Addition of home-based cognitive retraining to treatment as usual in first episode schizophrenia patients: a randomized controlled study

Pilot study to test the feasibility and clinical efficacy of a psychosocial care programme for patients with psychosis in low-resource settings

BACKGROUND

Home-based psychosocial care has the potential to improving outcomes in patients with schizophrenia and related disorders (SCZ). There is lack of India data for such care in early psychosis. We developed the "Saksham" programme, a bespoke self-managed home-based psychosocial care model, available in two formats: manual-based and mobile-application based. With the anticipated success of recruitment of early psychosis cases in our setting, we plan to test the such intervention in this population in future trials.

AIM

To assess the feasibility of the Saksham programme intervention in people with SCZ and its clinical efficacy as an adjunct to treatment as usual.

METHODS

Seventy-five patient-caregiver pairs (total n=150) were recruited. Patients received either: treatment-as-usual (TAU) (n=25), manual-based Saksham intervention+TAU (n=25), or app-based Saksham intervention+TAU (n=25). Feasibility (i.e. acceptability, practicality, demand, implementation and integration) was assessed at three-months. Participants were assessed for psychopathology, illness-severity, cognition, functioning, disability, and caregiver-coping at baseline, one-month, and three-month. The percentage changes over time were compared across three groups.

RESULTS

More found the mobile application-based intervention acceptable and easy-to-use than the manual-based intervention (92 % vs 68 %, and 76 % vs 68 %, respectively). Psychopathology and caregiver-burden improved significantly in all three groups (p<0.05). Cognition, disability, functioning, and caregiver burden improved significantly in the two Saksham intervention groups, with greater improvement in the Saksham app group (p<0.05).

CONCLUSION

Home-based intervention is feasible and acceptable in a low-resource setting, with preliminary evidence for effectiveness. These findings need corroboration with randomised controlled trials in early psychosis to ameliorate course of illness.

Development and validation of home-based psychosocial self-management interventions in schizophrenia and related disorders in low-resource settings: A mixed methods approach

Background

Psychosocial interventions, crucial for recovery in patients with schizophrenia, have often been developed and tested in high income countries. We aimed at developing and validating home-based a booklet based psycho-social intervention with inputs from stakeholders: patients, families, and mental health professionals (MHP) for patients with schizophrenia and related disorders in low resource settings.

Methods

We developed a preliminary version of psychosocial intervention booklets based on six themes derived from focus group discussions conducted with patients, families, and MHP. Initially, quantitative assessment of content validity was done by MHP on overall and Content Validity Index of individual items of the specific booklets, followed by in-depth interviews about their views. The booklets were modified based on their inputs. Further, pilot testing of manuals was done on the users - nine pairs of patients and caregivers followed by development of a final version of psycho-social intervention.

Results

The percentage content validity of individual modules and overall booklets was ≥78.5% indicating good validity. Most MHP reported that the manuals were relevant and easy to use but were text-heavy, and lengthy. On pilot testing of modified manuals with patients and their family caregivers, majority (77.8%) of them found booklets useful and suggested that there should be separate booklets for both patients and caregivers for providing information and entering separate response for the activities, integrating helpful tips. Language should be simple. Finally, two sets of booklets ("info book" and "workbook") named 'Saksham' (meaning empowered) were created with specific modules (viz., 'Medicine adherence', 'Daily routine', 'Eating right', 'Physical activity', 'Physical health monitoring', 'Self-reliance', and 'Psychoeducation') for patients and caregivers each, in two languages (Hindi and English).

Conclusion

Booklets with modules for psychosocial interventions for patients with schizophrenia and their caregivers were developed after establishing content validity and pilot testing.

Cognitive Training in Obsessive-Compulsive Disorder: A Systematic Review

Background

Cognitive training (CT) for illness-linked neuropsychological deficits has been attempted in psychiatric disorders and, more recently, in obsessive-compulsive disorder (OCD). However, studies are few and far between, with a limited understanding of factors contributing to efficacy. This article aims to provide a comprehensive critical review of studies employing CT in OCD.

