The impact of untreated psychosis in low and middle income (LAMI) countries and a paradigm for early intervention
Year: 2012
Type: dissertation
Abstract: ABSTRACT \nThis thesis is based on 13 papers published in peer reviewed journals. These include studies \non epidemiology and treatment of major psychotic disorders, and metanalysis of studies on \nDuration of Untreated Psychosis (DUP) and its relationship with the Gross Domestic \nProduct and the outcome in Low and Middle Income (LAMI) countries. Based on this \nresearch that highlighted the extent and impact of untreated psychosis, a series of papers \npresented a novel approach for early intervention in psychosis in LAMI countries. The final \npaper presents the randomised controlled trial evaluating this approach. \nSeven publications on puerperal psychosis, homicide by patients suffering from \nSchizophrenia, and the impact of cannabis use on symptomatology and course of \nschizophrenia highlighted significant gaps in the care of schizophrenia in developing \ncountries. Only 12 patients (24%), charged with homicide had received some form of \ntreatment before the index crime, despite the fact that duration of illness was more than 5 \nyears in most cases. In a clinical sample of 35 patients suffering from acute episode of \nPuerperal psychosis the mean time between the onset of symptoms and receiving \npsychiatric care was almost a month. Two third of mothers suffering from Puerperal \npsychosis could not breast feed, most showing almost total lack of concern for the baby and \nalso other behavior which could result in harm to baby. The publications on Puerperal \npsychosis argued that prevention of the disorder should be feasible in developing countries \nin view of high incidence of the disorder following an identifiable life event (childbirth) \nand the fact that most of the risk factors could be screened in the antenatal period. \nA paper published in British Journal of Psychiatry estimated the Duration of Untreated \nPsychosis (DUP) and its impact on the outcome of psychosis. Based on metanalysis of 98 \nstudies (23 from LAMI countries and 75 were from high-income countries) the DUP of \nLAMI countries (125 weeks) was twice as long as the DUP in high-income countries (63 \nweeks, p=0.012). The relationship between DUP and the gross domestic product (GDP) \npurchasing power parity was also examined using the data from International Monetary \nvii \nFund (IMF) and the World Bank. There was a strong negative correlation between DUP \nand GDP ppp, indicating that for every thousand dollars of additional GDP (purchasing \npower parity), mean DUP was reduced by 8 weeks and median DUP was reduced by 5 \nweeks. \nA study published in Schizophrenia Research examined the association between DUP and \nat least one of the following outcome measures; psychotic symptoms, cognitive function, \nsocial disability or mortality. Patients with a longer DUP had a smaller reduction in \nsymptom scores after treatment when compared to patients with shorter DUP. The pooled \nestimate indicated that longer DUP was negatively associated with the degree of reduction \nin symptom scores (random effects Meta analysis; r=−0.290, 95% CI=−0.483 to−0.069, \nz=−2.559, P < 0.011) and longer DUP was associated with greater level of disability (fixed \neffects Meta analysis; r=0.195, 95% CI=0.126 to 0.262, z=5.498, p<0.000; heterogeneity \nQ-value 1.245, p=NS, I2=0.00). \nThese studies clearly established the case for Early Intervention in psychosis. However, an \nentirely different approach was needed for this in resource poor settings. This approach is \ndescribed in three papers. This approach termed as ‘Supervised Treatment of Outpatient \nSchizophrenia’ (STOPS) was evaluated in a Randomized Controlled Trial. The paper \ndescribing this RCT which provided proof of the concept will soon be published by British \nJournal of Psychiatry. In this RCT, fifty five patients were recruited in each arm. Ninety \nfive (86.36%) patients completed the study; 49 in STOPS and 46 in Treatment As Usual \n(TAU) group. At one year follow up, 37 (67.3%) patients in STOPS group had complete \nadherence with medication compared to 25 (45.5%) in the TAU group (P<.02). The \npatients in STOPS group also showed more improvement in symptoms (P=0.003) and \nfunctioning (P<0.011).
Author: Saeed Farooq
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W762842446