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Cognitive behaviour therapy (CBT), self-help and guided self-help interventions have been found to be efficacious and cost effective for victims of trauma, but there are limited data from low- and middle-income countries on culturally adapted interventions for trauma.
To investigate the feasibility and acceptability of culturally adapted trauma-focused CBT-based guided self-help (CatCBT GSH) for female victims of domestic violence in Pakistan.
This randomized controlled trial (RCT) recruited 50 participants from shelter homes in Karachi and randomized them to two equal groups. The intervention group received GSH in nine sessions over 12 weeks. The control group was a waitlist control. The primary outcomes were feasibility and acceptability. Secondary outcomes included Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHO DAS 2). Assessments were carried out at baseline and at 12 weeks.
Out of 60 clients who met DSM-5 criteria for post-traumatic stress disorder (PTSD), 56 (93.3%) agreed to participate in the study. Retention to the intervention group was excellent, with 92% (23/25) attending more than six sessions. Statistically significant differences were noted post-intervention in secondary outcomes in favour of the intervention.
A trial of CatCBT GSH was feasible and the intervention was acceptable to Pakistani women who had experienced domestic violence. Furthermore, it may be helpful in improving symptoms of PTSD, depression, anxiety and overall functioning in this population. The results provide a rationale for a larger, confirmatory RCT of CatCBT GSH.
With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up.
To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au).
We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores.
The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262–4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434–820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394–77 399) (US$517), compared with PKR 10 705 (95% CI 7731–15 627) (US$102.93) using a local supervisor.
The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.
The waiting room in psychiatric services can provide an ideal setting for offering evidence-based psychological interventions that can be delivered through electronic media. Currently, there is no intervention available that have been developed or tested in mental health.
This proof-of-concept study aimed to evaluate a pilot design of RESOLVE (Relaxation Exercise, SOLving problem and cognitiVe Errors) to test the procedure and obtain outcome data to inform future, definitive trials (trial registration at Clinicaltrials.gov NCT02536924, REB Number: PSIY-477-15).
Forty participants were enrolled and equally randomised to the intervention, RESOLVE plus treatment as usual arm (TAU), or to a control group (TAU only). Those in the intervention group watched RESOLVE in a room adjacent to the waiting area. Participants in the control received routine care. Outcome measures included the Hospital Anxiety and Depression Scale; the Clinical Outcomes in Routine Evaluations outcome measure; and the World Health Organization Disability Assessment Schedule. These measures were performed by a masked assessor at baseline and at 6-week follow-up. Additionally, we measured the number of contacts with mental health services during the prior 4 weeks. Both intention-to-treat and per protocol analyses were performed.
The study proved feasible. We were able to recruit the required number of participants. There was a statistically significant improvement in depression (P < 0.001), anxiety (P < 0.001), general psychopathology (P < 0.001) and disability (P = 0.0361) in favour of the intervention group. People in the intervention group were less likely to contact the service (P = 0.012) post-intervention.
Findings provide preliminary evidence that evidence-based psychosocial interventions can be delivered through electronic media in a waiting-room setting. The outcome data from this study will be used for future definitive trials.
To systematically review the literature on barriers to the use of clozapine and identify any interventions for optimizing clozapine use in treatment-resistant schizophrenia. Journal databases were searched from 1972 to March 2018. The following search terms were used: treatment-resistant schizophrenia, clozapine, barriers, use, prescription rates, implementation, clozaril and prescribing practices. Following a review of the literature, 15 papers were included in the review.
The major barriers that were identified included mandatory blood testing, fear of serious side-effects and lack of adherence by the patients, difficulty in identifying suitable patients, service fragmentation, and inadequate training in or exposure to using clozapine.
In view of consistent evidence across the studies on inadequate knowledge and skills as a significant barrier, we suggest that a certification requiring competence in initiating and managing side-effects of clozapine becomes a mandatory requirement in training programmes.