Methods

This systematic review follows the Preferred Reporting of Items for Systematic Review and Meta-Analyses Protocols. Empirical studies that used any form of CT/remediation in individuals with OCD were included.

Results

Eight articles met the criteria for inclusion, of which five were randomized controlled trials, two were case series, and one was an open-label trial. The studies have predominantly demonstrated improved trained cognitive functions, with only two showing generalization to untrained domains like clinical symptoms and socio-occupational functioning.

Conclusion

There are few controlled trials of CT in OCD, which limits conclusions of efficacy. Given the sparse research in the area, the review summarizes the current status of research and examines important methodological considerations that may inform future studies.

A systematic review of the effectiveness and implementation readiness of psychosocial interventions for psychosis in South Asia

BACKGROUND

Little is known about the effectiveness and implementation of psychosocial interventions for psychosis in low- and middle-income countries (LMICs). In South Asia, specialist psychiatric resources are scarce. Support for psychosis often falls on the family or caregiver which can increase feelings of burden, impact caregivers' wellbeing, and increase mental health stigma. Psychosocial interventions are increasingly used for psychosis in South Asia and could reduce relapse and symptoms, reduce caregiver burden, conserve cost and resources. The aim of this review was to appraise the effectiveness and implementation readiness of psychosocial interventions for people with psychosis in South Asia.

METHOD

A systematic search was conducted on MEDLINE, PsycINFO, Global Health, and Web of Science. The review was prospectively registered on PROSPERO (CRD42022329254). Studies were rated on two scales assessing quality and implementation readiness.

RESULTS

Twenty-six papers were included, nine intervention-types including community-based interventions/assertive outreach; CaCBTp; FAP; psychoeducation; cognitive retraining/rehabilitation; social cognition/skills; family/ caregiver intervention; telehealth intervention; yoga-based intervention in six South Asian countries. Findings suggest a multicomponent community-based intervention (MCBI) was the most implementation ready due to its standardisation, good clinical outcomes for patients and caregivers, and training and cost evaluations.

CONCLUSION

Of the included studies, MCBI and community-based outreach interventions utilising lay health workers appear to be the most implementation ready and are suggested to best address the treatment gap in South Asia.

Effect of cognitive retraining treatment in mild to moderate depressive disorders

Background

Cognitive retraining or remediation approaches dispense high levels of stimulation and new learning tasks, leading to an increased neural connections, which facilitate rapid recovery in patients with neurological as well as psychiatric conditions.

Objectives

The current study aimed to investigate the effect of cognitive retraining (CR) in depressive disorders. We assigned 40 patients with mild to moderate depression to two sample groups, with 20 participants each: CR alone and CR with medicine. A 6-week CR module was delivered, and participants’ scores on measures such as the Beck Depression Inventory-II, Metacognition Questionnaire 30, World Health Organization Quality of Life- Brief, and Global Assessment of Functioning were compared.

Results

Analysis using Stata/IC version 16 included descriptive statistics, paired and independent t-tests, analysis of covariance, and propensity score matching. Cohen's d was computed to determine the effect size. Within-group analysis revealed statistically significant differences in pre-post scores of the outcome measures (p  < .05) and large effect size (d  = 3.41; d  = 3.60) in both groups. The difference in scores of outcome measures between the groups was not significant (p  > .05) even when covariates were controlled, or nearest neighbor match analysis was carried out. CR is effective in alleviating symptoms and dysfunctional metacognitive beliefs in addition to enhancing functioning and quality of life.

Conclusions

CR-based interventions may be essential mental health services owing to growing research in psychotherapy via virtual modes such as tele- and video-conferencing. These interventions can substantiate both prevention and remedy.

