A systematic review of care pathways for psychosis in low-and middle-income countries

Early Intervention in Psychosis and Management of First Episode Psychosis in Low- and Lower-Middle-Income Countries: A Systematic Review

BACKGROUND AND HYPOTHESIS

People with first-episode psychosis (FEP) in low- and lower-middle-income countries (LMIC) experience delays in receiving treatment, resulting in poorer outcomes and higher mortality. There is robust evidence for effective and cost-effective early intervention in psychosis (EIP) services for FEP, but the evidence for EIP in LMIC has not been reviewed. We aim to review the evidence on early intervention for the management of FEP in LMIC.

STUDY DESIGN

We searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) to identify studies describing EIP services and interventions to treat FEP in LMIC published from 1980 onward. The bibliography of relevant articles was hand-searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY RESULTS

The search strategy produced 5074 records; we included 18 studies with 2294 participants from 6 LMIC countries. Thirteen studies (1553 participants) described different approaches for EIP. Pharmacological intervention studies (n = 4; 433 participants) found a high prevalence of metabolic syndrome among FEP receiving antipsychotics (P ≤ .005). One study found a better quality of life in patients using injectables compared to oral antipsychotics (P = .023). Among the non-pharmacological interventions (n = 3; 308 participants), SMS reminders improved treatment engagement (OR = 1.80, CI = 1.02-3.19). The methodological quality of studies evidence was relatively low.

CONCLUSIONS

The limited evidence showed that EIP can be provided in LMIC with adaptations for cultural factors and limited resources. Adaptations included collaboration with traditional healers, involving nonspecialist healthcare professionals, using mobile technology, considering the optimum use of long-acting antipsychotics, and monitoring antipsychotic side effects.

Cost-effectiveness of early intervention in psychosis in low- and middle-income countries: economic evaluation from São Paulo, Brazil

AIMS

The effectiveness and cost-effectiveness of early intervention for psychosis (EIP) services are well established in high-income countries but not in low- and middle-income countries (LMICs). Despite the scarcity of local evidence, several EIP services have been implemented in LMICs. Local evaluations are warranted before adopting speciality models of care in LMICs. We aimed to estimate the cost-effectiveness of implementing EIP services in Brazil.

METHODS

A model-based economic evaluation of EIP services was conducted from the Brazilian healthcare system perspective. A Markov model was developed using a cohort study conducted in São Paulo. Cost data were retrieved from local sources. The outcome of interest was the incremental cost-effectiveness ratio (ICER) measured as the incremental costs over the incremental quality-adjusted life-years (QALYs). Sensitivity analyses were performed to test the robustness of the results.

RESULTS

The study included 357 participants (38% female), with a mean (SD) age of 26 (7.38) years. According to the model, implementing EIP services in Brazil would result in a mean incremental cost of 4,478 Brazilian reals (R$) and a mean incremental benefit of 0.29 QALYs. The resulting ICER of R$ 15,495 (US dollar [USD] 7,640 adjusted for purchase power parity [PPP]) per QALY can be considered cost-effective at a willingness-to-pay threshold of 1 Gross domestic product (GDP) per capita (R$ 18,254; USD 9,000 PPP adjusted). The model results were robust to sensitivity analyses.

CONCLUSIONS

This study supports the economic advantages of implementing EIP services in Brazil. Although cultural adaptations are required, these data suggest EIP services might be cost-effective even in less-resourced countries.

Comparing interventions for early psychosis: a systematic review and component network meta-analysis

Background

'Early Intervention in Psychosis' (EIP) services have been associated with improved outcomes for early psychosis. However, these services are heterogeneous and many provide different components of treatment. The impact of this variation on the sustained treatment effects is unknown.

Methods

We performed a systematic review and component network meta-analysis (cNMA) of randomised controlled trials (RCTs) that compared specialised intervention services for early psychosis. We searched CENTRAL (published and unpublished), EMBASE, MEDLINE, CINAHL, PsycINFO and Web of Science from inception to February 2023. Primary outcomes were negative and positive psychotic symptoms at 3-month and 1-year follow-up and treatment dropouts. Secondary outcomes were depressive symptoms and social functioning at 1-year follow-up. We registered a protocol for our study in PROSPERO (CRD42017057420).

