The effect of gender on the long-term course and outcome of schizophrenia in rural Ethiopia: a population-based cohort.

BACKGROUND: Although some studies have suggested that women with schizophrenia are more likely to achieve positive outcomes, the evidence-base is fraught with inconsistencies. In this study we compare the long-term course and outcomes for men and women living with schizophrenia in rural Ethiopia. METHODS: The Butajira course and outcome study for severe mental disorders is a population-based cohort study. Community ascertainment of cases was undertaken between 1998 and 2001, with diagnostic confirmation by clinicians using the Schedules for Clinical Assessment in Neuropsychiatry. Findings from annual outcome assessments were combined with clinical records, patient and caregiver report, and psychiatric assessments at 10-13 years using the Longitudinal Interval Follow-up Evaluation- LIFE chart. For the sub-group of people with schizophrenia (n = 358), we compared course of illness and treatment, co-morbidity, recovery, social outcomes and mortality between men and women. Multivariable analyses were conducted for modelling associations identified in bivariate analyses according to blocks shaped by our a priori conceptual framework of the biological and social pathways through which gender might influence the course and outcome of schizophrenia. RESULTS: Looking into over 10-13 years of follow-up data, there was no difference in the functioning or recovery in women compared to men (AOR = 1.79, 95% CI = 0.91, 3.57). Women were less likely to report overall life satisfaction (AOR = 0.22, 95% CI = 0.09, 0.53) or good quality of spousal relationships (AOR = 0.09, 95% CI = 0.01-1.04). Men were more likely to have co-morbid substance use and there was a trend towards women being more likely to be prescribed an antidepressant (AOR = 2.38, 95% CI = 0.94, 5.88). There were no gender differences in the course of illness, number of psychotic episodes or adherence to medications. CONCLUSION: In this rural African setting, we found little evidence to support the global evidence indicating better course and outcome of schizophrenia in women. Our findings are suggestive of a gendered experience of schizophrenia which varies across contexts. Further investigation is needed due to the important implications for the development of new mental health services in low and middle-income country settings.

"He can send her to her parents": The interaction between marriageability, gender and serious mental illness in rural Ethiopia.

BACKGROUND: For women in most low- and middle-income countries, the diagnosis with serious mental illness (SMI) leads to stigma and challenges related to starting or maintaining marriages. The purpose of this qualitative study was to explore perspectives on marriage, divorce and family roles of women with SMI in rural Ethiopia. METHODS: A qualitative study was conducted in a rural setting of Butajira, South Central Ethiopia. A total of 39 in-depth interviews were carried out with service users (n = 11), caregivers (n = 12), religious leaders (n = 6), health extension workers (n = 4), police officers (n = 2), teachers (n = 2) and government officials (n = 2). Data were analyzed using a thematic approach. RESULTS: Three themes emerged. (1) Marriage and SMI: Chances of getting married for individuals with SMI in general was perceived to be lower: Individuals with SMI experienced various challenges including difficulty finding romantic partner, starting family and getting into a long-term relationship due to perceived dangerousness and the widespread stigma of mental illness. (2) Gendered experiences of marriageability: Compared to men, women with SMI experienced disproportionate levels of stigma which often continued after recovery. SMI affects marriageability for men with SMI, but mens' chances of finding a marital partner increases following treatment. For women in particular, impaired functioning negatively affects marriageability as ability to cook, care and clean was taken as the measure of suitability. (3) Acceptability of divorce and separation from a partner with SMI: Divorce or separation from a partner with SMI was considered mostly acceptable for men while women were mostly expected to stay married and care for a partner with SMI. For men, the transition from provider to dependent was often acceptable. However, women who fail to execute their domestic roles successfully were considered inept and would be sent back to their family of origin. CONCLUSION: Women with SMI or those married to partners with SMI are at greater disadvantage. Reducing vulnerabilities through stigma reduction efforts such as community outreach and mental health awareness raising programs might contribute for better social outcomes for women with SMI.