Effectiveness of Community-Based Rehabilitation Interventions on Symptoms and Functioning for People with Schizophrenia: A Systematic Review and Meta-Analysis

Schizophrenia is a serious mental illness that imposes huge burden of illness on the society. We aimed to conduct a meta-analytic and systematic review of literature on the effectiveness of community-based rehabilitation interventions on symptoms and functioning for people with schizophrenia. The PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL databases were searched through April 16 and 17, 2021, including clinical trial registries and previous Cochrane reviews. We included 24 randomized controlled trials in this review. The content of interventions varied from single-faceted rehabilitation intervention or cognitive retraining, to multi-component rehabilitation interventions or case management. Among 20 studies that reported effects of community-based rehabilitation interventions on symptoms, the pooled SMDs across all interventions was 0.94 (95% CI = 0.11, 1.76; P < 0.001; I2 = 99.1%; n = 3694), representing a strong effect. 21 included studies showed that community-based rehabilitation interventions also had beneficial impacts on functioning (SMD = 1.65; 95% CI = 0.88, 2.43; P < 0.001; I2 = 98.9%; n = 3734). Overall quality of evidence was moderate with a high level of heterogeneity. Community-based rehabilitation interventions have positive effectiveness in improving patients' symptoms and functioning. Community-based rehabilitation interventions should therefore be provided as an adjuvant service in addition to facility-based care for people with schizophrenia.

Efficacy of Remotely Delivered Evidence-Based Psychosocial Treatments for Schizophrenia-Spectrum Disorders: A Series of Systematic Reviews and Meta-Analyses

BACKGROUND

Schizophrenia is among the most persistent and debilitating mental health conditions worldwide. The American Psychological Association (APA) has identified 10 psychosocial treatments with evidence for treating schizophrenia and these treatments are typically provided in person. However, in-person services can be challenging to access for people living in remote geographic locations. Remote treatment delivery is an important option to increase access to services; however, it is unclear whether evidence-based treatments for schizophrenia are similarly effective when delivered remotely.

STUDY DESIGN

The current study consists of a series of systematic reviews and meta-analyses examining the evidence-base for remote-delivery of each of the 10 APA evidence-based treatments for schizophrenia.

RESULTS

Of the 10 treatments examined, only cognitive remediation (CR), cognitive-behavioral therapy (CBT), and family psychoeducation had more than 2 studies examining their efficacy for remote delivery. Remote delivery of CBT produced moderate effects on symptoms (g = 0.43) and small effects on functioning (g = 0.26). Remote delivery of CR produced small-moderate effects on neurocognition (g = 0.35) and small effects on functioning (g = 0.21). There were insufficient studies of family psychoeducation with equivalent outcome measures to assess quantitatively, however, studies of remotely delivered family psychoeducation suggested that it is feasible, acceptable, and potentially effective.

CONCLUSIONS

Overall, the evidence-base for remotely delivered treatment for schizophrenia is limited. Studies to date suggest that remote adaptations may be effective; however, more rigorous trials are needed to assess efficacy and methods of remote delivery that are most effective.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Subjective cognitive complaints and its relation to objective cognitive performance, clinical profile, clinical insight, and social functioning in patients of schizophrenia: A cross-sectional study

CONTEXT

Neurocognitive deficits are well documented in schizophrenia. Neurocognitive insight (NI), described as awareness of neurocognitive deficits, has not been evaluated in the Indian context. Its relation to clinical profile and social functioning also remains unexplored.

AIMS

The aim of this study was to evaluate the subjective cognitive complaints (SCCs) and their relation to objective cognitive performance, clinical profile, clinical insight, and social functioning in patients of schizophrenia.

SETTINGS AND DESIGN

This was a cross-sectional study at the outpatient department of a tertiary care teaching hospital.

MATERIALS AND METHODS

One hundred individuals with schizophrenia were evaluated using Positive and Negative Syndrome Scale, Subjective Scale To Investigate Cognition in Schizophrenia, abbreviated version of Scale to Assess Unawareness in Mental Disorders, and Schizophrenia Research Foundation-Social Functioning Index. Cognitive performance was assessed using (1) Digit Span Test (attention) from Wechsler Adult Intelligence Scale, 3^rd edition and (2) Passages Test (explicit memory), (3) Verbal n-back Test (working memory), and (4) Stroop Test (executive functioning) from the National Institute of Mental Health and Neuro Sciences Battery.