Findings

We identified 37 RCTs including 4599 participants. Participants' mean age was 25.8 years (SD 6.0) and 64.0% were men. We found evidence that psychological interventions (this component grouped all psychological treatment intended to treat, or ameliorate the consequences of, psychotic symptoms) are beneficial for reducing negative symptoms (iSMD -0.24, 95% CI -0.44 to -0.05, p = 0.014) at 3-month follow-up and may be associated with clinically relevant benefits in improving social functioning scores at 1-year follow-up (iSMD -0.52, 95% CI -1.05 to 0.01, p = 0.052). The addition of case management has a beneficial effect on reducing negative symptoms (iSMD -1.17, 95% CI -2.24 to -0.11, p = 0.030) and positive symptoms (iSMD -1.05, 95% CI -2.02 to -0.08, p = 0.033) at 1-year follow-up. Pharmacotherapy was present in all trial arms, meaning it was not possible to examine the specific effects of this component.

Interpretation

Our findings suggest psychological interventions and case management in addition to pharmacotherapy as the core components of services for early psychosis to achieve sustained clinical benefits. Our conclusions are limited by the small number of studies and sparsely connected networks.

Funding

National Institute for Health and Care Research.

Adolopment of clinical practice guidelines and creation of referral pathways for psychiatric conditions in Pakistan

Psychiatric disorders are highly prevalent in Pakistan and burdens the scarce number of psychiatrists present in the country. The establishment of evidence-based clinical practice guidelines (EBCPGs) and primary-care referral pathways within the local context is imperative to make the process efficient. In this Health Policy, we aimed to develop EBCPGs and primary-care referral pathways that are specific to Pakistan's primary-care setting, with the aim of facilitating the management of psychiatric conditions. Ten EBCPGs were created through the GRADE-ADOLOPMENT process; two recommendations were adopted with minor changes, 43 were excluded, and all others were adopted without any changes. Ten primary-care referral pathways for managing ten psychiatric disorders were created and 23 recommendations were added which will help to bridge the gap in care provision. These psychiatric referral pathways and EBCPGs will bring Pakistan's healthcare system a step closer to achieving optimal health outcomes for patients.

Development of mental health first-aid guidelines for psychosis: a Delphi expert consensus study in Argentina and Chile

BACKGROUND

Psychotic symptoms may be less common than anxiety or affective symptoms, but they are still frequent and typically highly debilitating. Community members can have a role in helping to identify, offer initial help and facilitate access to mental health services of individuals experiencing psychosis. Mental health first aid guidelines for helping a person experiencing psychosis have been developed for the global north. This study aimed to adapt the English- language guidelines for Chile and Argentina.

METHODS

A Delphi expert consensus study was conducted with two panels of experts, one of people with lived experience of psychosis (either their own or as a carer; n = 29) and another one of health professionals (n = 29). Overall, 249 survey items from the original English guidelines and 26 items suggested by the local team formed a total of 275 that were evaluated in the first round. Participants were invited to rate how essential or important those statements were for Chile and Argentina, and encouraged to suggest new statements if necessary. These were presented in a second round. Items with 80% of endorsement by both panels were included in the guidelines for Chile and Argentina.

RESULTS

Data were obtained over two survey rounds. Consensus was achieved on 244 statements, including 26 statements locally generated for the second round. Almost 20% of the English statements were not endorsed (n = 50), showing the applicability of the original guidelines but also the importance of culturally adapting them. Attributions and tasks expected to be delivered by first aiders were shrunk in favour of a greater involvement of mental health professionals. Self-help strategies were mostly not endorsed and as were items relating to respecting the person's autonomy.

CONCLUSIONS

While panellists agreed that first aiders should be aware of human rights principles, items based on recovery principles were only partially endorsed. Further research on the dissemination of these guidelines and development of a Mental Health First Aid training course for Chile and Argentina is still required.

Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation

BACKGROUND

Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking.

OBJECTIVE

To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka.

METHODS

Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country.

RESULTS

The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka.

CONCLUSIONS

Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.

A scoping review of cardiovascular risk factor screening rates in general or family practice attendees living with severe mental ill-health

BACKGROUND

Primary care is essential to address the unmet physical health needs of people with severe mental ill-health. Continued poor cardiovascular health demands improved screening and preventive care. No previous reviews have examined primary care cardiovascular screening rates for people living with severe mental ill-health; termed in the literature "severe mental illness".

METHODS

A scoping review following Joanna Briggs Institute methodology was conducted. Cardiovascular risk factor screening rates in adults with severe mental ill-health were examined in general or family practices (as the main delivery sites of primary care). Literature published between 2001 and 2023 was searched using electronic databases including Medline, Embase, Web of Science, PsychINFO and CINAHL. Two reviewers independently screened titles and abstracts and conducted a full-text review. The term "severe mental illness" was applied as the term applied in the literature over the past decades. Study information, participant details and cardiovascular risk factor screening rates for people with 'severe mental illness' were extracted and synthesised.

RESULTS

Thirteen studies were included. Nine studies were from the United Kingdom and one each from Canada, Spain, New Zealand and the Netherlands. The general and/or family practice cardiovascular disease screening rates varied considerably across studies, ranging from 0 % to 75 % for people grouped within the term "severe mental illness". Lipids and blood pressure were the most screened risk factors.

CONCLUSIONS

Cardiovascular disease screening rates in primary care settings for adults living with severe mental ill-health varied considerably. Tailored and targeted cardiovascular risk screening will enable more comprehensive preventive care to improve heart health outcomes and address this urgent health inequity.

Pathways to care for psychosis in Malawi

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Prevalence, risk factors and multiple outcomes of treatment delay in Chinese patients with schizophrenia

BACKGROUND

People with schizophrenia often delay treatment. This issue is not fully understood, particularly in low-and middle-income countries. This study aimed to elucidate the prevalence, risk factors and multiple outcomes of treatment delay in schizophrenia in a Chinese metropolis.

METHODS

A two-stage whole cluster sampling survey was conducted in Beijing, China in 2020. A total of 1,619 patients with schizophrenia were included. Heterogeneity between groups and the changing trend of treatment delay were presented. Regression modelling methods were used to examine both the risk factors for treatment delay and related outcomes at individual and family levels.

RESULTS

The median treatment delay for schizophrenia was 89 days (about 13 weeks). 49.35% surveyed patients delayed treatment for more than three months. Early age of onset, low level of education, living in well developed districts were important risk factors. Treatment delay in schizophrenia was significantly associated with patients' poor medication adherence, comorbidity status and poor social functioning. It also increased the negative impact of the illness on families.

CONCLUSIONS

This study accumulated evidence of treatment delay in schizophrenia in China. It occurs even in the metropolis where mental health resources are relatively adequate. Further targeted interventions to raise public awareness should be crucial to reduce treatment delay.

Service users' perceptions of recovery from recent-onset psychosis and their long journey to and through psychiatric treatment

A growing body of evidence highlights that individuals' understanding of mental illness and recovery influences their mental health care preferences. Journeys to psychiatric care settings vary across regions with different socio-economic and developmental characteristics. However, these journeys in low-income African countries have not been well explored. This descriptive qualitative study aimed to describe service users' journeys to and through psychiatric treatment and explore their conceptualizations of recovery from recent-onset psychosis. Nineteen adults with recent-onset psychosis were recruited from three hospitals in Ethiopia for an individual semi-structured interview. Data from in-depth face-to-face interviews were transcribed and thematically analysed. Participants' conceptualizations of recovery are summarized into four themes; "domination over the disturbance of psychosis", "complete medical treatment course and stay normal", "stay active in life with optimal functioning", and "reconcile with the new reality and rebuild hope and life". These perceptions of recovery were reflected in their accounts of the long and hurdled journey to and through conventional psychiatric care settings. Participants' perceptions of psychotic illness, treatment, and recovery seemed to result in delayed or limited care in conventional treatment settings. Misunderstandings about only requiring a limited period/course of treatment for a full and permanent recovery should be addressed. Clinicians should work alongside traditional beliefs about psychosis to maximize engagement and promote recovery. Integrating conventional psychiatric treatment with spiritual/traditional healing services may make an important contribution to early treatment initiation and improving engagement.

