommodations, creating an environment that is permissive of disclosure, using family support and support from mental health professionals will facilitate employment. Addressing factors that hinder such as stigma, academic under-achievement, improving workplace environments, social support will also be important in vocational recovery.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income Sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India

Caring for a family member with a psycho-social disability can be both rewarding and burdensome. This study analyses the experiences of caregivers of people with psychosocial disabilities (PPSDs) in rural communities in North India using relational gender theory. In-depth interviews with 18 female and male caregivers of PPSDs probed the social, emotional and health impacts of their caregiving role. Nine themes were identified that were grouped under three meta-themes: intra-personal, inter-personal and institutional impacts. Under the intra-personal meta-theme, all caregivers experienced high tension, with women describing almost overwhelming stress. Women minimised their role as caregivers, and felt negative and hopeless about their futures, while men had a more positive view of the future and themselves. Embodied experiences of psychological and social distress were consistently described by women, but not by men. Within the interpersonal meta-theme, men experienced opportunity for social connection and social support that was seldom available to women. Interpersonal violence with other household members was described by both men and women. Within the institutional meta-theme, both men and women described strength in unity, and gestures leading to the reordering of gender relations. These findings underline the significant and diffuse impacts of a gender order that values males and disadvantages females as caregivers of PPSDs, with the asymmetry of a greater burden for women. The findings point to the urgent need for global mental health policies that support and empower caregivers and that strengthen gender equality.

Evaluating the effectiveness of a culturally adapted behavioral family psycho-educational program for Egyptian patients with schizophrenia

Although a growing body of evidence supports the effectiveness of behavioral family therapies for patients with schizophrenia, few studies have been carried out on the effectiveness of such programs for Egyptian patients. The current study translated and culturally adapted the Behavioral Family Psycho-Education Program (BFPEP) and conducted a preliminary efficacy evaluation for outpatients suffering from schizophrenia. Thirty patients received 14 sessions of culturally adapted Program (CA-BFPEP) and 30 received treatment as usual; all were followed up for 6 months. Pre- and post-intervention assessment included primary outcome measures that assessed the clinical, social, quality of life and attitude towards medications. The CA-BFPEP group demonstrated significant treatment effects as they had greater reductions in psychotic symptoms (PANSS), improvement of social function (SFQ), quality of life (QoL), and attitude towards medications (DAI), compared to patients in the control group. These results demonstrate the feasibility of implementing family therapy interventions in different cultural settings with relatively minor modifications. These promising findings invite further efforts to maximize the benefits of family therapy interventions internationally and to encourage mental health policy makers to integrate this mode of therapy in routine care management plans for patients with schizophrenia.

Exploration of the dialogue components in Avatar Therapy for schizophrenia patients with refractory auditory hallucinations: A content analysis

Auditory verbal hallucinations are hallmark symptoms of schizophrenia and are amongst the most disturbing symptoms of the disorder. Although not entirely understood, the relationship between the voice hearer and their voices has been shown to be an important treatment target. Understanding voice hearers' standpoints through qualitative analysis is central to apprehend a deeper comprehension of their experience and further explore the relevance of interpersonal interventions. Compared with other dialogical intervention, virtual reality-assisted therapy (Avatar Therapy) enables patients to be in a tangible relation with a representation of their persecutory voice. This novel therapy has shown favourable results, though the therapeutic processes remain equivocal. We consequently sought to begin by characterizing the main themes emerging during the therapy by exploring the hearer's discussion with their avatar. The therapy sessions of 12 of our referrals were transcribed, and the patients' responses were analysed using content analysis methods. Five themes emerged from data saturation: emotional responses to the voices, beliefs about voices and schizophrenia, self-perceptions, coping mechanisms, and aspirations. All patients had at least one element within each of these themes. Our analyses also enabled us to identify changes that were either verbalized by the patients or noted by the raters throughout therapy sessions. These findings are relevant as they allowed to identify key themes that are hypothesized to be related to therapeutic targets in a novel relational therapy using virtual reality. Future studies to further explore the processes implicated within Avatar Therapy are necessary.

