One year prevalence of psychotic disorders among first treatment contact patients at the National Psychiatric Referral and Teaching Hospital in Uganda

Factor structure of psychosis screening questionnaire in Ugandan adults

BACKGROUND

Psychotic disorders are common and contribute significantly to morbidity and mortality of people with psychiatric diseases. Therefore, early screening and detection may facilitate early intervention and reduce adverse outcomes. Screening tools that lay persons can administer are particularly beneficial in low resource settings. However, there is limited research evaluating the validity of psychosis screening instruments in Uganda. We aimed to assess the construct validity and psychometric properties of the Psychosis Screening Questionnaire (PSQ) in Uganda in a population with no history of a psychotic disorder.

METHODS

The sample consisted of 2101 Ugandan adults participating as controls in a larger multi-country case-control study on psychiatric genetics who were recruited between February 2018 and March 2020. Participants were individuals seeking outpatient general medical care, caretakers of individuals seeking care, and staff or students recruited from five medical facilities that were age 18 years or older and able to provide consent. Individuals were excluded who had acute levels of alcohol or substance use, including being under inpatient hospitalization or acute medical care for one of these conditions. We used confirmatory factor analysis (CFA) and item response theory (IRT) to evaluate the factor structure and item properties of the PSQ.

RESULTS

The overall prevalence screening positive for psychotic symptoms was 13.9% 95% CI (12.4,15.4). "Strange experiences" were the most endorsed symptoms 6.6% 95% CI (5.6,7.8). A unidimensional model seemed to be a good model or well-fitting based on fit indices including the root mean square error of approximation (RMSEA of 0.00), comparative fit index (CFI of 1.000), and Tucker-Lewis Index (TLI of 1.000). The most discriminating items along the latent construct of psychosis were items assessing thought disturbance followed by items assessing paranoia, with a parameter (discrimination) value of 2.53 and 2.40, respectively.

CONCLUSION

The PSQ works well in Uganda as an initial screening tool for moderate to high-level of psychotic symptoms.

Longitudinal study of the course and outcome of first-episode psychosis

Background

Study of first episode psychosis (FEP), an episode of psychotic nature, which manifests for the first time in an individual in the longitudinal continuum of his/her illness, has been a matter of research interest in recent years, as this may give more insight to the overall phenomenology and course of psychotic illnesses.

Methods

A study was undertaken to evaluate course and outcome of first episode psychosis. A total of 100 consecutive inpatients were selected for the study. Informed consent was obtained. Structured Proforma was used for recording psychosocial profiles and relevant medical history. Brief Psychiatric Rating Scale (BPRS) was given to assess the severity of psychopathology; Positive and Negative Symptom Scale (PANSS) to assess the severity of psychosis; Becks Suicidal Ideation Scale (BSI) to assess the extent of suicidality and Global Assessment of Functioning (GAF) to assess global functioning of the individual. The assessment was done at baseline, at six months, and at one year.

Results

First episode psychosis constituted around a tenth of the caseload. It commonly affected people in the third decade of life. There was an improvement in 92% of the cases over a year of study. Schizophrenia constituted the majority of first episode psychosis. The history of smoking was relatively higher in acute and transient psychotic disorders. Age inversely correlated with the severity of psychopathology. There was no difference in improvement in psychopathology over time in patients of schizophrenia and related disorder vis--vis other psychotic disorders.

Conclusion

Our study did not find any significantly varied sociodemographic factors in the course and outcome of the illness. It also refuted the schism between various types of psychosis based on the current classificatory system. It draws our attention toward the unitary concept of psychosis and is a call to re-think our strategies in the management of psychosis.

