Scholarly works in Psychiatry
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Item Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial(Elsevier Ltd, 2020) Gureje, O.; Appiah-Poku, J.; Bello, T.; Kola, L.; Araya, R.; Chisholm, D.; Esan, O.B.; Harris, B.; Makanjuola, V.; Othieno, C.; Price, L.Background: Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW). Methods: In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269. Findings: Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107∙3 (SD 17∙5) for the intervention group and 108∙9 (18∙3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53∙4 (19∙9) compared with 67∙6 (23∙3) for the control group (adjusted mean difference –15∙01 (95% CI –21∙17 to –8∙84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (–0∙48 [–0∙60 to –0∙37] (p<0.001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (–0·33 [–0∙45 to –0∙21] (p<0.001) with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6-month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects. Interpretation: A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resourcesItem Partnership for mental health development in Sub-Saharan Africa (PaM-D): a collaborative initiative for research and capacity building(Cambridge University Press & Assessment, 2019) Gureje, O.; Seedat, S.; Kola, L.; Appiah-Poku, J.; Othieno, C.; Harris, B.; Makanjuola, V.; Price, L.N.; Ayinde, O. O.; Esan, O. B.Aims In low and middleincome countries (LMIC) in general and sub-Saharan African (SSA) countries in particular, there is both a large treatment gap for mental disorders and a relative paucity of empirical evidence about how to fill this gap. This is more so for severe mental disorders, such as psychosis, which impose an additional vulnerability for human rights abuse on its sufferers. A major factor for the lack of evidence is the few numbers of active mental health (MH) researchers on the continent and the distance between the little evidence generated and the policymaking process. Methods: The Partnership for Mental Health Development in Africa (PaMD) aimed to bring together diverse MH stakeholders in SSA, working collaboratively with colleagues from the global north, to create an infrastructure to develop MH research capacity in SSA, advance global MH science by conducting innovative public health relevant MH research in the region and work to link research to policy development. Participating SSA countries were Ghana, Kenya, Liberia, Nigeria and South Africa. The research component of PaMD focused on the development and assessment of a collaborative shared care (CSC) program between traditional and faith healers (T&FHs) and biomedical providers for the treatment of psychotic disorders, as a way of improving the outcome of persons suffering from these conditions. The capacity building component aimed to develop research capacity and appreciation of the value of research in a broad range of stakeholders through bespoke workshops and fellowships targeting specific skillsets as well as mentoring for early career researchers. Results: In the research component of PaMD, a series of formative studies were implemented to inform the development of an intervention package consisting of the essential features of a CSC for psychosis implemented by primary care providers and T&FHs. A cluster rand was next designed to test the effectiveness of this package on the outcome of psychosis. In the capacity building component, 35 early and midcareer researchers participated in the training workshops and several established mentor mentee relationships with senior PaMD members. At the end of the funding period, 60 papers have been published and 21 successful grant applications made. CONCLUSION: The success of PaMD in energising young researchers and implementing a cutting-edge research program attests to the importance of partnership among researchers in the global south working with those from the north in developing MH research and service in LMIC.Item A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries(Springer Science + Business Media, 2019) Esan, O.B.; Appiah-Poku, J.; Othieno, C.; Kola, L.; Harris, B.; Nortje, G.; Makanjuola, V.; Oladeji, B.; Price, L.; Seedat, S.; Gureje, O.Background: Traditional and faith healers constitute an important group of complementary and alternative mental health service providers (CAPs) in sub-Sahara Africa. Governments in the region commonly express a desire to integrate them into the public health system. The aim of the study was to describe the profile, practices and distribution of traditional and faith healers in three sub-Saharan African countries in great need for major improvements in their mental health systems namely Ghana, Kenya and Nigeria. Materials and methods: A mapping exercise of CAPs who provide mental health care was conducted in selected catchment areas in the three countries through a combination of desk review of existing registers, engagement activities with community leaders and a snowballing technique. Information was collected on the type of practice, the methods of diagnosis and the forms of treatment using a specially designed proforma. Results: We identified 205 CAPs in Ghana, 406 in Kenya and 82 in Nigeria. Most (> 70%) of the CAPs treat both physical and mental illnesses. CAPs receive training through long years of apprenticeship. They use a combination of herbs, various forms of divination and rituals in the treatment of mental disorders. The use of physical restraints by CAPs to manage patients was relatively uncommon in Kenya (4%) compared to Nigeria (63.4%) and Ghana (21%). CAPs often have between 2- to 10-fold