Understanding components and predictors of delay of first treatment for mental health problems: A hospital-based study in China

BACKGROUND

Understanding components and predictors of delay of first treatment for mental health problems are crucial to inform interventions for earlier treatment. However, Chinese-context knowledge of this theme is still limited.

METHODS

We conducted an inpatient survey among 206 patients with various mental disorders in China. Delay of first utilization of mental healthcare (Delay-Total) and its two components of help-seeking delay (Delay-H) and referral delay (Delay-R) were assessed in terms of occurrence and duration. Binary logistic regression was performed to test predictors of Delay-Total, Delay-H and Delay-R, and multiple linear regression was used to test predictors of delay durations.

RESULTS

Overall, 66.0% patients experienced Delay-Total, with a duration range of 0 to 353 months; 49.5% patients had Delay-H (duration range = 0-207 months) and 29.6% with Delay-R (duration range = 0-323 months). Multivariate logistic regression analysis found that the diagnosis of severe mental disorders was a consistent predictor for a reduced chance of Delay-Total, Delay-H and Delay-R. Multiple linear regression analysis demonstrated that younger age of disorder onset and disorder onset before 2016 were significantly associated with longer delay.

CONCLUSIONS

Delay of first treatment for mental health problems is still common in China. However, the development of mental health policy and services promotes shorter treatment delay. The diagnosis of common mental disorders and younger age of onset are risk factors of the occurrence and duration of delay, respectively. Thus, education of the public and non-mental-healthcare professionals are needed for better disorder recognition and more efforts should be inputted to support youngsters' utilization of mental healthcare.

The role of culture on the phenomenology of hallucinations and delusions, explanatory models, and help-seeking attitudes: A narrative review

AIM

Culture has been posited to be involved in the formation and maintenance of delusions and hallucinations. The extent of these differences and how they affect explanatory models of psychosis and help-seeking attitudes remains to be understood. This review aims to present a cultural formulation to account for psychosis onset, symptom maintenance, and help-seeking attitudes.

METHODS

A narrative review was conducted to summarize the existing evidence base regarding cross-cultural differences in hallucinatory and delusional prevalence, explanatory models, and help-seeking attitudes in First Episode Psychosis (FEP) and Non-FEP Schizophrenia samples.

RESULTS

Sixteen studies were eligible for inclusion. In terms of positive symptom specificity, cross-cultural differences were found. Specifically, auditory and visual hallucinations occurred most frequently in African patients, persecutory and grandiose delusions occurred at higher rates in African, Pakistani, and Latino patients, while delusions of reference were most prevalent in White-British groups. Three explanatory models were identified. Westerners tended to endorse a bio-psychosocial explanation, which was associated with increased help-seeking, engagement, and positive medication attitudes. Asian, Latino, Polish, and Māori patients endorsed religious-spiritual explanatory models, while African patients opted for a bewitchment model. The religious-spiritual and bewitchment models were associated with a longer duration of untreated psychosis (DUP) and poorer engagement with mental health services.

CONCLUSIONS

These findings highlight the important influence of culture in the formation and maintenance of positive symptoms of psychosis, engagement, and help-seeking attitudes across different ethnic groups. The incorporation of cultural beliefs in formulation development could facilitate enriched CBTp practices and improved engagement amongst different cultural groups with Early Intervention Services.