Reprioritising global mental health: psychoses in sub-Saharan Africa

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Exhaustive in silico design and screening of novel antipsychotic compounds with improved pharmacodynamics and blood-brain barrier permeation properties

Antipsychotic drugs or neuroleptics are widely used in the treatment of psychosis as a manifestation of schizophrenia and bipolar disorder. However, their effectiveness largely depends on the blood-brain barrier (BBB) permeation (pharmacokinetics) and drug-receptor pharmacodynamics. Therefore, in this study, we developed and implemented the in silico pipeline to design novel compounds (n = 260) as leads using the standard drug scaffolds with improved PK/PD properties from the standard scaffolds. As a result, the best candidates (n = 3) were evaluated in molecular docking to interact with serotonin and dopamine receptors. Finally, haloperidol (HAL) derivative (1-(4-fluorophenyl)-4-(4-hydroxy-4-{4-[(2-phenyl-1,3-thiazol-4-yl)methyl]phenyl}piperidin-1-yl)butan-1-one) was identified as a "magic shotgun" lead compound with better affinity to the 5-HT2A, 5-HT1D, D2, D3, and 5-HT1B receptors than the control molecule. Additionally, this hit substance was predicted to possess similar BBB permeation properties and much lower toxicological profiles in comparison to HAL. Overall, the proposed rational drug design platform for novel antipsychotic drugs based on the BBB permeation and receptor binding might be an invaluable asset for a medicinal chemist or translational pharmacologist.Communicated by Ramaswamy H. Sarma.

Construct Validity of the Psychosis Screening Questionnaire in Ugandan Adults

Background

Psychotic disorders are common and contribute significantly to morbidity and mortality of people with psychiatric diseases. Therefore, early screening and detection may facilitate early intervention and reduce adverse outcomes. Screening tools that lay persons can administer are particularly beneficial in low resource settings. However, there is limited research evaluating the validity of psychosis screening instruments in Uganda. We aimed to assess the construct validity and psychometric properties of the Psychosis Screening Questionnaire (PSQ) in Uganda in a population with no history of a psychotic disorder.

Methods

The sample consisted of 2101 Ugandan adults participating as controls in a larger multi-country case-control study on psychiatric genetics. We used confirmatory factor analysis (CFA) and item response theory (IRT) to evaluate the factor structure and item properties of the PSQ.

Results

The overall prevalence screening positive for psychotic symptoms was 13.9%. "Strange experiences" were the most endorsed symptoms (6.6%). A unidimensional factor was the best fitting model based on the fit indices including the root mean square error of approximation (RMSEA of 0.00), comparative fit index (CFI of 1.000), and Tucker-Lewis Index (TLI of 1.000). The most discriminating items along the latent construct of psychosis were items assessing thought disturbance followed by items assessing paranoia, with a parameter (discrimination) value of 2.53 and 2.40, respectively.

Conclusion

The PSQ works well in Uganda as an initial screening tool for moderate to high-level of psychotic symptoms.

Evaluating construct and criterion validity of NeuroScreen in assessing neurocognition among hospitalized Ugandan first-episode psychosis patients

Introduction

Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda.

Methods

We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion.

Results

There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively.

Conclusion

There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended.

The association of cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients: a cross sectional study

Introduction

Cognitive impairment is common in first-episode psychosis patients and often associated with poor quality of life and functional impairment. However, most literature on this association is from high income countries and not low resource countries like Uganda. We aimed to determine the association between cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients.

Methods

At Butabika national psychiatric hospital of Uganda, we enrolled 94 first-episode psychosis patients aged 18–60 years with a confirmed first-episode of psychosis and no previous treatment with antipsychotic medication. Neuropsychological assessment was performed using the MATRICS consensus cognitive battery (MCCB). Quality of life and functional impairment were assessed using the brief version of the World Health Organisation Quality of Life scale (WHOQOL-BREF) and the MINI International Neuropsychiatric Inventory (MINI) respectively. Linear regression analyses determined the association between impairment in different cognitive domains with various quality of life and functional impairment domains while controlling for age, gender and level of education.