STATISTICAL ANALYSIS

Statistical analysis was done using descriptive statistics, nonparametric tests, and Pearson's coefficient of correlation.

RESULTS

Participants showed impairment in all cognitive domains. Except for working memory, there was no correlation between SCC and objective performance for other cognitive domains correspondingly, implying poor NI. Severity of psychosis and clinical insight did not have any correlation with SCC. Higher SCC correlated with poorer social functioning, especially in "occupational" and "other social roles" domains.

CONCLUSIONS

Individuals with schizophrenia have poor NI. This is independent of severity of psychosis or clinical insight into illness. Socio-occupational functioning and depression should be actively enquired into when patients present with SCC.

Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low-and middle-income countries

Background

There are approximately 1 billion people in the world with some form of disability. This corresponds to approximately 15% of the world's population (World Report on Disability, 2011). The majority of people with disabilities (80%) live in low- and middle-income countries (LMICs), where disability has been shown to disproportionately affect the most disadvantaged sector of the population. Decision makers need to know what works, and what does not, to best invest limited resources aimed at improving the well-being of people with disabilities in LMICs. Systematic reviews and impact evaluations help answer this question. Improving the availability of existing evidence will help stakeholders to draw on current knowledge and to understand where new research investments can guide decision-making on appropriate use of resources. Evidence and gap maps (EGMs) contribute by showing what evidence there is, and supporting the prioritization of global evidence synthesis needs and primary data collection.

Objectives

The aim of this EGM is to identify, map and describe existing evidence of effectiveness studies and highlight gaps in evidence base for people with disabilities in LMICs. The map helps identify priority evidence gaps for systematic reviews and impact evaluations.

Methods

The EGM included impact evaluation and systematic reviews assessing the effect of interventions for people with disabilities and their families/carers. These interventions were categorized across the five components of community-based rehabilitation matrix; health, education, livelihood, social and empowerment. Included studies looked at outcomes such as, health, education, livelihoods, social inclusion and empowerment, and were published for LMICs from 2000 onwards until January 2018. The searches were conducted between February and March 2018. The EGM is presented as a matrix in which the rows are intervention categories (e.g., health) and subcategories (e.g., rehabilitation) and the column outcome domains (e.g., health) and subdomains (e.g., immunization). Each cell lists the studies for that intervention for those outcomes, with links to the available studies. Included studies were therefore mapped according to intervention and outcomes assessed and additional filters as region, population and study design were also coded. Critical appraisal of included systematic review was done using A Measurement Tool to Assess Systematic Reviews' rating scale. We also quality-rated the impact evaluation using a quality assessment tool based on various approaches to risk of bias assessment.

Results

The map includes 166 studies, of which 59 are systematic reviews and 107 impact evaluation. The included impact evaluation are predominantly quasiexperimental studies (47%). The numbers of studies published each year have increased steadily from the year 2000, with the largest number published in 2017.The studies are unevenly distributed across intervention areas. Health is the most heavily populated area of the map. A total of 118 studies of the 166 studies concern health interventions. Education is next most heavily populated with 40 studies in the education intervention/outcome sector. There are relatively few studies for livelihoods and social, and virtually none for empowerment. The most frequent outcome measures are health-related, including mental health and cognitive development (n = 93), rehabilitation (n = 32), mortality and morbidity (n = 23) and health check-up (n = 15). Very few studies measured access to assistive devices, nutrition and immunization. Over half (n = 49) the impact evaluation come from upper-middle income countries. There are also geographic gaps, most notably for low income countries (n = 9) and lower-middle income countries (n = 34). There is a fair amount of evidence from South Asia (n = 73) and Sub-Saharan Africa (n = 51). There is a significant gap with respect to study quality, especially with respect to impact evaluation. There appears to be a gap between the framing of the research, which is mostly within the medical model and not using the social model of disability.