Traditional healers working with primary care and mental health for early intervention in psychosis in young persons: protocol for the feasibility cluster randomised controlled trial

OBJECTIVES

In low/middle-income countries (LMICs), more than half of patients with first-episode psychosis initially seek treatment from traditional and religious healers as their first care. This contributes to an excessively long duration of untreated psychosis (DUP). There is a need for culturally appropriate interventions to involve traditional and spiritual healers to work collaboratively with primary care practitioners and psychiatrists through task-shifting for early detection, referral and treatment of first episode of psychosis.

METHODS

To prevent the consequences of long DUP in adolescents in LMICs, we aim to develop and pilot test a culturally appropriate and context-bespoke intervention. Traditional HEalers working with primary care and mental Health for early interventiOn in Psychosis in young pErsons (THE HOPE) will be developed using ethnographic and qualitative methods with traditional healers and caregivers. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. Ninety-three union councils in district Peshawar, Pakistan will be randomised and allocated using a 1:1 ratio to either intervention arm (THE HOPE) or enhanced treatment as usual and stratified by urban/rural setting. Data on feasibility outcomes will be collected at baseline and follow-up. Patients, carers, clinicians and policymakers will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Keele University Ethical Review Panel (ref: MH210177), Khyber Medical University Ethical Review Board (ref: DIR/KMU-EB/IG/001005) and National Bioethics Committee Pakistan (ref no. 4-87/NBC-840/22/621). The results of THE HOPE feasibility trial will be reported in peer-reviewed journals and academic conferences and disseminated to local stakeholders and policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN75347421.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers' (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients' experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

Gone Too Soon: priorities for action to prevent premature mortality associated with mental illness and mental distress

Globally, too many people die prematurely from suicide and the physical comorbidities associated with mental illness and mental distress. The purpose of this Review is to mobilise the translation of evidence into prioritised actions that reduce this inequity. The mental health research charity, MQ Mental Health Research, convened an international panel that used roadmapping methods and review evidence to identify key factors, mechanisms, and solutions for premature mortality across the social-ecological system. We identified 12 key overarching risk factors and mechanisms, with more commonalities than differences across the suicide and physical comorbidities domains. We also identified 18 actionable solutions across three organising principles: the integration of mental and physical health care; the prioritisation of prevention while strengthening treatment; and the optimisation of intervention synergies across social-ecological levels and the intervention cycle. These solutions included accessible, integrated high-quality primary care; early life, workplace, and community-based interventions co-designed by the people they should serve; decriminalisation of suicide and restriction of access to lethal means; stigma reduction; reduction of income, gender, and racial inequality; and increased investment. The time to act is now, to rebuild health-care systems, leverage changes in funding landscapes, and address the effects of stigma, discrimination, marginalisation, gender violence, and victimisation.

Comparing treatment delays and pathways to early intervention services for psychosis in urban settings in India and Canada

INTRODUCTION

Although extensively studied in high-income countries (HICs) and less so in low- and middle-income countries (LMICs), pathways to care and treatment delays in early psychosis have not been compared across contexts. We compared pathways to early intervention for psychosis in an HIC (Montreal, Canada) and an LMIC (Chennai, India). We hypothesised that the duration of untreated psychosis (DUP) would be longer in Chennai.

METHODS

The number of contacts preceding early intervention, referral sources, first contacts, and DUP and its referral and help-seeking components of first-episode psychosis patients at both sites were similarly measured and compared using chi-square analyses and t tests/one-way ANOVAs.

RESULTS

Overall and help-seeking DUPs of Chennai (N = 168) and Montreal (N = 165) participants were not significantly different. However, Chennai patients had shorter referral DUPs [mean = 12.0 ± 34.1 weeks vs. Montreal mean = 13.2 ± 28.7 weeks; t(302.57) = 4.40; p < 0.001] as the early intervention service was the first contact for 44% of them (vs. 5% in Montreal). Faith healers comprised 25% of first contacts in Chennai. Those seeing faith healers had significantly shorter help-seeking but longer referral DUPs. As predicted, most (93%) Montreal referrals came from medical sources. Those seeing psychologists/counsellors/social workers as their first contact had longer DUPs.