The psychosis treatment gap and its consequences in rural Ethiopia.

BACKGROUND: The "treatment gap" (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services. METHOD: The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework. RESULTS: Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9-5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults. CONCLUSION: This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.

Development of a scalable mental healthcare plan for a rural district in Ethiopia.

BACKGROUND: Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. AIMS: To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. METHOD: A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). RESULTS: The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. CONCLUSIONS: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.

Excess mortality in severe mental illness: 10-year population-based cohort study in rural Ethiopia.

BACKGROUND: Evidence on mortality in severe mental illness (SMI) comes primarily from clinical samples in high-income countries. AIMS: To describe mortality in people with SMI among a population cohort from a low-income country. METHOD: We followed-up 919 adults (from 68 378 screened) with SMI over 10 years. Standardised mortality ratios (SMR) and years of life lost (YLL) as a result of premature mortality were calculated. RESULTS: In total 121 patients (13.2%) died. The overall SMR was twice that of the general population; higher for men and people with schizophrenia. Patients died about three decades prematurely, mainly from infectious causes (49.6%). Suicide, accidents and homicide were also common causes of death. CONCLUSIONS: Mortality is an important adverse outcome of SMI irrespective of setting. Addressing common natural and unnatural causes of mortality are urgent priorities. Premature death and mortality related to self-harm should be considered in the estimation of the global burden of disease for SMI.

Burden of mental disorders and unmet needs among street homeless people in Addis Ababa, Ethiopia.

BACKGROUND: The impact of mental disorders among homeless people is likely to be substantial in low income countries because of underdeveloped social welfare and health systems. As a first step towards advocacy and provision of care, we conducted a study to determine the burden of psychotic disorders and associated unmet needs, as well as the prevalence of mental distress, suicidality, and alcohol use disorder among homeless people in Addis Ababa, the capital of Ethiopia. METHODS: A cross-sectional survey was conducted among street homeless adults. Trained community nurses screened for potential psychosis and administered standardized measures of mental distress, alcohol use disorder and suicidality. Psychiatric nurses then carried out confirmatory diagnostic interviews of psychosis and administered a locally adapted version of the Camberwell Assessment of Needs Short Appraisal Schedule. RESULTS: We assessed 217 street homeless adults, about 90% of whom had experienced some form of mental or alcohol use disorder: 41.0% had psychosis, 60.0% had hazardous or dependent alcohol use, and 14.8% reported attempting suicide in the previous month. Homeless people with psychosis had extensive unmet needs with 80% to 100% reporting unmet needs across 26 domains. Nearly 30% had physical disability (visual and sensory impairment and impaired mobility). Only 10.0% of those with psychosis had ever received treatment for their illness. Most had lived on the streets for over 2 years, and alcohol use disorder was positively associated with chronicity of homelessness. CONCLUSION: Psychoses and other mental and behavioural disorders affect most people who are street homeless in Addis Ababa. Any programme to improve the condition of homeless people should include treatment for mental and alcohol use disorders. The findings have significant implications for advocacy and intervention programmes, particularly in similar low income settings.

Movement disorders in neuroleptic-naïve patients with schizophrenia spectrum disorders.

BACKGROUND: Spontaneous Movements Disorders (SMDs) or dyskinetic movements are often seen in patients with schizophrenia and other psychotic disorders, and are widely considered to be adverse consequences of the use of antipsychotic medications. Nevertheless, SMDs are also observed in the pre-neuroleptic ear and among patients who were never exposed to antipsychotic medications. The aim of this study was to determine the extent of SMDs among antipsychotic-naïve patients in a low income setting, and to evaluate contextually relevant risk factors. METHODS: The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting treatment-naïve patients with a diagnosis of schizophrenia, schizoaffective disorder and schizophreniform disorder contacting services for the first time were assessed using the Simpson-Angus Rating Scale (SAS) and the Abnormal Involuntary Movement Scale (AIMS) to evaluate the presence of SMDS. Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS) were administered to evaluate negative and positive symptom profiles respectively. Body mass index (BMI) was used as a proxy measure for nutritional status. RESULT: Sixty-four patients, 67.2% male (n = 43), with first contact psychosis who met the DSM-IV-TR criteria for schizophrenia (n = 47), schizophreniform disorder (n= 5), and schizoaffective disorder (n = 12) were assessed over a two month study period. Seven patients (10.9%) had SMDs. BMI (OR = 0.6, 95% CI = 0.40, 0.89; p = 0.011) and increasing age (OR = 1.10; 95% CI = 1.02, 1.20; p = 0.017) were associated with SMD. CONCLUSIONS: This finding supports previous suggestions that abnormal involuntary movements in schizophrenia and other psychotic disorders may be related to the pathophysiology of psychotic disorders and therefore cannot be attributed entirely to the adverse effects of neuroleptic medication.

