Gender, age at onset, and duration of being ill as predictors for the long-term course and outcome of schizophrenia: an international multicenter study.

BACKGROUND: The aim of the current study was to explore the effect of gender, age at onset, and duration on the long-term course of schizophrenia. METHODS: Twenty-nine centers from 25 countries representing all continents participated in the study that included 2358 patients aged 37.21 ± 11.87 years with a DSM-IV or DSM-5 diagnosis of schizophrenia; the Positive and Negative Syndrome Scale as well as relevant clinicodemographic data were gathered. Analysis of variance and analysis of covariance were used, and the methodology corrected for the presence of potentially confounding effects. RESULTS: There was a 3-year later age at onset for females (P < .001) and lower rates of negative symptoms (P < .01) and higher depression/anxiety measures (P < .05) at some stages. The age at onset manifested a distribution with a single peak for both genders with a tendency of patients with younger onset having slower advancement through illness stages (P = .001). No significant effects were found concerning duration of illness. DISCUSSION: Our results confirmed a later onset and a possibly more benign course and outcome in females. Age at onset manifested a single peak in both genders, and surprisingly, earlier onset was related to a slower progression of the illness. No effect of duration has been detected. These results are partially in accord with the literature, but they also differ as a consequence of the different starting point of our methodology (a novel staging model), which in our opinion precluded the impact of confounding effects. Future research should focus on the therapeutic policy and implications of these results in more representative samples.

Prevalence, associated factors and perinatal outcomes of antepartum depression in Ibadan Nigeria.

BACKGROUND: Antepartum depression is the most common mental health disorder in pregnancy and it is also a risk factor for adverse perinatal outcomes. Low and middle income countries like Nigeria bear a higher burden of antepartum depression compared with high income countries. Prioritizing mental health issues among pregnant women is crucial to achieving the Sustainable Development Goals. We determined the prevalence, associated factors and perinatal outcomes of antepartum depression among pregnant women in Ibadan, Nigeria. METHODS: A prospective cohort study was conducted among 1745 pregnant women enrolled early in pregnancy (≤ 20 weeks) at four comprehensive obstetric facilities within Ibadan metropolis. Antepartum depression was ascertained during the third trimester using the Edinburg Postpartum Depression Scale ≥ 12. The primary exposure was antepartum depression and the outcome variables were the perinatal outcomes. The associated factors assessed included sociodemographic, obstetric, psychological, and lifestyle characteristics. Bi-variate logistic and Poisson regression analyses were used to assess the factors and relative risk for perinatal outcomes of antepartum depression. RESULTS: The prevalence of antepartum depression was 14.1%. The significant factors associated with APD after adjusting for confounders were: high income (≥ 20, 000) which was protective (AOR) = 0.59; 95% CI: (0.40 - 0.88); p-value: 0.010] and perceived stress increased the odds of APD in a monotonic fashion: moderate stress [AOR = 2.39; 95% CI: (1.01 - 5.7); p-value: 0.047], high stress [AOR = 6.43; 95% CI: (2.28 - 18.2); p-value: < 0.001]. Preterm delivery was the only significant perinatal outcome [Relative Risk (RR) = 1.66; 95% CI (1.14 - 2.39); p-value =  0.007]. Depression did not increase the risk of having low birth weight babies (p = 0.513), macrosomia (p = 0.894), birth asphyxia (p = 0.317), and caesarean section (p = 0.298). CONCLUSIONS: APD was prevalent among our study population. The significant factors identified in this study can be targeted to reduce the occurrence of APD among pregnant women in Nigeria through appropriate social and public health interventions which include APD screening, counselling, and the provision of emotional support for pregnant women during antenatal care.

Body mass index (BMI) and obesity in Nigerians with schizophrenia.

BACKGROUND: Few Nigerian studies have examined BMI in people with schizophrenia. The aims of the present study were to assess the prevalence and distribution of obesity in Nigerians with schizophrenia and to examine the clinical correlates of BMI and obesity. METHODS: A total of 207 people with schizophrenia met the inclusion criteria and were evaluated for BMI.The Positive and Negative Syndrome Scale (PANSS), Hamilton Depression Rating Scale (HDRS), Social and Occupational Functioning Assessment Scale (SOFAS) were rated for all participants. Anthropometric measures such as weight and height were taken using a standard protocol. RESULTS: The prevalence of obesity was 12.6%. The non-obese participants were made up of underweight 24 (11.7%), normal weight 118 (57%) and overweight 38 (18.4%). Compared to non-obese participants, obese participants were older, more educated, more likely to be employed, had higher incomes, lower PANSS score (negative subscale), had fewer female participants, and better social and occupational functioning (p < 0.05). BMI was positively correlated with age and monthly income. In the adjusted model, age, gender and education were independently associated with obesity while only age was associated with BMI. CONCLUSION: The present study suggests that unlike in high-income countries, obese patients with schizophrenia in Nigeria have better social and psychological functioning than non-obese patients.