Conclusion

Investing in interventions to improve well-being of people with disabilities will be critical to achieving the 2030 agenda for sustainable development goals. The EGM summarized here provides a starting point for researchers, decision makers and programme managers to access the available research evidence on the effectiveness of interventions for people with disabilities in LMICs in order to guide policy and programme activity, and encourage a more strategic, policy-oriented approach to setting the future research agenda.

Perceptions of Community Involvement in the Peruvian Mental Health Reform Process Among Clinicians and Policy-Makers: A Qualitative Study

Background: The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation.

Methods: A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care.

Results: Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives.

Conclusion: Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.

Effectiveness of an Integrated Intervention Program for Alcoholism (IIPA) for enhancing self-regulation: Preliminary evidence

OBJECTIVE

Alcoholism could be a core problem of self-regulatory failure. Several neurocognitive theories have hypothesized hypo-functioning or dysfunction of reflective (executive) system and heightened functioning of reactive (impulsive) system in self-regulatory failure implicated in drug addiction. Similarly, stress and affect dysregulation may breakdown self-regulation. The present study aimed to develop an Integrated Intervention Program for Alcoholism (IIPA) to enhance self-regulation and to test its effectiveness in the treatment of alcoholism.

METHOD

Individuals with early onset alcoholism (n = 50) were recruited after getting written informed consent. The study used randomized case control design. The participants were matched on age (+/-1 year) and education (+/-1 year). The TAU group received usual treatment for alcoholism which included pharmacotherapy, 6 sessions/week yoga and 3 sessions/week group therapy on relapse prevention. The intervention group received IIPA for 18 days along with usual treatment (except yoga sessions). The IIPA included several cognitive remediation tasks and mind-body exercise (Qigong and Tai Chi Chuan). Both groups were assessed on executive function tests and affect regulation scale at pre and post-intervention. The subjects were also followed up for 6 months to compare the abstinence between groups.

RESULTS

Both groups were comparable at baseline. At post-intervention, the IIPA group showed a significant improvement compared to the TAU group on executive functioning and affect regulation. Follow-up results showed lower relapses in six months in the IIPA group.

CONCLUSION

Preliminary evidence showed that IIPA is effective in facilitating self-regulation. Further study may examine its utility and feasibility in other clinical conditions.

Caregiver assisted home-based cognitive remediation for individuals diagnosed with schizophrenia: A pilot study

Cognitive deficits in individuals diagnosed with schizophrenia are ubiquitous and, therefore, cognitive remediation is considered one of the prime targets of a comprehensive intervention program for schizophrenia. However, cognitive remediation is a resource consuming intervention and in lower and middle-income countries (LAMIC) such interventions are often neglected due to the resource constraints of the mental health services set-ups. Therefore, it is imperative to develop cognitive remediation programs that are less resource consuming for the mental health service delivery system. Keeping this in view, in the present pilot study, we tested the feasibility of a caregiver assisted home-based cognitive remediation program and compared its efficacy with a clinic-based cognitive remediation program. Findings show that it is feasible to conduct cognitive remediation program with the help of caregivers in patients' home settings and that the home-based cognitive remediation is as effective as the clinic-based cognitive remediation. The results of the study have been further discussed in the light of the practical implications, limitations and future research.

Diverse definitions of the early course of schizophrenia-a targeted literature review

Schizophrenia is a debilitating psychiatric disorder and patients experience significant comorbidity, especially cognitive and psychosocial deficits, already at the onset of disease. Previous research suggests that treatment during the earlier stages of disease reduces disease burden, and that a longer time of untreated psychosis has a negative impact on treatment outcomes. A targeted literature review was conducted to gain insight into the definitions currently used to describe patients with a recent diagnosis of schizophrenia in the early course of disease ('early' schizophrenia). A total of 483 relevant English-language publications of clinical guidelines and studies were identified for inclusion after searches of MEDLINE, MEDLINE In-Process, relevant clinical trial databases and Google for records published between January 2005 and October 2015. The extracted data revealed a wide variety of terminology and definitions used to describe patients with 'early' or 'recent-onset' schizophrenia, with no apparent consensus. The most commonly used criteria to define patients with early schizophrenia included experience of their first episode of schizophrenia or disease duration of less than 1, 2 or 5 years. These varied definitions likely result in substantial disparities of patient populations between studies and variable population heterogeneity. Better agreement on the definition of early schizophrenia could aid interpretation and comparison of studies in this patient population and consensus on definitions should allow for better identification and management of schizophrenia patients in the early course of their disease.