Results

High scores in the reasoning and problem solving cognitive domain were associated with better quality of life in the psychological domain of WHOQOL-BREF (p = 0.029). For functional impairment, high cognitive scores in the domains of speed of processing (p = 0.018), reasoning and problem solving (p = 0.015), working memory (p = 0.017) and visual learning and memory (p = 0.002) were associated with psychosis “having a greater impact on other members of the family” on the MINI. Higher scores in the social cognition domain were associated with “less aggressive and disruptive behaviour” (p = 0.003).

Conclusion

Cognitive impairment in Ugandan first-episode psychotic patients is associated with both poorer quality of life and functional impairment. Remediation of cognitive function may be a plausible intervention to improve outcomes in Ugandan first-episode psychosis patients.

Feasibility of conducting a pilot randomized control trial of a psycho-education intervention in patients with a first episode psychosis in Uganda—A study protocol

Background

Psychotic disorders contribute to significant morbidity and mortality partly due to the chronicity of the illness and high relapse rates. Delivering psycho-education messages about disease etiology, their signs and symptoms and the benefits of treatment adherence have been shown to improve clinical outcomes among individuals with psychoses. However, little has been done to examine the feasibility and efficacy of this intervention in low resourced settings.

Objective

Our primary objective will be to determine the feasibility of recruiting and retaining patients with a first episode psychosis (FEP) and for the secondary objective, we will determine the preliminary efficacy of psycho-education on illness self-management, stigma, adherence to medications and symptom severity.

Hypothesis

We hypothesize that (i) we will recruit 70% of eligible participants and accrue a sample size of 80 over 20-weeks, retaining 80% of the sample size for 24 weeks, (ii) the intervention will lead to improvement in clinical outcomes (described above).

Methods

We will recruit 80 adult patients who have been diagnosed with a FEP, received antipsychotic medication at Butabika Hospital and reside within 21km from the Hospital. Trained village health team (VHTs) members will deliver 6 psycho-education sessions to 40 participants and their family members (intervention arm). Participants in the control arm (n = 40) will receive routine care. We will document how feasible it will be to recruit and retain participants over 24 weeks and document the preliminary efficacy of the intervention on illness self-management, stigma, adherence to medications and severity of symptoms.

Data analysis

We will document the proportion of participants who consent and get recruited, the proportion of those who will get retained and reasons for drop out. We will conduct an intention to treat analysis comparing the groups at weeks 4, 12, 24 and assess the effect of the intervention on the clinical outcomes (described above). We will use the Bonferroni approach to correct for multiple comparisons.

Trial registration

Clinical trials.gov registration number: NCT 04602585.

Prevalence, profile and associations of cognitive impairment in Ugandan first-episode psychosis patients

Introduction

The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients.

Methods

Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education.

Results

Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p < 0.001) and visual learning and memory (p = 0.001). Cassava-rich diets and previous alternative and complementary therapy use were negatively associated with impairment in the visual learning (p = 0.04) and attention/vigilance domains (p = 0.012), respectively. There were no significant associations between sex, history of childhood trauma, or illness severity with any cognitive domain.

Conclusion

A significant burden of cognitive impairment in Ugandan first-episode psychosis patients is consistent with prior data from other contexts. However, the profile of and risk factors for impairment differ from that described in such work. Therefore, interventions to reduce cognitive impairment in FEP patients specific to this setting, including dietary modifications, are required.

Qualitative study of mental health attribution, perceptions and care-seeking in Kampala, Uganda

Background

Mental health problems contribute to a substantial proportion of the global burden of disease. In Uganda, the World Health Organization estimates that 2.2 million people are affected by mental health disorders. Further research is needed to highlight people’s views about mental health in order to ensure that services are appropriate, accessible and effective.

Aim

This qualitative study aimed to explore perceptions, experiences and care-seeking preferences to inform stakeholders looking to provide contextually appropriate mental health programmes.

Setting

A diverse neighbourhood in central Kampala, Uganda.