capacity for patient admission compared to conventional mental health facilities. The profile of CAPs in Kenya stands out from those of Ghana and Nigeria in many respects. Conclusion: CAPs are an important group of providers of mental health care in sub-Saharan Africa, but attempts to integrate them into the public health system must address the common use of harmful treatment practices.Item The perceived effectiveness of traditional and faith healing in the treatment of mental illness: a systematic review of qualitative studies(Springer Science+Business Media, 2018) Van der Watt, A.S.J.; van de Water, T.; Nortje, G.; Oladeji, B.D.; Seedat, S.; Gureje, O.; Partnership for Mental Health Development in Sub-Saharan Africa (PaM-D) Research Team, Collaborators; Kola, L.; Appiah-Poku, J.; Othieno, C.; Harris, B.; Esan, O.B.; Makanjuola, V.; Price, L.N.Purpose: This work complements a quantitative review by Nortje et al. (Lancet Psychiatry 3(2):154–170, 2016) by exploring the qualitative literature in regard to the perceived effectiveness of traditional and faith healing of mental disorders. Method: Qualitative studies focusing specifically on traditional and/or faith healing practices for mental illness were retrieved from eight databases. Data were extracted into basic coding sheets to facilitate the assessment of the quality of eligible papers using the COREQ. Results: Sixteen articles met the inclusion criteria. Despite methodological limitations, there was evidence from the papers that stakeholders perceived traditional and/or faith healing to be effective in treating mental illness, especially when used in combination with biomedical treatment. Conclusion: Patients will continue to seek treatment from traditional and/or faith healers for mental illness if they perceive it to be effective regardless of alternative biomedical evidence. This provides opportunities for collaboration to address resource scarcity in low to middle income countries.Item Collaborative shared care to improve psychosis outcome (COSIMPO): study protocol for a randomized controlled trial(BioMed Central, 2017) Gureje, O.; Makanjuola, V.; Kola, L.; Yusuf, B.; Price, L.; Esan, O.B.; Oladeji, B.D.; Appiah-Poku, J.; Haris, B.; Othieno, C.; Seedat, S.Keywords Background: Psychotic disorders are a group of severe mental disorders that cause considerable disability to sufferers and a high level of burden to families. In many low- and middle-income countries (LMIC), traditional and faith healers are the main providers of care to affected persons. Even though frequently canvassed as desirable for improved care delivery, collaboration between these complementary alternative health providers (CAPs) and conventional health providers has yet to be rigorously tested for feasibility and effectiveness on patient outcomes. Methods/design: COSIMPO is a single-blind, cluster randomized controlled trial (RCT) being conducted in Nigeria and Ghana to compare the effectiveness of a collaborative shared care (CSC) intervention program implemented by CAPs and primary health care providers (PHCPs) with care as usual (CAU) at improving the outcome of patients with psychosis. The study is designed to test the hypotheses that patients receiving CSC will have a better clinical outcome and experience fewer harmful treatment practices from the CAPs than patients receiving CAU at 6 months after study entry. An estimated sample of 296 participants will be recruited from across 51 clusters, with a cluster consisting of a primary care clinic and its neighboring CAP facilities. CSC is a manualized intervention package consisting of regular and scheduled visits of PHCPs to CAP facilities to assist with the management of trial participants. Assistance includes the administration of antipsychotic medications, management of comorbid physical condition, assisting the CAP to avoid harmful treatment practices, and engaging with CAPs, caregivers and participants in planning discharge and rehabilitation. The primary outcome, assessed at 6 months following trial entry, is improvement on the Positive and Negative Symptom Scale (PANSS). Secondary outcomes, assessed at 3 and 6 months, consist of levels of disability, experience of harmful treatment practices and of victimization, and levels of perceived stigma and of caregivers’ burden. Discussion: Information about whether collaboration between orthodox and complementary health providers is feasible and can lead to improved outcome for patients is important to formulating policies designed to formally engage the services of traditional and faith healers within the public health system.Item Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways(SAGE Publishing, 2017) "Van der Watt, A.S.J.; Nortje, G.; Kola, L.; Appiah-Poku, J.; Othieno, C.; Harris, B.; Oladeji, B.D.; Esan, O.B.; Makanjuola, V.; Price, L.N.; Seedat, S.; Gureje, O.We examined the scope of collaborative care for persons with mental illness as implemented by traditional healers, faith healers, and biomedical care providers. We conducted semistructured focus group discussions in Ghana, Kenya, and Nigeria with traditional healers, faith healers, biomedical care providers, patients, and their caregivers. Transcribed data were thematically analyzed. A barrier to collaboration was distrust, influenced by factionalism, charlatanism, perceptions of superiority, limited roles, and responsibilities. Pathways to better collaboration were education, formal policy recognition and regulation, and acceptance of mutual responsibility. This study provides a novel cross-national insight into the perspectives of collaboration from four stakeholder