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.

The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies

Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.

Community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis

BACKGROUND

There is consensus that the treatment of schizophrenia should combine anti-psychotic medication and psychosocial interventions in order to address complex social, economic and health needs. It is recommended that family therapy or support; community-based rehabilitation; and/or self-help and support groups should be provided for people with schizophrenia in low and middle-income countries. The effectiveness of community-based psychosocial interventions in these settings is unclear.

METHODS

Studies evaluating community-based psychosocial interventions for people with schizophrenia were identified through database searching up to April 2016. Randomised controlled trials were included if they compared the intervention group with a control group receiving treatment as usual including medication. Only studies set in low and middle-income countries were included. Random effects meta-analyses were performed separately for each intervention type.

RESULTS

Eleven randomised controlled trials in five middle-income countries were identified, with a total of 1580 participants. The content of included interventions varied from single-faceted psychoeducational interventions, to multi-component rehabilitation-focused interventions, to case management interventions. A third of the included studies did not incorporate any community involvement in the intervention. The quality of evidence was often low. Amongst the seven studies that reported on symptom severity up to 18 months post intervention, the pooled standardised mean difference (SMD) across all intervention types was 0.95 (95% CI 0.28, 1.61; P 0.005; I 2 = 95%; n = 862), representing a strong effect. A strong effect on symptom severity remained after excluding two studies with a high risk of bias (SMD 0.80; 95% CI 0.07, 1.53; P 0.03; I 2 = 94%; n = 676). Community-based psychosocial interventions may also have beneficial impacts on functioning (SMD 1.12; 95% CI 0.25, 2.00; P 0.01; I 2 = 94%; n = 511) and reducing hospital readmissions (SMD 0.68; 95% CI 0.27, 1.09; P 0.001; I2 = 33%; n = 167).

CONCLUSION

The limited evidence from low and middle-income countries supports the feasibility and effectiveness of community-based psychosocial interventions for schizophrenia, even in the absence of community mobilisation. Community-based psychosocial interventions should therefore be provided in these settings as an adjuvant service in addition to facility-based care for people with schizophrenia.

A review of Indian research on cognitive remediation for schizophrenia

Cognitive deficits play a central role in recovery from Schizophrenia (SZ). Cognitive remediation (CR) is increasingly being examined to improve cognitive functions in SZ. It is becoming an inevitable component of treatment for this debilitating illness. This review article presents the current status of research on CR for SZ in India. In contrast to the numerous studies reported from across the globe, there are only five studies on CR for SZ published from India. Of the five, only two are randomized controlled trials, two are non-randomized studies and one is a series of case reports. With different strategies used for CR and a variety of tools and measurements as outcome measures, combined analysis of the data was not feasible. Improvement in cognitive functions and sustenance of the improvement observed at follow-up period ranging from 2 to 6 months duration was underscored by all the four studies. Indigenous methods such as home-based CR techniques and Yoga therapy as an adjunct CR technique have been researched upon. Established method of CR such as the Integrated Psychological Therapy (IPT) has been used with modifications made to suit the cultural scenario. Other treatment methods such as family therapy have been added along with CR for chronic patients. The limited number of research studies has tried to encompass various dimensions. However, there is a dire need for studies with larger sample size with stringent research methods. Culturally feasible CR technique and multi-centric studies with larger sample size can be the next way forward.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Cognitive remediation in schizophrenia-The view from India

The prevalence and disability due to Schizophrenia (SZ) in India is similar to other parts of the world. Cognitive impairments are also present in a large group of Indian persons with SZ. Interventions to address these impairments - termed cognitive remediation or cognitive retraining - are being tested all over the world. Indian research on remediation in schizophrenia has been eclectic and is reviewed here. Some investigators have focused mainly on symptom control and quality of life, as yoga could be a cost effective and culturally acceptable intervention for remediation and rehabilitation. Although participants were not exhaustively tested for improvement in cognitive function in the majority of such trials, published results are encouraging.