Spousal Caregiver Burden and Its Relation with Disability in Schizophrenia

BACKGROUND

Schizophrenia, a chronic psychiatric disorder, can affect one's productivity and psychosocial functioning. In Indian context, the responsibility of caring persons with schizophrenia is increasingly on their spouses. Spousal caregiver experience and its relation with disability in schizophrenia need to be studied.

MATERIALS AND METHODS

We conducted a cross-sectional study among 52 outpatients with schizophrenia and their spouses attending a tertiary psychiatric center. The objectives were: (a) to explore spousal caregiver burden in schizophrenia and (b) to assess the relation between disability and spousal caregiver burden. The study adopted recommended ethical principles. Scales such as Burden Assessment Schedule, Indian Disability Evaluation and Assessment Scale (IDEAS), and Positive and Negative Syndrome Scale were used to collect appropriate data. Descriptive analysis, bivariate analysis, and multivariate analysis were done in SPSS software version 16.0.

RESULTS

The mean spousal caregiver burden score was 73.5 (standard deviation: 14.0). In bivariate analysis, disability, duration of schizophrenia, severity of schizophrenia, place of residence, and socioeconomic status had statistically significant relation with spousal caregiver burden. Adjusted for spouses' age, gender, and other significant factors in bivariate analysis, the IDEAS global disability score (2.6, [confidence interval 0.5-3.8, P = 0.013]) retained statistically significant association with spousal caregiver burden.

CONCLUSION

Spouses of persons with schizophrenia experience significant caregiver burden. Disability was found to be the most powerful determinant of spousal caregiver burden in the sample. Focus on disability alleviation in the management of schizophrenia may help reduce spousal caregiver burden.

Does the Social Functioning Scale reflect real-life social functioning? An experience sampling study in patients with a non-affective psychotic disorder and healthy control individuals

BACKGROUND

The ecological validity of retrospective measures of social functioning is currently unknown in patients with schizophrenia. In the present study, patients with a diagnosis of non-affective psychosis were compared with controls on two measures of social functioning: the Social Functioning Scale (SFS) and daily-life measures collected with the Experience Sampling Methodology (ESM). The associations between both measures were examined in each group of participants to test for the ecological validity of the SFS.

METHODS

A total of 126 participants with a non-affective psychotic disorder and 109 controls completed the SFS and a 6-day momentary ESM protocol assessing various aspects of social functioning. Multiple linear and multilevel regression analyses were performed to test for group differences in social functioning level and examine associations between the two assessment techniques.

RESULTS

Lower social functioning was observed in patients compared with controls on retrospective and momentary measures. The SFS interpersonal domain (social engagement/withdrawal and interpersonal behaviour dimensions) was associated with the percentage of time spent alone and negative appraisal of social interactions. The SFS activity domain (pro-social and recreational activities dimensions) was negatively associated with time spent in leisure activities.

CONCLUSIONS

The SFS showed some degree of ecological validity at assessing broad aspects of social functioning. Low scores on the SFS social engagement/withdrawal and interpersonal behaviour dimensions captured social isolation and social avoidance in daily life, but not lack of interest in socializing. Ecological validity of the SFS activity domain was low. ESM offers a rich alternative to classical assessment techniques of social functioning.

The role of life context and self-defined well-being in the outcomes that matter to people with a diagnosis of schizophrenia

OBJECTIVE

Conduct a deep exploration of the outcomes that matter to people with a diagnosis of schizophrenia and understand from their perspective how these outcomes can be achieved.

SAMPLE AND METHODS

In-depth qualitative interviews were conducted with 22 people with a diagnosis of schizophrenia. Interviews were analysed using thematic frameworks, and a realist informed theories of change approach.

RESULTS

Our study revealed the potential causal relationships between the context of a person's life, short-term goals and long-term outcomes. We provide a nuanced and detailed exploration of outcomes that matter for people with schizophrenia in relation to self-defined well-being. Achieving life milestones, feeling safe and outcomes related to improved physical health along with employment, a positive sense of self and psychosocial outcomes, were highly valued. For short- and long-term outcomes to be achieved, individuals required medication with minimal side-effects, cognitive behavioural therapy, family/social support and meaningful activities in their lives. Well-being was influenced by life context and short- and long-term outcomes, but in a circular nature also framed what short-term goals could be achieved.