Suicide and suicide attempts in people with severe mental disorders in Butajira, Ethiopia: 10 year follow-up of a population-based cohort.

BACKGROUND: People with severe mental disorders (SMD) are at higher risk of suicide. However, research into suicide attempts and completed suicide in people with SMD in low- and middle-income countries is mostly limited to patients attending psychiatric facilities where selection bias is likely to be high. METHODS: A population-based cohort of 919 people with SMD from rural Ethiopia (who received standardized clinician diagnoses of schizophrenia (n = 358) major depressive disorder (n = 216) and bipolar I disorder (n = 345)) were followed up annually for an average of 10 years. The Longitudinal Interval Follow-up Evaluation chart was administered by psychiatrists and used to evaluate systematically suicidal behavior and risk factors, which may be amenable to intervention. RESULTS: Over the follow-up period, the cumulative risk of suicide attempt was 26.3% for major depression, 23.8% for bipolar I disorder and 13.1% for schizophrenia, (p < 0.001). The overall incidence of completed suicide was 200.2/100,000 person-years (CI = 120.6, 312.5). Hanging was the most frequent method used (71.5%) for both attempters and completers. Most people who completed suicide were successful on the first attempt (84.2%), but the case-fatality rate for suicide attempt was 9.7%. In the adjusted logistic regression model, being currently married (Adjusted OR) =2.17, 95% CI = 1.21, 3.91), and having a diagnosis of bipolar I disorder (Adjusted OR = 2.59, 95% CI = 1.57, 4.26) or major depression (Adjusted OR = 2.71, 95% CI = 1.60, 4.58) were associated significantly with increased risk of suicide attempts. CONCLUSION: In this sample of people with SMD from a rural setting, the rate of suicide was high. Initiatives to integrate mental health service into primary care need to focus on limiting access to suicide methods in people with SMD in addition to expanding access to mental health care.

Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper.

BACKGROUND: Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery. METHODS: The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.

Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers.

BACKGROUND: Levels of non-adherence to antipsychotic medication in persons with schizophrenia in rural African settings have been shown to be comparable to those found in high-income countries. Improved understanding of the underlying reasons will help to inform intervention strategies relevant to the context. METHODS: A qualitative study was conducted among persons with schizophrenia (n = 24), their caregivers (n = 19), research field workers (n = 7) and health workers (n = 1) involved in the ongoing population-based cohort study, 'The Butajira Study on Course and Outcome of Schizophrenia and Bipolar Disorder', based in rural Ethiopia. Six focus group discussions and 9 in-depth interviews were conducted to elicit perspectives on non-adherence to antipsychotic medication. Thematic analysis was used to identify prominent perspectives. RESULTS: Predominant reasons for non-adherence specific to a low-income country setting included inadequate availability of food to counter appetite stimulation and the perceived strength of antipsychotic medications. The vital role of the family or other social support in the absence of a statutory social safety net was emphasised. Expectations of cure, rather than need for continuing care, were reported to contribute to non-adherence in the longer-term. Many of the factors associated with non-adherence in high-income countries were also considered important in Ethiopia, including lack of insight, failure to improve with treatment, medication side effects, substance abuse, stigma and dissatisfaction with the attitude of the care provider. CONCLUSION: This study identifies additional barriers to medication adherence faced by persons with schizophrenia in Ethiopia compared to those in high-income countries. In this era of scaling up of mental health care, greater attention to provision of social and financial assistance will potentially improve adherence and thereby enable patients to benefit more fully from medication.

