Non-pharmacological interventions for schizophrenia—analysis of treatment guidelines and implementation in 12 Southeast European countries

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries—Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia—included non-pharmacological interventions. The remaining three countries—Kosovo (UN Resolution), Romania, and Slovenia—have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5–11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey

BACKGROUND

Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE).

OBJECTIVE

To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE.

METHODS

An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo^†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers.

RESULTS

In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia.

CONCLUSION

Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study

BACKGROUND

Implementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources.

METHODS

Thirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants' accounts.

RESULTS

Six major themes were identified. Three themes (Intervention characteristics; Carers' involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention's implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists' time constrains.

CONCLUSIONS

This study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe - a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Trends in suicide mortality in Montenegro from 2000 to 2018

BACKGROUND

This is an ecological study that analyzes suicides committed in Montenegro during the 2000-2018 period, taking into account gender, age and methods of suicide.

METHODS

Suicide rates and trends up until 2009 were obtained from the official registers of Bureau of Statistics of Montenegro (MONSTAT) while the later data were obtained from the Department of Interior's. MONSTAT also provided data on unemployment and average salary. As per statistical methods, descriptive and correlations were calculated.

RESULTS

The average crude suicide rate was 21.06, for males 29.93 and for females 12.42. Crude suicide rates were not associated with unemployment rate or average salary. However, the unemployment rate was significantly correlated with lethal methods of suicide, namely suicide by firearm and by hanging. Average net salary was negatively correlated with suicide by firearm.

CONCLUSIONS

The ratio of males and females who committed suicide was 2.41. In the last three years, this ratio continues to rise in favor of males (reaching 4.29 in 2018). This could be explained by specific cultural features where males are expected to be the main financial contributors to the households. The labor market of Montenegro does not offer adequate opportunities to set and maintain a stable economic situation which puts additional pressure and stress on males.

Gender differences in relation to suicides committed in the capital of Montenegro (Podgorica) in the period 2000-2006

BACKGROUND

The purpose of the study was to research gender differences in suicides committed in Podgorica between 2000 and 2006, including sociodemographic variables (e.g. age, marital status, education etc.), methods of and motives for committing suicide. Data were taken from the Police Directorate of Montenegro.

SUBJECTS AND METHODS

We used data on 220 males and 83 females who committed suicide. Statistical analysis was done by using the crude specific rate. Significance between two independent crude rates is constructed around their 95% confidence intervals and it utilizes the difference between the two rates (D) to determine significance.

RESULTS

The incidence of suicide in males was found to be higher than in females (the male to female suicide ratio is 2.6 to 1). Females were older than males. Females had completed elementary education more frequently , and they were single or divorced or widows. Males had completed secondary education more frequently and they were married. The most frequent employment status of both gender groups implied pensioner and unemployment statuses. There was a significant difference in suicide rates between the genders during the reporting period. Suicide rates increase with age in both genders. Males chose firearms, hanging, strangulation and suffocation and jumping. Females chose hanging, strangulation and suffocation, jumping and drowning as the most frequent methods of suicide. The most frequent motive for suicide in both gender groups was physical illness. The second most frequent motive was mental illness. Emotional and financial difficulties were motives which were more common in males, whereas family problems appeared to be motives two times more frequent in females.

CONCLUSIONS

The complex multifactorial etiology of suicide suggests the need to consider gender differences when developing effective strategies for the therapy and the prevention of suicide.