CONCLUSIONS

Working with people with a diagnosis of schizophrenia to identify and achieve better outcomes will necessitate a person-centred approach. This will require an appreciation of the relationship between the statutory and non-statutory resources that are available and a consideration of an individual's current well-being status. This approach acknowledges personal strengths and encourages ownership of goals and supports self-management.

Treatment outcomes in schizophrenia: qualitative study of the views of family carers

BACKGROUND

Schizophrenia is a complex, heterogeneous disorder, with highly variable treatment outcomes, and relatively little is known about what is important to patients. The aim of the study was to understand treatment outcomes informal carers perceive to be important to people with schizophrenia.

METHOD

Qualitative interview study with 34 individuals and 8 couples who care for a person with schizophrenia/schizoaffective disorder. Interviews were transcribed verbatim and analysed by a thematic framework based approach.

RESULTS

Carers described well-recognised outcomes of importance, alongside more novel outcomes relating to: Safety (of the patient/others); insight (e.g. into non-reality of psychotic phenomena); respite from fear, distress or pain; socially acceptable behaviour; getting out of the house; attainment of life milestones; changes in personality and/or temperament; reduction of vulnerability to stress; and several aspects of physical health.

CONCLUSIONS

These findings have the potential to inform the development of patient- or carer- focused outcome measures that take into account the full range of domains that carers feel are important for patients.

Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India

Stigma associated with schizophrenia significantly affects family caregivers, yet few studies have examined the nature and determinants of family stigma and its relationship to their knowledge about the condition. This paper describes the experiences and determinants of stigma reported by the primary caregivers of people living with schizophrenia (PLS) in India. The study used mixed methods and was nested in a randomised controlled trial of community care for people with schizophrenia. Between November 2009 and October 2010, data on caregiver stigma and functional outcomes were collected from a sample of 282 PLS–caregiver dyads. In addition, 36 in-depth-interviews were conducted with caregivers. Quantitative findings indicate that ‘high caregiver stigma’ was reported by a significant minority of caregivers (21%) and that many felt uncomfortable to disclose their family member's condition (45%). Caregiver stigma was independently associated with higher levels of positive symptoms of schizophrenia, higher levels of disability, younger PLS age, household education at secondary school level and research site. Knowledge about schizophrenia was not associated with caregiver stigma. Qualitative data illustrate the various ways in which stigma affected the lives of family caregivers and reveal relevant links between caregiver-stigma related themes (‘others finding out’, ‘negative reactions’ and ‘negative feelings and views about the self’) and other themes in the data.

Findings highlight the need for interventions that address both the needs of PLS and their family caregivers. Qualitative data also illustrate the complexities surrounding the relationship between knowledge and stigma and suggest that providing ‘knowledge about schizophrenia’ may influence the process of stigmatisation in both positive and negative ways. We posit that educational interventions need to consider context-specific factors when choosing anti-stigma-messages to be conveyed. Our findings suggest that messages such as ‘recovery is possible’ and ‘no-one is to blame’ may be more helpful than focusing on bio-medical knowledge alone.

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Experiences of being blamed and worries about marital prospects were salient.

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Caregivers' and PLS' experiences of stigma were determined by similar factors.

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Knowledge was linked to stigma in qualitative but not in quantitative analyses.

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Context-specific messages rather than biomedical knowledge may help reduce stigma.

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Family caregivers need access to emotional and social support in their own right.

Universal Health Coverage for Schizophrenia: A Global Mental Health Priority

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.

Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study

BACKGROUND

The functional outcome of people with severe mental disorders (SMD) is purported to be better in low- and middle-income countries compared to high-income countries; however, cross-cultural measures of functioning may not capture adequately the relevant functional activities in rural, non-Western settings. This study aimed to gain in-depth understanding of day-to-day functioning in a rural Ethiopian setting and the functional impairments associated with SMD.

METHOD

A qualitative study was carried out in the Butajira area, south Ethiopia. In-depth interviews were conducted with people with SMD (n = 6), religious healers (n = 2) and psychiatric nurses (n = 2). Four focus group discussions were carried out with caregivers of people with SMD (n = 37) and one with project outreach workers (n = 5). A thematic analysis approach was used.

RESULTS

Participants emphasized that functional impairment in people with SMD arose not only because of the symptoms associated with the illness, but also due to poverty, social exclusion and lack of social support. Within this rural community, the ability to work productively, engage in family life, maintain self-care and fulfill social obligations were the most highly valued domains of functioning. A wide range of farming tasks were elaborated in detail and noted to be of varying levels of difficulty. Although many people with symptomatic SMD were reported to be able to carry out simple farming tasks, this was distinguished from effective farming. Gender differences were most apparent in the domains of work and family life. Impaired functioning was reported to have a critical immediate impact on survival and longer-term impacts on the lifetime opportunities of people with SMD, their caregivers and the younger generation within the family.

CONCLUSIONS

The study indicates that tackling social exclusion and poverty is needed alongside medical treatment through contextual community based rehabilitation programs. The gendering of functional roles and the complexity of work activities in this subsistence farming community lend support to arguments for locally contextualized measures of functioning in people with SMD.

Systematic review of feasibility and acceptability of psychosocial interventions for schizophrenia in low and middle income countries

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.

Illness perception in Turkish schizophrenia patients: a qualitative explorative study

BACKGROUND

Schizophrenia is a serious mental illness that is highly complex and not fully understood. Individuals with serious mental illnesses like schizophrenia experience difficulty trying to access mental health services. Few have the opportunity to receive the most optimal evidence-based treatment and only half of those who do actually adhere to the recommended treatment. Understanding what it is like to have this illness would help in our approaches to treatment.

METHODS

In-depth interviews were conducted on nine Turkish patients with schizophrenia in order to explore the illness from the perspective of patients in remission.

RESULTS

Five themes emerged from the patients' descriptions of schizophrenia: schizophrenia is a complicated illness, a mystery, a lost life, a dynamic journey towards recovery, and a developmental process of recovery.

CONCLUSION

This study has identified areas of concern about reflecting the patients' perspectives on their experiences thoroughly, which should help improve healthcare provision and guide future research.

Experiences of stigma and discrimination of people with schizophrenia in India

Stigma contributes greatly to the burden of schizophrenia and is a major obstacle to recovery, yet, little is known about the subjective experiences of those directly affected in low and middle income countries. This paper aims to describe the experiences of stigma and discrimination of people living with schizophrenia (PLS) in three sites in India and to identify factors influencing negative discrimination.

The study used mixed methods and was nested in a randomised controlled trial of community care for schizophrenia. Between November 2009 and October 2010, data on four aspects of stigma experienced by PLS and several clinical variables were collected from 282 PLS and 282 caregivers and analysed using multivariate regression. In addition, in-depth-interviews with PLS and caregivers (36 each) were carried out and analysed using thematic analysis.

Quantitative findings indicate that experiences of negative discrimination were reported less commonly (42%) than more internalised forms of stigma experience such as a sense of alienation (79%) and significantly less often than in studies carried out elsewhere. Experiences of negative discrimination were independently predicted by higher levels of positive symptoms of schizophrenia, lower levels of negative symptoms of schizophrenia, higher caregiver knowledge about symptomatology, lower PLS age and not having a source of drinking water in the home. Qualitative findings illustrate the major impact of stigma on ‘what matters most’ in the lives of PLS and highlight three key domains influencing the themes of 'negative reactions' and ‘negative views and feelings about the self’, i.e., ‘others finding out’, ‘behaviours and manifestations of the illness’ and ‘reduced ability to meet role expectations’.

Findings have implications for conceptualising and measuring stigma and add to the rationale for enhancing psycho-social interventions to support those facing discrimination. Findings also highlight the importance of addressing public stigma and achieving higher level social and political structural change.

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Internalised experiences of stigma were reported more commonly than discrimination.

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A range of negative reactions beyond ‘discrimination’ led to feelings of devaluation.

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Negative discrimination was predicted by illness features, e.g., positive symptoms.

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Negative reactions were also linked to reduced ability to meet role expectations.

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What mattered most to PLS was to achieve role expectations in marriage and work.