The association of cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients: a cross sectional study.

INTRODUCTION: Cognitive impairment is common in first-episode psychosis patients and often associated with poor quality of life and functional impairment. However, most literature on this association is from high income countries and not low resource countries like Uganda. We aimed to determine the association between cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients. METHODS: At Butabika national psychiatric hospital of Uganda, we enrolled 94 first-episode psychosis patients aged 18-60 years with a confirmed first-episode of psychosis and no previous treatment with antipsychotic medication. Neuropsychological assessment was performed using the MATRICS consensus cognitive battery (MCCB). Quality of life and functional impairment were assessed using the brief version of the World Health Organisation Quality of Life scale (WHOQOL-BREF) and the MINI International Neuropsychiatric Inventory (MINI) respectively. Linear regression analyses determined the association between impairment in different cognitive domains with various quality of life and functional impairment domains while controlling for age, gender and level of education. RESULTS: High scores in the reasoning and problem solving cognitive domain were associated with better quality of life in the psychological domain of WHOQOL-BREF (p = 0.029). For functional impairment, high cognitive scores in the domains of speed of processing (p = 0.018), reasoning and problem solving (p = 0.015), working memory (p = 0.017) and visual learning and memory (p = 0.002) were associated with psychosis "having a greater impact on other members of the family" on the MINI. Higher scores in the social cognition domain were associated with "less aggressive and disruptive behaviour" (p = 0.003). CONCLUSION: Cognitive impairment in Ugandan first-episode psychotic patients is associated with both poorer quality of life and functional impairment. Remediation of cognitive function may be a plausible intervention to improve outcomes in Ugandan first-episode psychosis patients.

Quality of individual and group level interventions for first-episode psychosis at the tertiary psychiatric hospital in Uganda.

BACKGROUND: Individual and group level interventions have the largest effect on outcomes in patients with the first episode of psychosis. The quality of these individual and group level interventions provided to first-episode psychosis patients in Uganda is unclear. AIM: To determine the quality of the individual and group level interventions provided to first episode psychosis patients in Uganda. SETTING: The study was performed at the only tertiary psychiatric hospital in Uganda. METHODS: A retrospective chart review of recently discharged adult in-patients with the first episode of psychosis was performed. The proportion of participants who received different essential components for individual and group level interventions were calculated. From the different proportions, the quality of the services across the individual and group interventions was determined using the first-episode psychosis services fidelity scale (FEPS-FS). The FEPS-FS assigns a grade of 1-5 on a Likert scale depending on the proportion of patients who received the different components of the intervention. Twelve essential components across the individual and group interventions were assessed and their quality quantified. RESULTS: The final sample included 156 first-episode psychosis patients. The median age was 27 years (inter-quartile range [IQR] [24-36]) and 55% of the participants were female. All 12 essential components had poor quality with the range of scores on the FEPS-FS between one and three. Only one essential component assessed (use of single antipsychotics) had moderate quality. CONCLUSION: Amongst current services at the Butabika National Referral Mental Hospital in Uganda, the essential components for individual and group level interventions for psychotic disorders are of poor quality. Further studies are required on how the quality of these interventions can be improved.

Depression with pain co morbidity effect on quality of life among HIV positive patients in Uganda: a cross sectional study.

BACKGROUND: Depression with pain comorbidity (DPC) has not been clearly defined among HIV positive patients in sub-Saharan Africa. It still remains a challenge despite many studies in Africa documenting a high prevalence of pain and depression among people living with HIV/AIDS. Both are associated with a grave impact on the health related outcomes in this pandemic. This study aimed at determining the prevalence, factors associated and effect on quality of life of DPC among HIV positive patients. METHODS: In a cross-sectional survey, 345 HIV positive patients were enrolled into the study. Using a pre-tested standardised questionnaire the presence of DPC was assessed after a written informed consent. The associations between DPC, quality of life, depression history, severity, and cognition were determined. A p-value of <0.05 was considered to be significant. RESULTS: Among people living with HIV/AIDS (PLWHA), the prevalence of DPC was about 5%. PLWHA with DPC were more likely to perceive their overall quality of life as poor and scored poorly in all the domains on the WHOQOL-BREF. They were also more likely to have more severe forms of depression and recurrent episodes of depression. CONCLUSIONS: DPC is common, under diagnosed and undertreated in PLWHA in Uganda. Depression and pain screening as well as appropriate access to care for DPC have potential to improve quality of life and health outcomes. This calls for the integration and training of mental health services into HIV/AIDS care and future efforts by policy makers and HIV caregivers to address this treatment gap to advance the care of people living with HIV in Uganda.

Prevalence, profile and associations of cognitive impairment in Ugandan first-episode psychosis patients.