The significance of sleep quality in euthymic bipolar patients from Nigeria.

Background: Bipolar disorder is highly under-researched in Africa. Existing studies show that racial/ethnic disparities exist for sleep quality. Poor sleep quality in bipolar disorder causes significant morbidity and mortality even during periods of euthymia. Aim: This study aimed to assess sleep quality and its correlates amongst euthymic patients with bipolar I disorder from Nigeria. Setting: The study was carried out in a teaching hospital, and state hospital, in Ibadan, Nigeria. Method: This cross-sectional study was conducted amongst 76 euthymic bipolar patients aged between 18 and 60 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for bipolar disorder. Euthymia was defined as having a score of ≤ 5 on the Young Mania Rating Scale and < 8 on the Hamilton Depression Rating Scale. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Results: A total of 37 (48.7%) participants had poor quality sleep. Sleep quality was associated with marital status (p = 0.013) and suicide plan (p = 0.047). Participants with good sleep quality had higher total sleep duration, lower time to fall asleep (sleep latency), better subjective quality of sleep, were less likely to use sleep medications and had less daytime dysfunction than participants with poor sleep quality. All p-values were < 0.05. Subjective quality of sleep, ongoing use of sleep medication, daytime dysfunction were independently associated with poor sleep quality. Conclusion: Poor sleep quality frequently persists during euthymic periods in patients with bipolar disorder. The correlates identified can be targeted for intervention during treatment.

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.

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 resources. FUNDING: US National Institute of Mental Health.

Modeling psychological function in patients with schizophrenia with the PANSS: an international multi-center study.

BACKGROUND: The aim of the current study was to explore the changing interrelationships among clinical variables through the stages of schizophrenia in order to assemble a comprehensive and meaningful disease model. METHODS: Twenty-nine centers from 25 countries participated and included 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Multiple linear regression analysis and visual inspection of plots were performed. RESULTS: The results suggest that with progression stages, there are changing correlations among Positive and Negative Syndrome Scale factors at each stage and each factor correlates with all the others in that particular stage, in which this factor is dominant. This internal structure further supports the validity of an already proposed four stages model, with positive symptoms dominating the first stage, excitement/hostility the second, depression the third, and neurocognitive decline the last stage. CONCLUSIONS: The current study investigated the mental organization and functioning in patients with schizophrenia in relation to different stages of illness progression. It revealed two distinct "cores" of schizophrenia, the "Positive" and the "Negative," while neurocognitive decline escalates during the later stages. Future research should focus on the therapeutic implications of such a model. Stopping the progress of the illness could demand to stop the succession of stages. This could be achieved not only by both halting the triggering effect of positive and negative symptoms, but also by stopping the sensitization effect on the neural pathways responsible for the development of hostility, excitement, anxiety, and depression as well as the deleterious effect on neural networks responsible for neurocognition.

Spontaneous and emergent extrapyramidal syndromes in Black Africans with first-episode schizophrenia and first exposure to antipsychotics.

BACKGROUND: Persons of African ancestry are thought to carry a higher risk for extrapyramidal syndromes (EPS) in schizophrenia. AIM: We investigated the phenomenon of spontaneous and treatment-emergent EPS in a sample comprising Xhosa (South Africa) and Yoruba (Nigeria) Africans with first-episode schizophrenia and first exposure to antipsychotics. METHODS: The Extrapyramidal Symptom Rating Scale (ESRS) and a variety of validated tools were used for the assessment of participants before, and two-weekly after treatment with low dose flupenthixol decanoate. Participants were followed up for 12 months. Association of EPS with clinical characteristics was investigated using Pearson's correlation and linear regression analyses. RESULTS: Of 88 participants at baseline, 16 (18.1%) had at least one definite EPS prior to antipsychotic exposure and 34 (38.6%) had treatment-emergent EPS. While spontaneous Parkinsonism was associated with negative symptoms (r = 0.2, p = 0.043; ß = 0.6, p = 0.043), treatment-emergent EPS demonstrated non-significant correlations with clinical characteristics. Apart from dyskinesia, the frequency of treatment-emergent EPS decreased over 12 months observation. CONCLUSION: These findings support the hypothesis suggesting that spontaneously occurring Parkinsonism in schizophrenia may be the motor spectrum of negative symptomatology. Future studies of this relationship may lead to early identification of patients who may be more sensitive to EPS.

Spirituality and Suicidality Among Patients with Schizophrenia: A Cross-sectional Study from Nigeria.

Studies which have explored the effect of spirituality on suicidality among patients with schizophrenia have been characterized by inconsistent results. The aim of this study was to examine the relationship between spirituality and suicidality among stable patients with schizophrenia in Nigeria. The Daily Spiritual Experience Scale was applied to measure spirituality. There was found a significant relationship between spirituality and having had suicidal thoughts in a lifetime. Spirituality was negatively correlated with the severity of negative symptoms, total positive and negative syndrome scale score (PANSS), the severity of depression, and positively correlated with functioning.

Childhood generalized specific phobia as an early marker of internalizing psychopathology across the lifespan: results from the World Mental Health Surveys.

BACKGROUND: Specific phobia (SP) is a relatively common disorder associated with high levels of psychiatric comorbidity. Because of its early onset, SP may be a useful early marker of internalizing psychopathology, especially if generalized to multiple situations. This study aimed to evaluate the association of childhood generalized SP with comorbid internalizing disorders. METHODS: We conducted retrospective analyses of the cross-sectional population-based World Mental Health Surveys using the Composite International Diagnostic Interview. Outcomes were lifetime prevalence, age of onset, and persistence of internalizing disorders; past-month disability; lifetime suicidality; and 12-month serious mental illness. Logistic and linear regressions were used to assess the association of these outcomes with the number of subtypes of childhood-onset (< 13 years) SP. RESULTS: Among 123,628 respondents from 25 countries, retrospectively reported prevalence of childhood SP was 5.9%, 56% of whom reported one, 25% two, 10% three, and 8% four or more subtypes. Lifetime prevalence of internalizing disorders increased from 18.2% among those without childhood SP to 46.3% among those with one and 75.6% those with 4+ subtypes (OR = 2.4, 95% CI 2.3-2.5, p < 0.001). Twelve-month persistence of lifetime internalizing comorbidity at interview increased from 47.9% among those without childhood SP to 59.0% and 79.1% among those with 1 and 4+ subtypes (OR = 1.4, 95% CI 1.4-1.5, p < 0.001). Respondents with 4+ subtypes also reported significantly more disability (3.5 days out of role in the past month) than those without childhood SP (1.1 days) or with only 1 subtype (1.8 days) (B = 0.56, SE 0.06, p < 0.001) and a much higher rate of lifetime suicide attempts (16.8%) than those without childhood SP (2.0%) or with only 1 subtype (6.5%) (OR = 1.7, 95% CI 1.7-1.8, p < 0.001). CONCLUSIONS: This large international study shows that childhood-onset generalized SP is related to adverse outcomes in the internalizing domain throughout the life course. Comorbidity, persistence, and severity of internalizing disorders all increased with the number of childhood SP subtypes. Although our study cannot establish whether SP is causally associated with these poor outcomes or whether other factors, such as a shared underlying vulnerability, explain the association, our findings clearly show that childhood generalized SP identifies an important target group for early intervention.

Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study.

INTRODUCTION: A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method. METHODS: Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed. RESULTS: Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients. DISCUSSION: This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.

Mental health and wellbeing of medical students in Nigeria: a systematic review.

In addition to the stresses common to medical school training, medical students in Nigeria face additional peculiar contemporary social problems due to income inequality, poverty, insecurity and political instability. These have a direct impact on their mental health and wellbeing. The aim of this study was to systematically review articles reporting on the epidemiology of psychiatric disorders among medical students in Nigeria. Studies were identified using MEDLINE, HINARI, African Journal Online (AJOL) and Google Scholar databases using search terms encompassing psychiatric morbidity amongst medical students. No date restrictions were applied to the search. The pooled prevalence estimate was calculated for each disorder. Psychological distress was present in 25.2% of the students, perceived stress in 60.5%, depression in 33.5% and anxiety in 28.8%. The current use of at least one psychoactive substance was present in up to 44.2%, while 35.5% of all the respondents had experienced one or more forms of abuse during their training as medical students. The prevalence of psychiatric disorders among medical students in Nigeria is high. Positive coping mechanisms such as religiosity, positive reframing and resilience which were identified in this review should be optimized to reduce the burden.

A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries.

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.

Sexual Dysfunction Among Patients With Schizophrenia in Southwest Nigeria.

Sexual functioning has received little attention as an important aspect of patient care for those suffering from schizophrenia. In Nigeria, cultural and religious factors often prevent patients from talking with their clinician about their sexual life. The aim of our study was to assess the frequency and nature of sexual dysfunction in patients with schizophrenia and assess the determinants of sexual dysfunction in such patients. Sexual dysfunction was assessed with the Arizona Sexual Experience Scale in 90 patients with schizophrenia. Demographic and clinical characteristics including quality of life, the severity of schizophrenia, and perceived stigma were recorded using a standardized protocol and data collection. The prevalence of sexual dysfunction was 36.7%. Higher scores on the negative subscale of the Positive and Negative Syndrome Scale (PANSS), the general subscale of the PANSS, the total scores on the PANSS, and a family history of mental illness were significantly associated with sexual dysfunction. The only significant predictor of sexual dysfunction was the severity of the negative subscale of the PANSS. This study highlights the high prevalence of sexual dysfunction among patients with schizophrenia. Efforts should be made to identify and address this problem.

Risk of manic switch with antidepressants use in patients with bipolar disorder in a Nigerian neuropsychiatric hospital.

BACKGROUND: Depressive disorders are common among those with bipolar affective disorder (BAD) and may necessitate the use of antidepressants. This has been suggested to precipitate manic episodes in some patients. OBJECTIVES: This study aims to determine the prevalence of and factors associated with manic switch in patients with BAD being treated with antidepressants. METHODS: Case notes of patients who were treated at a Nigerian neuropsychiatric hospital for a BAD from 2004 to 2015 were reviewed. BAD diagnosis was made using ICD-10 criteria. Treatment for bipolar depression included monotherapy (i.e. antidepressants, antipsychotics or mood stabilisers) or combination therapy (mood stabiliser with an antidepressant or a combination of mood stabilisers, antipsychotics and antidepressants). The primary outcome measure was a switch to mania or hypomania within 12 weeks of commencing an antidepressant. RESULTS: Manic or hypomanic switch (MS) was observed in 109 (44.3%) of the participants. Female gender, younger age, number of previous episodes and a past history of psychiatric hospitalisation were all significantly associated with a risk of MS. There was no significant difference in the rate of MS in either those treated with adjunct antidepressants therapy with a mood stabiliser or an antipsychotic or those placed on a combination of antidepressants, antipsychotics and mood-stabilising agents. CONCLUSION: A large proportion of patients with BAD on antidepressants experience medication-induced manic or hypomanic switch.

Bipolar I disorder in remission vs. schizophrenia in remission: Is there a difference in burden?

INTRODUCTION: Bipolar disorder (BD) is considered to have a better outcome in comparison to schizophrenia. However, recent data dispute this notion. The current study aimed to compare the burden of patients with BD type I (BD-I) in remission with similar patients with schizophrenia (SZ) in remission. MATERIALS AND METHODS: Patients with schizophrenia (n=75) and BD-I (n=54) aged 18-64years were included in the study. The diagnosis was made with the SCID-I/P. Patients were assessed for sociodemographic variables, stigma, quality of life, disability, suicidality and current symptomatology. The statistical analysis included analysis of covariance (ANCOVA) and chi-square test. RESULTS: ANCOVA with age at onset as a covariate and marital status and diagnosis as grouping variables returned no significant difference. DISCUSSION: The results of the current study suggest that when in remission, BD-I patients do not differ from patients with schizophrenia with regards to stigma, quality of life, disability level and suicidality. Also, when in remission, they do not differ regarding the severity of their psychopathology.

Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways.

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.

Prevalence and correlates of major depressive disorder (MDD) among adolescent patients with epilepsy attending a Nigerian neuropsychiatric hospital.