Feasibility and effectiveness of the Integrated Psychological Therapy (IPT) in patients with schizophrenia: a preliminary investigation from India

Functional outcome is an important index of recovery in patients with Schizophrenia (SZ). Several factors impact social functioning, including neurocognition. The Integrated Psychological Therapy (IPT) has been effective in improving social-functioning in SZ patients, but needs to be evaluated for its feasibility and impact in the Indian subcontinent. The study examined the effectiveness of the IPT on neurocognition and social functioning in patients with SZ. An open label design with baseline, post-intervention and 3-month follow-up assessments was adopted. Twenty nine clinically stable out-patients with schizophrenia/schizo-affective disorder (DSM IV-TR) providing written informed consent were recruited, of whom 23 completed the intervention. Patients were assessed on tests of neurocognition, social functioning and symptomatology. Following baseline assessment, patients received 16-20, 1h individual sessions of the IPT over 2.5-3 months. The structure and content of the IPT was modified to make it culturally appropriate for the Indian subcontinent. Therapy comprised of psycho education and the first four modules of the IPT. Repeated measures analysis of variance (RMANOVA) for the completers sample (N=23) indicated significant improvement in social-functioning, symptom severity and certain domains of neurocognition following the intervention. Large effect sizes of 1.21 and 1.01 were obtained for scores on Social and Occupational Functioning Scale (SOFS) and Groningen Social Disabilities Schedule (GSDS) respectively at 3-month follow-up. The IPT was effective in improving social-functioning and neurocognition in Indian patients with SZ. The study demonstrated the durability of these improvements.

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.

Cognitive deficits and its relation with psychopathology and global functioning in first episode schizophrenia

AIM

The aim was to examine the cognitive deficits profile in first episode schizophrenia patients as well as examine the correlation between cognitive deficits, psychopathology and global functioning. Better understanding of these various facets of this debilitating illness is imperative in planning treatment, thereby limiting decline in global functioning.

METHODS

Forty-nine schizophrenia patients with illness duration less than two years comprised the sample. A comprehensive battery of neuropsychological tests, the Positive and Negative Syndrome Scale and WHO Disability Assessment schedule were administered to assess cognitive functions, psychopathology and global functioning respectively.

RESULTS

Cognitive deficit quotient for each patient was calculated. In this cohort 16.3% of patients had less than 25% of cognitive deficits, 38.8% had 25-50% of cognitive deficits, 36.7% had 50-75% of cognitive deficits and 8.2% of patients had more than 75% cognitive deficits. More than 50% of the patients in the present cohort showed deficits in the domains of attention, executive functions and learning and memory. Psychopathology significantly correlated with global functioning. Negative symptoms significantly correlated with cognitive functions of motor speed, attention and executive functions. Step wise linear regression analysis showed that duration of illness, attention (sustained attention), executive function (response inhibition), negative and positive psychopathology predicted level of global functioning at varied levels.

CONCLUSIONS

Cognitive deficits in multiple domains were observed in the present cohort. Attention and executive functions predicted global functioning. There is a need for longitudinal studies with larger sample to examine the course of the cognitive deficits with progress in illness.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.

Psychoeducation for schizophrenia

BACKGROUND

Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis.

OBJECTIVES

To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (February 2010).

SELECTION CRITERIA

All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixed-effects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data.

MAIN RESULTS

This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ˜ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life.

AUTHORS' CONCLUSIONS

Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach.