Improving the mental health of women intimate partner violence survivors: Findings from a realist review of psychosocial interventions.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent and is associated with a range of mental health problems. A broad range of psychosocial interventions have been developed to support the recovery of women survivors of IPV, but their mechanisms of action remain unclear. METHODS: Realist review following a prospectively published protocol in PROSPERO (CRD42018114207) and reported using the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMSES) guidelines. RESULTS: Evidence was extracted from 60 reviews and triangulated in expert consultations. Mechanisms of action were categorised as either associated with intervention design and delivery or with specific intervention components (access to resources and services; safety, control and support; increased knowledge; alterations to affective states and cognitions; improved self-management; improved family and social relations). CONCLUSIONS: Findings suggest that psychosocial interventions to improve the mental health of women survivors of IPV have the greatest impact when they take a holistic view of the problem and provide individualised and trauma-informed support.

"Medical treatments are also part of God's gift": Holy water attendants' perspectives on a collaboration between spiritual and psychiatric treatment for mental illness in Ethiopia.

In Ethiopia, traditional and spiritual treatments, such as holy water, are used by people with mental disorders instead of, or alongside, psychiatric services. Collaborations between traditional and psychiatric providers may increase access to evidence-based treatments and address human rights abuses. This study aimed to explore the perspectives of holy water attendants on a novel collaboration between holy water and psychiatric care, at St Mary's Clinic, Entoto, Ethiopia, and to characterize the users of this service. Semi-structured interviews were conducted with 14 holy water attendants, who run group houses for holy water residents and are paid by family members. A thematic analysis was conducted. Socio-demographic and clinical data were extracted from the records of all service users who had attended the clinic. A total of 174 individuals have attended the clinic in the three years since it opened. The majority were diagnosed with schizophrenia. Holy water attendants provide a partial gatekeeping role to psychiatric care, selecting which of their clients they think will benefit and, for these individuals, facilitating attendance to the clinic and antipsychotic medication adherence. Psychiatric care was felt to be compatible with holy water by some, but not all, attendants. However, family members often had the "final say" in individuals attending the clinic, in some cases putting up strong resistance to using psychiatric care. A novel collaboration is acceptable to some holy water attendants and may increase access to psychiatric care amongst people with mental illness living at a holy water site in Ethiopia.

"Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia.

BACKGROUND: There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries. METHODS: We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data. RESULTS: There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. CONCLUSION: It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

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.

Global mental health and schizophrenia.

PURPOSE OF REVIEW: The aim was to synthesize recent evidence on schizophrenia illness experience and outcomes and models of care in low and middle-income countries (LMICs). RECENT FINDINGS: There is a plurality of explanatory models for psychosis and increasing evidence that context influences experiences of stigma. People with schizophrenia in LMICs are vulnerable to food insecurity, violence and physical health problems, in addition to unmet needs for mental healthcare. Family support may help to improve outcomes if present, but caregivers may be overwhelmed by the challenges faced. Despite efforts to increase availability, evidence-based care remains inaccessible to many people with schizophrenia. Non-randomized evaluations in South Africa and Mexico indicate that psychosocial support groups for people with schizophrenia and caregivers may be acceptable and useful. Randomized controlled trials in Pakistan and China show that culturally adapted cognitive-behavioural therapy can reduce symptom severity. There is emerging evidence that alternative medicine, such as Tai Chi, may be beneficial, but to date most studies are of low quality. The challenges of biomedical-traditional provider collaborations have been highlighted. Evaluations of integrated mental healthcare in primary care are underway and promise to provide vital information about how to scale-up quality care. SUMMARY: Acceptable and effective responses to schizophrenia in LMICs should be cognisant of both cultural context and universal concerns. Efforts to enhance the quality of family support should be central to models of care.