Methods

The authors conducted 56 in-depth semi-structured interviews with people over the age of 37 years from November 2018 to May 2019.

Results

Participants discussed interpersonal and systemic issues that affect mental health in their community and the existing coping mechanisms that people employ. Social factors were often associated with mental health problems, with 36% of participants attributing them to economic stressors in particular. Mental health services were often perceived to be unavailable, costly or stigmatised, which can mean that care-seeking is delayed until problems become severe. Some people said they prefer to turn to prayer (25%) or counselling within their family or community (12.5%).

Conclusion

Mental health problems are often attributed to socioeconomic factors, which can also hinder access to services. An understanding of perceptions about mental health can help to align programmes for appropriateness and effectiveness. Our study suggests that beneficial additional services for people living in low-income urban settings in Uganda could include those which are free, community-based or offering financial support.

Comparison of antipsychotic naïve first-episode psychosis patients and healthy controls in Uganda

INTRODUCTION

The risk factors for a first episode of psychosis in low and middle-income countries (LMICs) are not well described. The study compared the association of different risk factors in patients with first-episode psychosis patients and healthy controls from an LMIC context.

METHODS

A comparative, descriptive, cross-sectional study was performed in antipsychotic naïve first-episode psychosis patients and healthy controls at the National referral hospital in Uganda. Standardized tools were used to assess sociodemographic (e.g., age, sex, socioeconomic status) and clinical (e.g., childhood trauma, quality of life) variables. First episode psychosis participants were compared to healthy controls in terms of sociodemographic and clinical variables, and logistic regression was used to determine predictors of FEP.

RESULTS

Our final sample included 198 antipsychotic naïve first-episode psychosis participants and 82 controls. Most participants were female (68.5%) with a mean age of 29.4 years. After adjusting for age and sex, FEP patients when compared to controls were less likely to be female [AOR 0.18 (95%CI 0.03-0.85; p = .031)], more likely to have experienced emotional abuse [AOR 1.30 (95%CI 1.02-1.65; p = .032)] and more likely to have a poor quality of life [AOR 0.93 (95%CI 0.89-0.97; p = .002)].

DISCUSSION

The risk factors for a first episode of psychosis in this low and middle-income population were like those described in high-income countries. Further studies on interventions to prevent the transition to psychotic disorders in this sub-groups of patients are recommended. Also, the use of specialized early intervention services in improving the quality of life needs to be evaluated.

Quality of individual and group level interventions for first-episode psychosis at the tertiary psychiatric hospital in Uganda

Background

Individual and group level interventions have the largest effect on outcomes in patients with the first episode of psychosis. The quality of these individual and group level interventions provided to first-episode psychosis patients in Uganda is unclear.

Aim

To determine the quality of the individual and group level interventions provided to first episode psychosis patients in Uganda

Setting

The study was performed at the only tertiary psychiatric hospital in Uganda.

Methods

A retrospective chart review of recently discharged adult in-patients with the first episode of psychosis was performed. The proportion of participants who received different essential components for individual and group level interventions were calculated. From the different proportions, the quality of the services across the individual and group interventions was determined using the first-episode psychosis services fidelity scale (FEPS-FS). The FEPS-FS assigns a grade of 1–5 on a Likert scale depending on the proportion of patients who received the different components of the intervention. Twelve essential components across the individual and group interventions were assessed and their quality quantified.

Results

The final sample included 156 first-episode psychosis patients. The median age was 27 years (inter-quartile range [IQR] [24–36]) and 55% of the participants were female. All 12 essential components had poor quality with the range of scores on the FEPS-FS between one and three. Only one essential component assessed (use of single antipsychotics) had moderate quality.

Conclusion

Amongst current services at the Butabika National Referral Mental Hospital in Uganda, the essential components for individual and group level interventions for psychotic disorders are of poor quality. Further studies are required on how the quality of these interventions can be improved.