Pathways to care and supernatural beliefs among patients with psychotic disorders in Nepal

Early intervention in psychosis programs in Africa, Asia and Latin America; challenges and recommendations

Background

While early intervention in psychosis (EIP) programs have been increasingly implemented across the globe, many initiatives from Africa, Asia and Latin America are not widely known. The aims of the current review are (a) to describe population-based and small-scale, single-site EIP programs in Africa, Asia and Latin America, (b) to examine the variability between programs located in low-and-middle income (LMIC) and high-income countries in similar regions and (c) to outline some of the challenges and provide recommendations to overcome existing obstacles.

Methods

EIP programs in Africa, Asia and Latin America were identified through experts from the different target regions. We performed a systematic search in Medline, Embase, APA PsycInfo, Web of Science and Scopus up to February 6, 2024.

Results

Most EIP programs in these continents are small-scale, single-site programs that serve a limited section of the population. Population-based programs with widespread coverage and programs integrated into primary health care are rare. In Africa, EIP programs are virtually absent. Mainland China is one of the only LMICs that has begun to take steps toward developing a population-based EIP program. High-income Asian countries (e.g. Hong Kong and Singapore) have well-developed, comprehensive programs for individuals with early psychosis, while others with similar economies (e.g. South Korea and Japan) do not. In Latin America, Chile is the only country in the process of providing population-based EIP care.

Conclusions

Financial resources and integration in mental health care, as well as the availability of epidemiological data on psychosis, impact the implementation of EIP programs. Given the major treatment gap of early psychosis in Africa, Latin America and large parts of Asia, publicly funded, locally-led and accessible community-based EIP care provision is urgently needed.

Duration of untreated psychosis and associated sociodemographic and clinical factors in first-episode psychosis: A study from Eastern Nepal

OBJECTIVE

Duration of untreated psychosis (DUP) is considered an important factor in outcome. Individual, familial and illness factors may prolong DUP. Little data on this issue is available from the country of Nepal. The purpose of the present study was to assess DUP in patients with first-episode psychosis and identify associations with patients' sociodemographic and clinical factors.

METHODS

A cross-sectional, descriptive study was conducted in the department of psychiatry at Tertiary Hospital in the Eastern part of Nepal. Eighty-six patients were enrolled. ICD-10 was used to make the diagnosis. The Nottingham Onset Schedule-DUP version (NOS-DUP) was used to assess DUP. Positive and Negative Syndrome Scale (PANSS) was used to assess patients' clinical symptoms.

RESULTS

The mean (SD) DUP was 21.4 (42.1) months and median DUP was 3.0 months (IQR = 23.5). Participants from mountainous regions, those who were unemployed, having an insidious onset of illness, and patients with a diagnosis of schizophrenia had significantly longer DUP (P < .005). Duration of untreated psychosis was also positively correlated with negative symptoms (r = .42, P < .001) and total PANSS score (r = .42, P < .001).

CONCLUSION

Duration of untreated psychosis in first-episode psychotic patients was relatively long (compared to studies in other countries) and was found to be positively associated with living in mountainous regions of Nepal, being unemployed, having an insidious onset of illness, and having a diagnosis of schizophrenia. Programs and educational efforts are needed to ensure early treatment of patients with first-episode psychosis, especially in the mountainous rural areas of Nepal.

Schizophrenia: jinn, magic or disease? Experiences of family caregivers of patients with schizophrenia in Baloch ethnicity

BACKGROUND

Cultural and religious beliefs are effective on people's attitudes towards schizophrenia and their help-seeking behaviors. This study aimed to explain the experiences of family caregivers of patients with schizophrenia in Baloch ethnicity.

METHODS

This is a qualitative study with conventional content analysis approach. Purposive sampling was used and 21 participants, including family caregiver for patients with schizophrenia, a psychologist, a prayer-writer, and a normal person were interviewed in Sistan and Balochistan province in the southeast of Iran. Qualitative data were analyzed by Granheim and Lundman method.