CONCLUSION

Differences in cultural views about mental illnesses and organizational structures shape pathways to care and their associations with treatment delays across contexts. Both formal and informal sources need to be targeted to reduce delays. Early intervention services being the first portal where help is sought can reduce DUP especially if accessed early on in the illness course.

Pathways to care in first-episode psychosis in low-resource settings: Implications for policy and practice

OBJECTIVE

Developing countries such as India face a major mental health care gap. Delayed or inadequate care can have a profound impact on treatment outcomes. We compared pathways to care in first episode psychosis (FEP) between North and South India to inform solutions to bridge the treatment gap.

METHODS

Cross-sectional observation study of 'untreated' FEP patients (n = 177) visiting a psychiatry department in two sites in India (AIIMS, New Delhi and SCARF, Chennai). We compared duration of untreated psychosis (DUP), first service encounters, illness attributions and socio-demographic factors between patients from North and South India. Correlates of DUP were explored using logistic regression analysis (DUP ≥ 6 months) and generalised linear models (DUP in weeks).

RESULTS

Patients in North India had experienced longer DUP than patients in South India (β = 17.68, p < 0.05). The most common first encounter in North India was with a faith healer (45.7%), however, this contact was not significantly associated with longer DUP. Visiting a faith healer was the second most common first contact in South India (23.6%) and was significantly associated with longer DUP (Odds Ratio: 6.84; 95% Confidence Interval: 1.77, 26.49). Being in paid employment was significantly associated with shorter DUP across both sites.

CONCLUSIONS

Implementing early intervention strategies in a diverse country like India requires careful attention to local population demographics; one size may not fit all. A collaborative relationship between faith healers and mental health professionals could help with educational initiatives and to provide more accessible care.

Intervention Programs for First-Episode Psychosis: A Scoping Review Protocol

Early intervention programs for first-episode psychosis aim to intervene in the early stages of the disease. They are essential to prevent and delay the progression of the illness to a more advanced stage, but information about their characteristics is not systematized. The scoping review considered all studies of first-episode psychosis intervention programs, regardless of their context (hospital or community), and explored their characteristics. The scoping review was developed according to the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. The PCC mnemonic (population, concept, and context) addressed research questions, the inclusion and exclusion criteria, and the search strategy. The scoping review sought to identify the literature that meets the predefined inclusion criteria. The research was conducted in the following databases: Web of Science Core Collection, MEDLINE, CINAHL Complete and PsycINFO, Scopus, Cochrane Library, and JBI Evidence Synthesis. The search for unpublished studies included OpenGrey (a European repository) and MedNar. It used sources in English, Portuguese, Spanish, and French. It included quantitative, qualitative, and multi-method/mixed methods studies. It also considered gray or unpublished literature. After removing duplicates, two independent reviewers extracted the relevant information after selecting the articles. If there were disagreements, a third reviewer was used. The researchers have developed a tool based on the JBI model that will allow them to extract the relevant information for the review. The results are presented schematically in narratives and tables. This scoping review maps first-episode psychosis intervention programs by identifying their characteristics, participants, and specific implementation contexts and allows researchers to create multicomponent programs tailored to different contexts.

Inequality and barriers in psychosis prevention: A systematic review on clinical high-risk for psychosis studies from developing countries

Background

The clinical high-risk for psychosis (CHR) paradigm is one of the best studied preventive paradigms in psychiatry. However, most studies have been conducted in high-income countries. It is unclear if knowledge from such countries applies to low and middle-income countries (LAMIC), and if there are specific limitations hindering CHR research there. Our aim is to systematically review studies on CHR from LAMIC.

Methods

A multistep PRISMA-compliant literature search was performed in PubMed and Web of Science for articles published until 1/03/2022, conducted in LAMIC, addressing the concept and correlates of CHR. Study characteristics as well as limitations were reported. Corresponding authors of the included studies were invited to answer an online poll. Quality assessment was done with the MMAT.