Magnitude, clinical and sociodemographic correlate of depression in diabetic patients, Addis Ababa, Ethiopia.

BACKGROUND: Depression is a major factor in causing hospital admissions and deaths in persons with diabetes mellitus. So far there is no study available on depression among Ethiopian diabetic patients. OBJECTIVE: This study aimed to determine the magnitude of clinical depression in diabetic patients and its association with the various clinical and sociodemographic factors related to diabetes mellitus. METHODS: 313 diabetic patients were selected from diabetic clinics of Black Lion & St. Paul hospitals, using systematic randomized sampling technique and assessed for over a period of three months, October - December 2009. Presence and severity of depression was evaluated using clinical interviews and a structured questionnaire, the Hamilton Depression Rating Scale. RESULTS: Of the total 313 patients, females account for 58.8% (n = 184), patients having type I diabetes 37.2% (n = 116) and type 2 diabetes 62.8% (n = 197). The average duration of illness with diabetes among male patients is found to be 8.2 +/- 6 years and 10.3 +/- 8 years for female patients. The mean duration of diabetes is 9.4 +/- 7.2 years. The magnitude of depression was 61% (n = 188) with mild, moderate, severe depression occurring in 40.9%, 14.7% and 4.5% of patients respectively. In this study depression diagnosed in 52.6% (n = 61) of type 1 DM and 64.8% (n = 127) of type 2 DM, 63% (n = 116) of females and 55.8% (n = 72) males. Occurrence of depression was more in patients with diabetic complications 68.2% (n = 107) and among patients in 36-54 years age group 66.7% (n = 80) compared to the rest age groups. The diagnosis of depression was also more prevalent in those with educational status below secondary level 63.9% (n = 152), (X2 = 5.868, P = 0.0075), among those with duration of DM greater than 5 yrs, 64.2% (n = 140) (X2 = 58.52, p < 0.023). CONCLUSION: Depression is an important psychiatric co morbidity in diabetic patients. The magnitude of depression in our study is significantly higher than reports from other countries. Raising awareness about co morbid emotional disorders in such chronic illnesses and availing effective treatment for depression with the basic diabetic care at these clinics may improve glycemia and diabetic related complications.

Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study.

BACKGROUND: Culture affects the way people conceptualize causes of severe mental disturbance which may lead to a variation in the preferred intervention methods. There is a seemingly dichotomous belief regarding what causes severe mental disturbance: people living in western countries tend to focus mainly on biological and psychosocial risk factors; whereas, in non-western countries the focus is mainly on supernatural and religious factors. These belief systems about causation potentially dictate the type of intervention preferred. Studying such belief systems in any society is expected to help in planning and implementation of appropriate mental health services. METHODS: A qualitative study was conducted among the Borana semi-nomadic population in southern Ethiopia to explore perceived causes of severe mental disturbance and preferred interventions. We selected, using purposive sampling, key informants from three villages and conducted a total of six focus group discussions: three for males and three for females. RESULTS: The views expressed regarding the causes of mental disturbance were heterogeneous encompassing supernatural causes such as possession by evil spirits, curse, bewitchment, 'exposure to wind' and subsequent attack by evil spirit in postnatal women and biopsychosocial causes such as infections (malaria), loss, 'thinking too much', and alcohol and khat abuse. The preferred interventions for severe mental disturbance included mainly indigenous approaches, such as consulting Borana wise men or indigenous healers, prayer, holy water treatment and seeking modern mental health care as a last resort. CONCLUSIONS: These findings will be of value for health care planners who wish to expand modern mental health care to this population, indicating the need to increase awareness about the causes of severe mental disturbance and their interventions and collaborate with influential people and indigenous healers to increase acceptability of modern mental health care. It also provides information for further research in the area of mental health in this semi-nomadic population.

Internalized stigma among patients with schizophrenia in Ethiopia: a cross-sectional facility-based study.

BACKGROUND: Despite the potential impact on treatment adherence and recovery, there is a dearth of data on the extent and correlates of internalized stigma in patients with schizophrenia in low income countries. We conducted a study to determine the extent, domains and correlates of internalized stigma amongst outpatients with schizophrenia in Ethiopia. METHODS: The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting individuals with a diagnosis of schizophrenia were recruited and assessed using an Amharic version of the Internalized Stigma of Mental Illness (ISMI) scale. RESULTS: Data were collected from 212 individuals, who were mostly single (71.2%), unemployed (70.3%) and male (65.1%). Nearly all participants (97.4%) expressed agreement to at least one stigma item contained in the ISMI; 46.7% had a moderate to high mean stigma score. Rural residence (OR = 5.67; 95% CI = 2.30, 13.00; p < 0.001), single marital status (OR = 3.39; 95% CI = 1.40, 8.22; p = 0.019) and having prominent psychotic symptoms (OR = 2.33; 95% CI = 1.17, 4.61; p = 0.016) were associated independently with a higher stigma score. Almost half of those who discontinued their treatment reported that they had done so because of perceived stigma. Those who had attempted suicide (45.3%) were more likely to have a high stigma score (OR = 2.29; 95% CI = 1.27, 4.11; p = 0.006). Over 60% of the variation in the experience of stigma was explained by four factors: social withdrawal (16.7%), perceived discrimination (14.1%), alienation (13.9%) and stereotype endorsement (12.7%). CONCLUSION: Internalized stigma is a major problem among persons with schizophrenia in this outpatient setting in Ethiopia. Internalized stigma has the potential to substantially affect adherence to medication and is likely to affect the recovery process.

Predictors of carer-burden in schizophrenia: a five-year follow-up study in Butajira, Ethiopia.

OBJECTIVE: We assessed carer-burden and its predictors in a traditional rural Ethiopian community in order to establish the longitudinal course of carer-burden and factors predicting changes. METHODS: Using a 5-year follow-up data from the ongoing Butajira outcome study on SMI, carer-burden was assessed annually with the Family Interview Schedule (FIS). Multilevel modeling was used to identify clinical predictors of severity and rate of change of burden. RESULTS: Scores in all domains of carer burden decreased over time, although the greatest reduction was seen in the first year. In a univariate analyses, longitudinal reduction in burden score was predicted by longer period in remission during follow-up, while negative and positive symptom severity scores predicted higher burden score. In the fully adjusted model, poor social support predicted higher burden score (beta=0.38, 95%CI 0.04, 0.72), and longer period in remission predicted lower level of carer-burden (beta = -0.49, 95%CI = -0.89, - 0.10). Reduction in positive symptoms was associated with the instantaneous rate of reduction of burden score (beta = -0.03, 95%CI - 0.05, -0.01). CONCLUSION: There is a significant reduction in carer-burden over the years in all burden domains. Providing accessible mental health care has the potential to alleviate carer-burden, as positive symptoms are believed to be more amenable to intervention. The study also indicates that remission is associated with reduction in carer-burden.

Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial.