To review the literature to examine the factors that may be affecting recruitment into psychiatry in the UK. We systematically searched four databases to identify studies from 1974 to 2016 and identified 27 papers that met the specified inclusion criteria.
Most papers (n = 24) were based on questionnaire surveys. The population in all studies comprised of 1879 psychiatrists, 6733 students and 220746 trainees. About 4–7% of students opt for a career in psychiatry. Enrichment activities helped to attract students more towards psychiatry than just total time spent in the specialty. Job content in terms of the lack of scientific basis, poor prognosis and stigma towards psychiatry, work-related stress and problems with training jobs were common barriers highlighted among students and trainees, affecting recruitment. Job satisfaction and family-friendly status of psychiatry was rated highly by students, with lifestyle factors appearing to be important for trainees who tend to choose psychiatry.
Negative attitudes and stigma towards psychiatry continue to persist. Teaching and training in psychiatry needs rethinking to improve student experience and recruitment into the specialty.
To investigate whether medication adherence is monitored during follow-up in out-patient reviews. A retrospective audit was carried out with a sample of 50 follow-up patients with a diagnosis of schizophrenia or schizoaffective disorder. Following this, interventions were made prior to the re-audit (including text messaging clinicians and prompt sheets in the out-patient department to encourage adherence discussions).
There was an improvement on all the standards set for this audit following the interventions. More doctors had discussed medication adherence (62% second cycle v. 50% first cycle) with their patient and there was increased discussion and documentation regarding medication side-effects (60% second cycle v. 30% first cycle). More clinicians discussed the response to medication (60% second cycle v. 46% first cycle).
Treatment adherence is not regularly monitored or recorded in clinical notes in routine psychiatric out-patient appointments. This highlights the need for regular training to improve practice.
Smartphones are used by patients and clinicians alike. Vast numbers of software applications (apps) run on smartphones and carry out useful functions. Clinician- and patient-oriented mental health apps have been developed. In this article, we provide an overview of apps that are relevant for mental health. We look at clinician-oriented apps that support assessment, diagnosis and treatment as well as patient-oriented apps that support education and self-management. We conclude by looking at the challenges that apps pose with a discussion of possible solutions.
Background: Cognitive Behaviour Therapy (CBT) has an established evidence base and is recommended by the national organizations in United Kingdom and the United States. CBT remains under utilized in low and middle income countries. CBT was developed in the west and it has been suggested that it is underpinned by western values. It therefore follows that to make CBT accessible for non western clients, it needs adapting into a given culture. Aims: Our aim was to develop guidelines for adapting CBT for psychosis in Pakistan by incorporating the views of the patients, their carers and mental health professionals. Method: We conducted a series of qualitative studies in Pakistan to adapt CBT for psychosis (a total of 92 interviews). The data were analyzed by systematic content and question analysis. Analysis started by identifying emerging themes and categories. Themes emerging from the analyses of interviews by each interviewer were compared and contrasted with others interviewers constantly. Triangulation of themes and concepts was undertaken to further compare and contrast the data from the different participating groups. Results: The results of these studies highlighted the barriers in therapy as well as strengths while working with this patient group. Patients and their carers in Pakistan use a bio-psycho-spiritual-social model of illness. They seek help from various sources. Therapists make minor adjustments in therapy. Conclusions: The findings from this study will help therapists working with this client group using CBT for psychosis in Pakistan. These results need to be tested through controlled trials.
Early intervention in psychosis has significantly improved outcomes compared with standard treatment but it is considered as a luxury for low- and middle-income (LAMI) countries. However, a public health approach that is based on the principles of supplying all essential medication free of charge for at least the first 2 years of illness, medication being taken under supervision of a caregiver and treatment following a standardised treatment algorithm can prove a cost-effective early intervention model for LAMI countries.
Most people with schizophrenia in low- and middle-income (LAMI) countries receive minimal formal care, and there are high rates of non-adherence to medication.
To evaluate the effectiveness of an intervention that involves a family member in supervising medication administration – supervised treatment in out-patients for schizophrenia (STOPS) – in improving treatment adherence and clinical outcomes.