INTRODUCTION: The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients. METHODS: Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education. RESULTS: Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p < 0.001) and visual learning and memory (p = 0.001). Cassava-rich diets and previous alternative and complementary therapy use were negatively associated with impairment in the visual learning (p = 0.04) and attention/vigilance domains (p = 0.012), respectively. There were no significant associations between sex, history of childhood trauma, or illness severity with any cognitive domain. CONCLUSION: A significant burden of cognitive impairment in Ugandan first-episode psychosis patients is consistent with prior data from other contexts. However, the profile of and risk factors for impairment differ from that described in such work. Therefore, interventions to reduce cognitive impairment in FEP patients specific to this setting, including dietary modifications, are required.

Feasibility of conducting a pilot randomized control trial of a psycho-education intervention in patients with a first episode psychosis in Uganda-A study protocol.

BACKGROUND: Psychotic disorders contribute to significant morbidity and mortality partly due to the chronicity of the illness and high relapse rates. Delivering psycho-education messages about disease etiology, their signs and symptoms and the benefits of treatment adherence have been shown to improve clinical outcomes among individuals with psychoses. However, little has been done to examine the feasibility and efficacy of this intervention in low resourced settings. OBJECTIVE: Our primary objective will be to determine the feasibility of recruiting and retaining patients with a first episode psychosis (FEP) and for the secondary objective, we will determine the preliminary efficacy of psycho-education on illness self-management, stigma, adherence to medications and symptom severity. HYPOTHESIS: We hypothesize that (i) we will recruit 70% of eligible participants and accrue a sample size of 80 over 20-weeks, retaining 80% of the sample size for 24 weeks, (ii) the intervention will lead to improvement in clinical outcomes (described above). METHODS: We will recruit 80 adult patients who have been diagnosed with a FEP, received antipsychotic medication at Butabika Hospital and reside within 21km from the Hospital. Trained village health team (VHTs) members will deliver 6 psycho-education sessions to 40 participants and their family members (intervention arm). Participants in the control arm (n = 40) will receive routine care. We will document how feasible it will be to recruit and retain participants over 24 weeks and document the preliminary efficacy of the intervention on illness self-management, stigma, adherence to medications and severity of symptoms. DATA ANALYSIS: We will document the proportion of participants who consent and get recruited, the proportion of those who will get retained and reasons for drop out. We will conduct an intention to treat analysis comparing the groups at weeks 4, 12, 24 and assess the effect of the intervention on the clinical outcomes (described above). We will use the Bonferroni approach to correct for multiple comparisons. TRIAL REGISTRATION: Clinical trials.gov registration number: NCT04602585.

Comparison of antipsychotic naïve first-episode psychosis patients and healthy controls in Uganda.

INTRODUCTION: The risk factors for a first episode of psychosis in low and middle-income countries (LMICs) are not well described. The study compared the association of different risk factors in patients with first-episode psychosis patients and healthy controls from an LMIC context. METHODS: A comparative, descriptive, cross-sectional study was performed in antipsychotic naïve first-episode psychosis patients and healthy controls at the National referral hospital in Uganda. Standardized tools were used to assess sociodemographic (e.g., age, sex, socioeconomic status) and clinical (e.g., childhood trauma, quality of life) variables. First episode psychosis participants were compared to healthy controls in terms of sociodemographic and clinical variables, and logistic regression was used to determine predictors of FEP. RESULTS: Our final sample included 198 antipsychotic naïve first-episode psychosis participants and 82 controls. Most participants were female (68.5%) with a mean age of 29.4 years. After adjusting for age and sex, FEP patients when compared to controls were less likely to be female [AOR 0.18 (95%CI 0.03-0.85; p = .031)], more likely to have experienced emotional abuse [AOR 1.30 (95%CI 1.02-1.65; p = .032)] and more likely to have a poor quality of life [AOR 0.93 (95%CI 0.89-0.97; p = .002)]. DISCUSSION: The risk factors for a first episode of psychosis in this low and middle-income population were like those described in high-income countries. Further studies on interventions to prevent the transition to psychotic disorders in this sub-groups of patients are recommended. Also, the use of specialized early intervention services in improving the quality of life needs to be evaluated.

Knowledge Gaps about Autism Spectrum Disorders and its Clinical Management among Child and Adolescent Health Care Workers in Uganda: A Cross-Sectional Study.

BACKGROUND: There is limited literature on the knowledge about Autism Spectrum Disorder (ASD) among child and adolescent health professionals from resource limited settings. METHODS: 40 child and adolescent health professionals were purposively sampled from the two national referral hospitals in Uganda. Participants completed a standardized questionnaire that collected data on socio-demographic characteristics, the Knowledge about Childhood Autism among Health Workers (KCAHW) and the challenges related to diagnosing and managing ASD. General linear model with the Poisson regression was used to evaluate bivariate and multivariate factors associated with limited knowledge about ASD. RESULTS: The study participation rate was 90% with the majority being females (N = 21, 58%). Also, most (N = 20, 55.6%) were mental health professionals working at the Butabika pediatric out-patient clinic while (N = 16, 44.4%) were pediatric health professionals working at the Mulago mental and neurological pediatric clinics. The mean score on KCAHW was 11.8 (SD = 3.75). The participants (36.1%) who scored below the mean score were regarded as having limited knowledge about ASD. Health workers with limited knowledge about ASD (KCAHW score < 11.8) were less likely to have a degree [adjusted Prevalence rate ratio (aPRR) = 0.26, 95%CI = 0.08 to 0.78, p-value = 0.018. Mental health and Non-mental health workers had comparable KCAHW mean scores. Clinical Psychologists, Psychiatrists, psychiatry residents and pediatric nurses had the highest KCAHW scores while psychiatric nurses and medical social workers had the lowest scores. CONCLUSION: The proportion of child and adolescent health professionals with limited knowledge about ASD is substantial. There is urgent need to increase focus on training in autism spectrum disorders especially among non-specialist health workers.