groups. Collaboration was viewed as a means to reach their own goals, rooted in a deep sense of distrust and superiority. In the absence of openness, understanding, and respect for each other, efficient collaboration remains remote. The strongest foundation for mutual collaboration is a shared sense of responsibility for patient well-being.Item Explanatory model of psychosis: impact on perception of self-stigma by patients in three sub-saharan African cities(Springer Science + Business Media, 2016) Makanjuola, V.; Esan, O.B.; Oladeji, B.; Kola, L.; Appiah-Poku, J.; Harris, B.; Othieno, C.; Price, L.; Seedat, S.; Gureje, O.Mental disorders are cross-culturally ubiquitous [1]. Psychosis is, by far, the more easily recognisable form of mental disorder by the lay public and traditional healers [2]. While the experience of psychosis is universal, interpretation of the experience, notions of causation, treatment, preferred source of care, and the consequences and perceptions of associated stigma vary from one culture to another. We used a mixed-methods approach consisting of in-depth interviews with key informants to explore respondents’ explanatory models of the causation of psychosis as well as questionnaire assessment of the level of internalized (or self) stigma. The conduct of the interviews was guided by the specifications of the McGill Illness Narrative Interview (MINI) [32], a semi-structured interview guide which, among other things, elicits lay illness narratives. A purposively selected sample of patients who were receiving treatment from traditional healers was interviewed. The transcribed interviews were read several times by the first author and subjected to thematic analysis. Supernatural and biopsychosocial explanatory models of the causation of psychosis were both endorsed by our respondents. Despite this, the majority of the respondents with severe forms of self-stigma held supernatural attributions. However, we also found that some respondents with low self-stigma embraced a supernatural model while some respondents with high self-stigma proffered a biopsychosocial explanation. Our findings suggest that individualising interventions to minimize self-stigma may be a better approach than programs that generically promote biopsychosocial models or discourage supernatural models.Item Determinants of transition across the spectrum of alcohol use and misuse in Nigeria(Elsevier Inc, 2013) Esan, O.B.; Makanjuola, V.; Oladeji, B.; Gureje, O.Many studies have examined the risk factors associated with alcohol use disorders. No information is available from developing countries about the factors that may determine the transitions across different levels of use and misuse. Alcohol use and its misuse were assessed in a cohort of 2143 Nigerians using Version 3.0 of the World Health Organization Composite International Diagnostic Interview (WHO-CIDI). This generated six levels of alcohol use and related disorders. Using age of onset variables created for the purpose, analysis was done to determine rates of and risk factor for transition between the levels. Lifetime prevalence estimates were 57.8% for alcohol use, 27.6% for regular use, 2.9% for abuse, and 0.3% for dependence. Whereas 47.8% transited to regular use from lifetime ever use, only 10.5% transited to abuse from regular use and 9.5% from abuse to dependence. Male sex, age 18e49 years and being never married predicted onset of alcohol use. Transition to regular use was predicted only by male sex while transition to abuse was predicted by male sex and age 35e49 years. Factors associated with recovery from abuse were female sex and a student status. Higher rates of transition occurred in the stages preceding the onset of alcohol use disorders. Sex and age were the main determinants of transition, with male gender and middle age being risk factors for transition to problematic use of alcohol.Item The natural history of insomnia in the Ibadan study of ageing(Oxford University Press, 2011) Gureje, O.; Oladeji, B.D.; Abiona, T.; Makanjuola, V.; Esan, O.B."Study Objectives: To determine the incidence and risk factors for insomnia among an under-studied population of elderly persons in Sub-Saharan Africa. Setting: Eight contiguous predominantly Yoruba-speaking states in south-west and north-central Nigeria representing about 22% of the national population. Participants: 1307 elderly community-dwelling persons, aged 65 years and older. Measurements: Face-to-face assessment with the Composite International Diagnostic Interview, version 3 (CIDI.3) in 2007 and 12 months later in 2008 to determine the occurrence and risk factors of incident and persistent insomnia, defined as syndrome or symptom. Results: The incidence of insomnia syndrome in 2008 at 12 months was 7.97% (95% CI, 6.60–9.60), while that of insomnia symptom was 25.68% (22.68-28.66). Females were at elevated risk for both syndrome and symptom. Among persons with insomnia symptom or syndrome at the base line, 47.36% (95% CI 43.07–51.68) continued to have it one year later. Decreasing economic status was associated with increasing incidence of insomnia. Persons with chronic medical conditions at baseline were at increased risk for new onset of insomnia. Compared to persons with the lowest body mass index (BMI) (< 18.5), those with higher BMI were at elevated risk for persistence of their insomnia, with those in the obese range (≥ 30) having a 4-fold risk. Conclusions: There is a high incidence and chronicity of insomnia in this elderly population. Persons with chronic health conditions are particularly at risk of new onset as well as persistence of insomnia. "