Individuals (n = 110) with schizophrenia or schizoaffective disorders were allocated to STOPS or to treatment as usual (TAU) and followed up for 1 year. The primary outcome was adherence to the treatment regimen. Positive and Negative Syndrome Scale for Schizophrenia and Global Assessment of Functioning scores were also assessed.
Participants in the STOPS group had better adherence (complete adherence: 37 (67.3%) in STOPS v. 25 (45.5%) in TAU; P<0.02) and significant improvement in symptoms and functioning.
STOPS may be useful in enhancing adherence to treatment for schizophrenia in LAMI countries.
Evidence concerning the superior efficacy and effectiveness of clozapine has not fully informed routine clinical practice. This is possibly because of the perception that clozapine is a dangerous therapeutic agent. Clozapine use may actually promote longevity, and earlier use of clozapine in adequate dosages represents a neglected therapeutic opportunity in this age of stagnated antipsychotic innovation.
Management issues in the cultural context
Saeed Farooq, Professor and Head of Department of Psychiatry, Post- Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan,
Chris Fear, Consultant General Psychiatrist, Gether Foundation NHS Trust, Gloucester, UK
Summary Language is the essential psychiatric tool for eliciting history and mental state. Both diagnosis and treatment are handicapped if there is no common language between doctor and patient and understanding is facilitated through a third party, who usually has no psychiatric training. Many factors can affect this process, resulting in a convoluted interview and greater potential for misunderstandings and diagnostic errors. Linguistics and the use of interpreters are rarely mentioned in standard psychiatric texts. The different processes of translation and interpretation and their use in psychiatry are explored here. The variety of errors and pitfalls described in the literature are considered. We offer advice on the use of trained and untrained interpreters to minimise errors and make the most of the information available.
In a language that we know we have substituted for the opacity of sounds the transparency of ideas. But a language that we do not know is a fortress sealed within whose walls the one we love is free to play false, while we, standing outside desperately keyed up in one impotence, can see, can prevent nothing.
Marcel Proust, quoted in Antinucci-Mark (1990)
Language is the principal investigative and therapeutic tool in psychiatry. Interference with communication impairs our ability to assess a patient comprehensively. Nowhere is this more apparent than in the situation where patient and professional are separated by a language barrier, creating a state of dependency on an interpreter, who holds the key to mutual understanding. In today's multiracial society, particularly in larger cities, it is not uncommon to encounter such a situation, where particular skills are required of both interpreter and doctor. Nevertheless, the study of linguistics in relation to psychiatry is rarely mentioned in psychiatric texts, where disorders of communication are often seen as a consequence of disordered attention and the important influences of social cognition and context are ignored (Thomas & Fraser, 1994). A survey of 1000 professionals working in different psychiatric services in Australia found that more than one-third reported having contact, at least on a weekly basis, with patients with whom effective communication was either limited or impossible because of language barriers (Minas et al, 1994).
The duration of untreated psychosis (DUP), the period between the first
onset of psychotic symptoms and treatment, has an important influence on
the outcome of schizophrenia.
To compare the published studies of DUP in low- and middle-income (LAMI)
countries with the DUP of high-income countries, and examine a possible
association between DUP and per capita income.
We used six search strategies to locate studies of the DUP from LAMI
countries published between January 1975 and January 2008. We then
examined the relationship between DUP and measures of economic activity,
which was assessed using the LAMI classification of countries and gross
domestic product (GDP) purchasing power parity.
The average mean DUP in studies from LAMI countries was 125.0 weeks
compared with 63.4 weeks in studies from high-income countries
(P=0.012). Within the studies from LAMI countries,
mean DUP fell by 6 weeks for every $1000 of GDP purchasing power
There appears to be an inverse relationship between income and DUP in
LAMI countries. The cost of treatment is an impediment to care and
subsidised antipsychotic medication would improve the access to treatment
and the outcome of psychotic illness in LAMI countries.