Results

A total of 109 studies were included in the review: none from low-income countries, 8 from lower middle-income countries, and 101 from upper middle-income countries. The most frequent limitations were small sample size (47.9%), cross-sectional design (27.1%), and follow-up issues (20.8%). Mean quality of included studies was of 4.4. Out of the 43 corresponding authors, 12 (27.9%) completed the online poll. They cited further limitations as few financial resources (66.7%), no involvement of population (58.2%) and cultural barriers (41.7%). Seventy five percent researchers reported that CHR research should be conducted differently in LAMIC compared to high-income countries, due to structural and cultural issues. Stigma was mentioned in three out of five sections of the poll.

Discussion

Results show the discrepancy of available evidence on CHR in LAMIC, given the shortage of resources in such countries. Future directions should aim to increase the knowledge on individuals at CHR in such settings, and to address stigma and cultural factors that may play a role in the pathways toward care in psychosis.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=316816, CRD42022316816.

Schizophrenia Assessment, Referral and Awareness Training for Health Auxiliaries (SARATHA): Protocol for a Mixed-Methods Pilot Study in Rural India

BACKGROUND

Workforce shortages pose major obstacles to the timely detection and treatment of schizophrenia, particularly in low-income and middle-income countries. The SARATHA (Schizophrenia Assessment, Referral, and Awareness Training for Health Auxiliaries) project involves the systematic development, iterative refinement, and pilot testing of a digital program for training community health workers in the early detection and referral of schizophrenia in primary care settings in rural India.

METHODS

SARATHA is a three-phase study. Phase 1 involves consulting with experts and clinicians, and drawing from existing evidence to inform the development of a curriculum for training community health workers. Phase 2 consists of designing and digitizing the training content for delivery on a smartphone app. Design workshops and focus group discussions will be conducted to seek input from community health workers and service users living with schizophrenia to guide revisions and refinements to the program content. Lastly, Phase 3 entails piloting the training program with a target sample of 20 community health workers to assess feasibility and acceptability. Preliminary effectiveness will be explored, as measured by community health workers' changes in knowledge about schizophrenia and the program content after completing the training.

DISCUSSION

If successful, this digital training program will offer a potentially scalable approach for building capacity of frontline community health workers towards reducing delays in early detection of schizophrenia in primary care settings in rural India. This study can inform efforts to improve treatment outcomes for persons living with schizophrenia in low-resource settings.

Differences of affective and non-affective psychoses in early intervention services from Latin America

BACKGROUND

Psychosis presentation can be affected by genetic and environmental factors. Differentiating between affective and non-affective psychosis (A-FEP and NA-FEP, respectively) may influence treatment decisions and clinical outcomes. The objective of this paper is to examine differences between patients with A-FEP or NA-FEP in a Latin American sample.

METHODS

Patients from two cohorts of patients with a FEP recruited from Brazil and Chile. Subjects included were aged between 15 and 30 years, with an A-FEP or NA-FEP (schizophrenia-spectrum disorders) according to DSM-IV-TR. Sociodemographic data, duration of untreated psychosis and psychotic/mood symptoms were assessed. Generalized estimating equation models were used to assess clinical changes between baseline-follow-up according to diagnosis status.

RESULTS

A total of 265 subjects were included. Most of the subjects were male (70.9 %), mean age was 21.36 years. A-FEP and NA-FEP groups were similar in almost all sociodemographic variables, but A-FEP patients had a higher probability of being female. At baseline, the A-FEP group had more manic symptoms and a steeper reduction in manic symptoms scores during the follow- up. The NA-FEP group had more negative symptoms at baseline and a higher improvement during follow-up. All domains of The Positive and Negative Syndrome Scale improved for both groups. No difference for DUP and depression z-scores at baseline and follow-up.

LIMITATIONS

The sample was recruited at tertiary hospitals, which may bias the sample towards more severe cases.

CONCLUSIONS

This is the largest cohort comparing A-FEP and NA-FEP in Latin America. We found that features in FEP patients could be used to improve diagnosis and support treatment decisions.