BACKGROUND: There have been no trials of task-shared care (TSC) using WHO's mental health Gap Action Programme for people with severe mental disorders (psychosis or affective disorder) in low-income or middle-income countries. We aimed to evaluate the efficacy and cost-effectiveness of TSC compared with enhanced specialist mental health care in rural Ethiopia. METHODS: In this single-blind, phase 3, randomised, controlled, non-inferiority trial, participants had a confirmed diagnosis of a severe mental disorder, recruited from either the community or a local outpatient psychiatric clinic. The intervention was TSC, delivered by supervised, non-physician primary health care workers trained in the mental health Gap Action Programme and working with community health workers. The active comparison group was outpatient psychiatric nurse care augmented with community lay workers (PSY). Our primary endpoint was whether TSC would be non-inferior to PSY at 12 months for the primary outcome of clinical symptom severity using the Brief Psychiatric Rating Scale, Expanded version (BPRS-E; non-inferiority margin of 6 points). Randomisation was stratified by health facility using random permuted blocks. Independent clinicians allocated groups using sealed envelopes with concealment and outcome assessors and investigators were masked. We analysed the primary outcome in the modified intention-to-treat group and safety in the per-protocol group. This trial is registered with ClinicalTrials.gov, number NCT02308956. FINDINGS: We recruited participants between March 13, 2015 and May 21, 2016. We randomly assigned 329 participants (111 female and 218 male) who were aged 25-72 years and were predominantly of Gurage (198 [60%]), Silte (58 [18%]), and Mareko (53 [16%]) ethnicity. Five participants were found to be ineligible after randomisation, giving a modified intention-to-treat sample of 324. Of these, 12-month assessments were completed in 155 (98%) of 158 in the TSC group and in 158 (95%) of 166 in the PSY group. For the primary outcome, there was no evidence of inferiority of TSC compared with PSY. The mean BPRS-E score was 27·7 (SD 4·7) for TSC and 27·8 (SD 4·6) for PSY, with an adjusted mean difference of 0·06 (90% CI -0·80 to 0·89). Per-protocol analyses (n=291) were similar. There were 47 serious adverse events (18 in the TSC group, 29 in the PSY group), affecting 28 participants. These included 17 episodes of perpetrated violence and seven episodes of violent victimisation leading to injury, ten suicide attempts, six hospital admissions for physical health conditions, four psychiatric admissions, and three deaths (one in the TSC group, two in the PSY group). The incremental cost-effectiveness ratio for TSC indicated lower cost of -US$299·82 (95% CI -454·95 to -144·69) per unit increase in BPRS-E scores from a health care sector perspective at 12 months. INTERPRETATION: WHO's mental health Gap Action Programme for people with severe mental disorders is as cost-effective as existing specialist models of care and can be implemented effectively and safely by supervised non-specialists in resource-poor settings. FUNDING: US National Institute of Mental Health.

Five-year mortality in a cohort of people with schizophrenia in Ethiopia.

BACKGROUND: Schizophrenia is associated with a two to three fold excess mortality. Both natural and unnatural causes were reported. However, there is dearth of evidence from low and middle income (LAMIC) countries, particularly in Africa. To our knowledge this is the first community based report from Africa. METHODS: We followed a cohort of 307 (82.1% males) patients with schizophrenia for five years in Butajira, rural Ethiopia. Mortality was recorded using broad rating schedule as well as verbal autopsy. Standardized Mortality Ratio (SMR) was calculated using the mortality in the demographic and surveillance site as a reference. RESULT: Thirty eight (12.4%) patients, 34 men (11.1%) and 4 women (1.3%), died during the five-year follow up period. The mean age (SD) of the deceased for both sexes was 35 (7.35). The difference was not statistically significant (p = 0.69). It was 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87). Rural residents had lower mortality with adjusted hazard ratio (HR) of 0.30 (95% CI = 0.12-0.69) but insidious onset and antipsychotic treatment for less than 50% of the follow up period were associated with higher mortality, adjusted HR 2.37 (95% CI = 1.04-5. 41) and 2.66(1.054-6.72) respectively. CONCLUSION: The alarmingly high mortality observed in this patient population is of major concern. Most patients died from potentially treatable conditions. Improving medical and psychiatric care as well as provision of basic needs is recommended.

Serum antibodies to Toxoplasma gondii and Herpesvidae family viruses in individuals with schizophrenia and bipolar disorder: a case-control study.

