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It is unknown whether patient disengagement from early intervention services for psychosis is as prevalent in low- and middle-income countries (LMICs) like India, as it is in high-income countries (HICs). Addressing this gap, we studied two first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized lower service disengagement among patients and higher engagement among families in Chennai, and that family engagement would mediate cross-site differences in patient disengagement.
Sites were compared on their 2-year patient disengagement and family engagement rates conducting time-to-event analyses and independent samples t tests on monthly contact data. Along with site and family involvement, Cox proportional hazards regression included known predictors of patient disengagement (e.g. gender).
The study included data about 333 patients (165 in Montreal, 168 in Chennai) and their family members (156 in Montreal, 168 in Chennai). More Montreal patients (19%) disengaged before 24 months than Chennai patients (1%), χ2(1, N = 333) = 28.87, p < 0.001. Chennai families had more contact with clinicians throughout treatment (Cohen's d = −1.28). Family contact significantly predicted patient disengagement in Montreal (HR = 0.87, 95% CI 0.81–0.93). Unlike in Chennai, family contact declined over time in Montreal, with clinicians perceiving such contact as not necessary (Cohen's d = 1.73).
This is the first investigation of early psychosis service engagement across a HIC and an LMIC. Patient and family engagement was strikingly higher in Chennai. Maintaining family contact may benefit patient engagement, irrespective of context. Findings also suggest that differential service utilization may underpin cross-cultural variations in psychosis outcomes.
Purported superior outcomes for treatment of psychosis in low- and middle-income (LMICs) compared with high-income (HICs) countries have not been examined in the context of early intervention services (EIS).
To compare 2-year clinical outcomes in first-episode psychosis (FEP) treated in EIS in Chennai (LMIC) and Montreal (HIC) using a similar EIS treatment protocol and to identify factors associated with any outcome differences.
Patients with FEP treated in EIS in Chennai (n = 168) and Montreal (n = 165) were compared on change in level of symptoms and rate and duration of positive and negative symptom remission over a 2-year period. Repeated-measures analysis of variance, and logistic and linear regression analyses were conducted.
Four patients died in Chennai compared with none in Montreal. Family support was higher for Chennai patients (F = 14.05, d.f. = 1, P < 0.001, ƞp2 = 0.061) and increased over time at both sites (F = 7.0, d.f. = 1.915, P < 0.001, ƞp2 = 0.03). Negative symptom outcomes were significantly better in Chennai for level of symptoms (time × site interaction F = 7.36, d.f. = 1.49, P = 0.002, ƞp2 = 0.03), duration of remission (mean 16.1 v. 9.78 months, t = −7.35, d.f. = 331, P < 0.001, Cohen's d = 0.80) and the proportion of patients in remission (81.5% v. 60.3%, χ2 = 16.12, d.f. = 1, P < 0.001). The site differences in outcome remained robust after adjusting for inter-site differences in other characteristics. Early remission and family support facilitated better outcome on negative symptoms. No significant differences were observed in positive symptom outcomes.
Patients with FEP treated in EIS in LMIC contexts are likely to show better outcome on negative symptoms compared with those in HIC contexts. Early remission and family support may benefit patients across both contexts.
This chapter discusses the results of the World Mental Health (WMH) surveys regarding the burden of mental disorders. The mental disorders were assessed with Composite International Diagnostic Interview (CIDI), a fully structured lay-administered interview designed to generate research diagnoses of commonly occurring mental disorders according to the definitions and criteria of both the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10) Diagnostic Criteria for Research (DCR) diagnostic systems. Generalized linear modeling (GLM) was used to assess the effects of mental disorders on continuous outcome variables with skewed distributions. The CIDI included retrospective disorder age-of-onset (AOO) reports based on a special question sequence that has been shown experimentally to improve recall accuracy. Mental disorders are important causes of productivity loss and low perceived health. They are among the most important disorders at both individual and societal levels.
Ellen Corin, Psychologist and Professor of Anthropology and Psychiatry, McGill University; Researcher, Psychosocial Research Division, Douglas Hospital Research Centre,
Rangaswami Thara, Director, Schizophrenia Research Foundation,
Ramachandran Padmavati, Clinical Psychiatrist and the Deputy Director, Schizophrenia Research Foundation, Madras (now Chennai), India
I was frightened without my knowledge … confusion only increased and I couldn't control it … the fear, only this fear, not anxiety, only some kind of fear …
The experience of psychosis is permeated by fear and confusion, radiating through the perceived world of suffering persons, infiltrating relationships with themselves and others. These feelings give to ordinary things an aura of strangeness and, to use Tellenbach's (1983) words, transform the “atmospheric quality” of the world. In the narratives of psychotic people, expressions of distress entwine and interlace to form the texture of a shifting world of agony. These aspects of the psychotic person's world cannot be neglected when considering the role of culture in psychosis; from such a frame emerge the questions and responses posed in this chapter.
An investigation of psychotic experience forces us to confront difficult ethical questions: How do we speak about others' suffering without redoubling the lived violence by an interpretive violence anchored in the position of the “well-informed” researcher? How do we find a language that may constitute or preserve the frightening dimension of that experience without succumbing to its fascination or objectifying it? Can we ever be justified in soliciting narratives and asking questions of people who are so deeply immersed in a world of suffering? The first two questions raise epistemological and methodological issues that will be explored in this chapter.
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