Mental health gaps characteristics in the management of schizophrenia in a developing upper middle-income South-East Asian country

OBJECTIVE

The Mental Health Gap Action Program (mhGAP) was launched by the World Health Organization (WHO) in 2008 to address the lack of care of people in low and middle-income countries The purpose of this narrative review is to examine Mental Health Gaps in the management of Schizophrenia in Malaysia.

METHOD

A search was conducted using the five keywords in the following databases: Embase, MEDLINE, Web of Science, PubMed and Google Scholar.

FINDINGS

A review of the mental health system in Malaysia was conducted through the lens of the mhGAP context with a particular focus on Schizophrenia. Gaps in service delivery and lack of fidelity to evidence-based practices to this population of patients are examined in context of social security and health coverage, evidenced-based practices in Schizophrenia and health and allied delivery systems.

CONCLUSIONS

and Implications for Practice: Mental health service delivery and associated systems in Malaysia are found wanting in several aspects of mental health management of schizophrenia. There is an urgent need for a thorough review and realignment of the management of Schizophrenia by all stakeholders involved in the multi-sectoral inter-system delivery of services to people with schizophrenia i.e. Mental health professionals, Social Welfare officers, policy makers, local and federal government agencies involved in education, employment, transport and housing.

Implementing psychosocial interventions within low and middle-income countries to improve community-based care for people with psychosis-A situation analysis

BACKGROUND

Globally, a treatment gap exists for individuals with severe mental illness, with 75% of people with psychosis failing to receive appropriate care. This is most pronounced in low and middle-income countries, where there are neither the financial nor human resources to provide high-quality community-based care. Low-cost, evidence-based interventions are urgently needed to address this treatment gap.

AIM

To conduct a situation analysis to (i) describe the provision of psychosocial interventions within the context of existing care in two LMICs-India and Pakistan, and (ii) understand the barriers and facilitators of delivering a new psychosocial intervention.

METHOD

A situation analysis including a quantitative survey and individual interviews with clinicians, patients and caregivers was conducted. Quantitative survey data was collected from staff members at 11 sites (private and government run hospitals) to assess organizational readiness to implement a new psychosocial intervention. To obtain in-depth information, 24 stakeholders including clinicians and service managers were interviewed about the typical care they provide and/or receive, and their experience of either accessing or delivering psychosocial interventions. This was triangulated by six interviews with carer and patient representatives.

RESULTS AND DISCUSSION

The results highlight the positive views toward psychosocial interventions within routine care and the enthusiasm for multidisciplinary working. However, barriers to implementation such as clinician time, individual attitudes toward psychosocial interventions and organizational concerns including the lack of space within the facility were highlighted. Such barriers need to be taken into consideration when designing how best to implement and sustain new psychosocial interventions for the community treatment of psychosis within LMICs.

Systematic review of pathways to care in the U.S. for Black individuals with early psychosis

The pathway to receiving specialty care for first episode psychosis (FEP) among Black youth in the US has received little attention despite documented challenges that negatively impact engagement in care and clinical outcomes. We conducted a systematic review of US-based research, reporting findings related to the pathway experiences of Black individuals with FEP and their family members. A systematic search of PubMed, PsycInfo, and Embase/Medline was performed with no date restrictions up to April 2021. Included studies had samples with at least 75% Black individuals and/or their family members or explicitly examined racial differences. Of the 80 abstracts screened, 28 peer-reviewed articles met the inclusion criteria. Studies were categorized into three categories: premordid and prodromal phase, help-seeking experiences, and the duration of untreated psychosis (DUP). Compounding factors such as trauma, substance use, and structural barriers that occur during the premorbid and prodromal contribute to delays in treatment initiation and highlight the limited use of services for traumatic childhood experiences (e.g., sexual abuse). Studies focused on help-seeking experiences demonstrated the limited use of mental health services and the potentially traumatic entry to services (e.g., law enforcement), which is associated with a longer DUP. Although the majority of studies focused on help-seeking experiences and predictors of DUP, findings suggests that for Black populations, there is a link between trauma and substance use in the pathway to care that impacts the severity of symptoms, initiation of treatment, and DUP. The present review also identifies the need for more representative studies of Black individuals with FEP.