BACKGROUND: Recent etiological studies for schizophrenia and bipolar disorder have focused on the protozoan Toxoplasma gondii and Herpesvirdae family viruses. OBJECTIVE: To determine the magnitude of T. gondii, cytomegalovirus (CMV), herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) infection in individuals with schizophrenia, bipolar disorder and healthy controls by using serologic diagnostic methods. MATERIAL AND METHODS: Serologic diagnostic method was used to determine the prevalence and level of antibodies to T gondii, CMV HSV-1 and HSV-2 in individuals with schizophrenia, bipolar disorder, and unaffected controls recruited from Butajira, Ethiopia. The study was conducted from March to May 2009. A total of 495 serum samples were analysed for the presence and level of immunoglobulin G (IgG) to T. gondii, CMV HSV-1, and HSV-2. RESULTS: The seroprevalence of T gondii infection was higher in individuals with schizophrenia [adjusted odds ratio = 4.7; 95% CI (1.5, 15.1)] and bipolar disorder [adjusted odds ratio = 3.0; 95% CI (1.1, 8.6)] than in unaffected controls. The level of IgG to CMV was also significantly higher in individuals with schizophrenia and bipoar disorder than in unaffected controls. Younger individuals with schizophrenia (< 25 years old) also had a significantly higher level of IgG to CMV than matched unaffected controls. CONCLUSION: This study provides additional evidence that infection with 7T gondii and CMV may be associated with some cases of schizophrenia and bipolar disorder. Additional studies should focus on antibodies to these agents in the sera and CSF of individuals with recent-onset psychosis.

Ethical and professional challenges in mental health care in low- and middle-income countries.

Mental health practitioners in low- and middle-income countries (LAMICs) face particular ethical and professional challenges in their day-to-day clinical practice. A systematic review of the published literature from all LAMICs identified 42 relevant articles. The majority of papers dealt with violations of individual autonomy, particularly in the context of involuntary admission, use of electro-convulsive therapy and the lack of information given to patients about prescribed psychotropic medications. However, the appropriateness of this focus on individual autonomy was challenged in settings where values emphasizing the interconnectedness of communities prevail and the family shoulder the burden for most mental health care. When access to the least restrictive, culturally relevant, evidence-based care is limited to the privileged few, caregivers may be forced to over-ride the individual autonomy of the patient in order to ensure receipt of effective treatment or protection of others. Enactment of modern mental health legislation in all LAMICs remains an essential goal to protect the rights of the mentally ill. In parallel with this, supporting calls for the scaling up of mental health care will do more to ensure the right to mental health care and ensure actual implementation of international ethical frameworks.

Toxoplasmosis as a cause for behaviour disorders--overview of evidence and mechanisms.

BACKGROUND: There is growing interest in the role of microbial agents in the causation of psychiatric disorders. The neurotropic protozoan parasite Toxoplasma gondii is one of the main candidates and has been associated with various psychiatric conditions, including schizophrenia. METHODS: A narrative review of the literature from the main medical databases (Medline, PubMed, PsycINFO), Google Scholar and Google using combinations of applicable terms. RESULTS: T. gondii affects the brain in both the acute and the latent stages of infection causing apparent brain pathologies in infected rodents and both immuno-compromised and immuno-competent humans. In immuno-competent individuals, behavioural disorders are primarily related to the latent stages of the illness. Behavioural/mental disorders that include schizophrenia, mood disorders, personality changes and cognitive impairments may be related to infection with T. gondii. Evidence for a behavioural effect of T. gondii comes from observational reports in animal models and controlled behavioural analysis in humans. Indirect clues of infection also come from raised seroprevalence or serotitres of antitoxoplasma antibodies among those with mental disorders. The pathophysiologic mechanism through which T. gondii may exert its effect is not clear, but direct impact on the brain and changes in neuroimmunomodulation, neurotransmission and some gene-environment interactions are postulated. CONCLUSION: There is evidence supporting a potential role of T. gondii infection in the onset of some behavioural disorders. Confirmation of such a role would prove a significant breakthrough in the search for the aetiology, treatment and prevention of behavioural disorders, such as schizophrenia. However, the associations remain preliminary.

Correction to: Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial.

An amendment to this paper has been published and can be accessed via the original article.