RESULTS

One main theme, three categories, and 10 Sub-categories were extracted from analysis of interviews. "Immersion in the cultural beliefs" was the main theme of the study with categories of "Belief in the superstitious and supernatural nature of the psychological disease", "Superstitious beliefs, an attempt to free the patient", and "Conflict between cultural beliefs and science".

CONCLUSIONS

Help-seeking behaviors of family caregivers in Baloch ethnicity are influenced by their religious, superstitious, and cultural beliefs. Psycho-education should be part of all mental health education programs in these communities, as delays in treatment worsen the prognosis of people with schizophrenia. Training the medical staff to consider the culture, religion and therapeutic preferences of the Baloch people can be effective in advancing the goals. In addition, local influencers should stress the importance of health care alongside harmless local remedies.

A systematic review of factors prolonging or reducing the duration of untreated psychosis for people with psychosis in low- and middle-income countries

AIM

This review aims to identify factors that may prolong or reduce the duration of untreated psychosis for people with psychosis in low- and middle-income countries.

METHODS

Electronic searches of six databases were conducted, to find studies from low- and middle-income countries on people with psychotic disorders provided they statistically measured an association between factors that may prolong or reduce the duration of untreated psychosis. Studies were critically appraised and a narrative synthesis exploring differences between and within studies is presented. A socio-ecological model is used to convey the main findings.

RESULTS

Thirty studies of 16 473 participants in total were included in this review. Taken together participants were 51.5% male and 48.5% female. Various factors potentially associated with longer duration of untreated psychosis for people with psychosis in low- and middle-income countries were found. Examples of these factors are an insidious mode of onset, greater family stigma and low social class. Other factors, such as marital status, educational level, diagnostic type, predominant symptoms and employment status, yielded inconsistent results.

CONCLUSIONS

The methodological quality of the included studies limits the conclusions of this review. The results indicate an urgent need for further high-quality research in these countries. The socio-ecological model is a helpful framework for clinicians, scholars, and decision-makers to conceptualize factors that may affect the duration of untreated psychosis, highlight gaps in the literature as well as reflect on potential prevention strategies that may ultimately support early intervention services for people with psychosis in developing countries.

Pathways to mental health care in Nepal: a 14-center nationwide study

BACKGROUND

Pathways to care studies are feasible and tested means of finding the actual routes taken by patients before reaching proper care. In view of the predominance of nonprofessional service providers and the lack of previous large studies on pathways in Nepal, this multicenter study is needed. The aim of the study was to trace the various pathways and carers involved in mental health care; assess clinical variables such as the duration of untreated illness, clinical presentation and treatment; and compare geographically and culturally diverse landscapes.

METHODS

This was a cross-sectional, convenience sampling study performed at 14 centers where new cases were being taken. The World Health Organization Study of the Pathways-to-Care Schedule was applied. The Nepali version of the encounter form was used. The data were collected between 17 September and 16 October 2020 and were analyzed using the Statistical Package for the Social Sciences (SPSS). Additionally, perspectives from local investigators were collected and discussed.

RESULTS

Most of the first carers were native/religious faith healers (28.2%), followed by psychiatrists (26%). The median duration for the first psychiatric consultation was 3 weeks. The duration of untreated illness was 30.72 ± 80.34 (median: 4) weeks, and the time taken for this journey was 94.99 ± 274.58 (median: 30) min. The longest delay from the onset of illness to psychiatric care was for epilepsy {90.0 ± 199.0 (median: 25.5)} weeks, followed by neurotic illness {22.89 ± 73.45 (median: 2)} and psychotic illness {10.54 ± 18.28 (median: 2)} weeks. Overall, most patients with severe mental illnesses (SMIs) had their first contact with faithhealers (49%), then met with medical doctors (13%) or psychiatrists (28%). Marked differences in clinical presentation surfaced when hilly centers were compared with the Terai belt.

CONCLUSIONS

Faith healers, general practitioners and hospital doctors are major carers, and the means of educating them for proper referral can be considered. The investigators see several hindrances and opportunities in the studied pathways. The employment of more mental health professionals and better mental health advocacy, public awareness programs and school education are suggested strategies to improve proper mental health care.