A systematic review of research on neuropsychological measures in psychotic disorders from low and middle-income countries: The question of clinical utility.

INTRODUCTION: Several studies of neuropsychological measures have been undertaken in patients with psychotic disorders from low- and middle-income countries (LMICs). It is, however, unclear if the measures used in these studies are appropriate for cognitive screening in clinical settings. We undertook a systematic review to determine if measures investigated in research on psychotic disorders in LMICs meet the clinical utility criteria proposed by The Working Group on Screening and Assessment. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed. We determined if tests had been validated against a comprehensive test battery, the duration and scope of the tests, the personnel administering the tests, and the means of administration. RESULTS: A total of 31 articles were included in the review, of which 11 were from Africa. The studies included 3254 participants with psychosis and 1331 controls. 3 studies reported on the validation of the test against a comprehensive cognitive battery. Assessments took 1 h or less to administer in 6/31 studies. The average number of cognitive domains assessed was four. Nonspecialized staff were used in only 3/31 studies, and most studies used pen and paper tests (17/31). CONCLUSION: Neuropsychological measures used in research on psychotic disorders in LMICs typically do not meet the Working Group on Screening and Assessment clinical utility criteria for cognitive screening. Measures that have been validated in high-income countries but not in LMICs that do meet these criteria, such as the Brief Assessment of Cognition in Schizophrenia, therefore deserve further study in LMIC settings.

Classification and description of chronic pain among HIV positive patients in Uganda.

INTRODUCTION: Chronic pain classification in HIV positive patients is essential for diagnosis and treatment. However, this is rarely done despite association with poor outcomes. METHODS: A cross-sectional survey of 345 consented patients at a specialized HIV care center in Uganda was conducted. Chronic pain was defined as pain of more than two weeks duration. Data was collected using a socio-demographic questionnaire, the IASP classification of chronic pain; the StEP; Mini Mental Status Examination, Patient Health Questionnaire, Mini International Neuropsychiatric Interview and the World Health Organization quality of life instrument brief version. Chi-square, Fisher's exact, t-test and logistic regression analyses were carried out to determine factors associated with chronic pain. RESULTS: Description of pain aetiology was difficult. Chronic pain was reported in 21.5% of the participants. Non-neuropathic (92.0%) was more common than neuropathic pain (8.0%). Chronic pain was found to be associated with feeling ill [OR=6.57 (3.48 - 12.39)], and worse scores in the quality of life domain for physical health [OR=0.71 (0.60 - 0.83)]. CONCLUSION: People living with HIV/AIDS commonly have chronic pain that is associated with poor quality of life. More sensitive tools are needed to accurately describe chronic pain in resource limited settings.

The association between depression, quality of life, and the health care expenditure of patients with diabetes mellitus in Uganda.

BACKGROUND: Depression is one of the commonest neuropsychiatric disorders in patients with diabetes mellitus (DM) and is associated with poor glycaemic control, vascular complications, a low quality of life and increased health care expenditure. Co-morbid DM and depression remains poorly identified and inadequately treated in sub-Saharan Africa. METHODS: We conducted a cross-sectional survey of 437 patients with DM at 3 DM clinics in Uganda. Participants were assessed for depression, blood sugar levels, diabetic neuropathy, quality of life, and health care expenditures. RESULTS: The prevalence of depression was 34.8%. Depressed participants were more likely to be suicidal [OR=3.81, (CI 2.87-5.04)], younger [OR=3.98 CI (1.20-13.23)], un-employed [OR=1.99(CI 1.04-3.81)], and having lost a spouse [OR=2.36 (CI 1.29-4.31)]. Overall quality of life was poor [OR=0.67 (CI 0.47-0.96)], they scored poorer in the physical [OR=0.97, (CI 0.95-0.99)], psychological [OR=1.05 (CI 1.03-1.07)], and environmental [OR=0.97, (CI 0.95-0.99)] domains. They had an increased likelihood of incurring direct out-of-pocket payments for health care services [OR=1.56 (CI 1.03-2.36)], and were more likely to be impoverished [OR=1.52 (CI 1.01-2.28)]. LIMITATION: The cross sectional nature of this study makes it difficult to examine causation. More studies are required in order to better understand the associations and impact of the factors examined above on patient outcomes. CONCLUSIONS: Depression is highly prevalent among patients with DM in Uganda, and is associated with a number of adverse outcomes. A holistic approach that focuses on the depression management among patients with diabetes is recommended.