BACKGROUND: A high prevalence of mood disorders exists in patients with epilepsy. In most cases, this is not detected and, consequently, not treated. This study aimed to determine the prevalence and correlates of major depressive disorder (MDD) among adolescents with epilepsy attending a child and adolescent clinic in Nigeria. METHODS: We recruited 156 participants consecutively for the study. Adherence was assessed using the 8-item Morisky Medication Adherence Questionnaire, while the K-SADS was used to assess the presence of major depressive disorder. Seizure control was evaluated by the frequency of seizures within a year. RESULTS: Major depressive disorder (DSM-IV criteria) was diagnosed in 28.2% of the participants. The age of participants (p=0.013), seizure control (p=0.03), medication adherence (p=0.045), frequency of seizures in the preceding 4weeks (p<0.001), and duration of illness (p<0.001) were all significantly associated with the presence of MDD. Participants with seizures occurring more than once weekly in the preceding 4weeks were 16 times more likely to have a MDD compared with those with no seizures in the preceding 4weeks (p<0.001, 95% C.I. [4.13, 65.43]), while participants with a duration of illness more than 10years were more than four times likely to have MDD compared with those with an illness duration of 5-10years (p<0.01, 95% C.I. [0.07, 0.70]). CONCLUSION: The prevalence of MDD among patients with epilepsy was high. Poor seizure control, poor medication adherence, and long duration of illness were associated with the presence of MDD among such patients. Intervention should focus on ensuring good seizure control and optimal adherence in order to mitigate the impact of MDD in patients with epilepsy.

Concepts of madness in diverse settings: a qualitative study from the INTREPID project.

BACKGROUND: In order to facilitate case identification of incident (untreated and recent onset) cases of psychosis and controls in three sites in India, Nigeria and Trinidad, we sought to understand how psychoses (or madness) were conceptualized locally. The evidence we gathered also contributes to a long history of research on concepts of madness in diverse settings. METHODS: We conducted focus group discussions and individual interviews to collect information about how informants in each site make sense of and respond to madness. A coding framework was developed and analyses of transcripts from the FGDs and interviews were conducted. RESULTS: Analyses suggest the following: a) disturbed behaviors are the primary sign of madness; b) madness is attributed to a wide range of causes; and, c) responses to madness are dictated by cultural and pragmatic factors. These findings are congruent with similar research that has been conducted over the past 50 years. CONCLUSIONS: The INTREPID research suggests that concepts about madness share similar features across diverse settings: a) terms for madness are often derived from a common understanding that involves disruptions in mental processes and capacities; b) madness is recognized mostly by disruptive behaviours or marked declines in functioning; c) causal attributions are varied; and, d) help-seeking is a complex process.

Epidemiology and burden of bipolar disorder in Africa: a systematic review of data from Africa.

BACKGROUND: Bipolar disorder impacts negatively on the patient, the family, as well as the society. It taxes the health care services due to a combination of the illness with associated medical and psychiatric comorbidities. In Africa, unfortunately, knowledge of the epidemiology and burden of bipolar disorder is based mainly on studies from the USA and Europe. In this systematic review of literature from Africa, we highlight the epidemiology and burden of bipolar disorder. METHODS: A systematic review of publications from Africa relating to the epidemiology and burden of bipolar disorder was conducted. RESULT: Data from community surveys conducted in Nigeria and Ethiopia indicated a lifetime prevalence estimate of 0.1 % to 1.83 for bipolar disorder. Missed diagnosis rate of bipolar disorder was up to 36.2 %. In one study, 8.1 % of the males and 5.4 % of the females reported a previous suicide attempt. A study showed that up to 60 % of patients with bipolar disorder had at least one comorbidity. There were no reports on all-cause mortality and cost of illness. CONCLUSION: Bipolar disorder is a major mental health problem in Africa. Scientific findings on bipolar disorder from Africa are consistent with the existing literature from other parts of the world. There still exists a dearth of high quality studies addressing the epidemiological, clinical, social, and economic burden of the disorder.

Searching for psychosis: INTREPID (1): systems for detecting untreated and first-episode cases of psychosis in diverse settings.

PURPOSE: Our understanding of psychotic disorders is largely based on studies conducted in North America, Europe and Australasia. Few methodologically robust and comparable studies have been carried out in other settings. INTREPID is a programme of research on psychoses in India, Nigeria, and Trinidad. As a platform for INTREPID, we sought to establish comprehensive systems for detecting representative samples of cases of psychosis by mapping and seeking to engage all professional and folk (traditional) providers and potential key informants in defined catchment areas. METHOD: We used a combination of official sources, local knowledge of principal investigators, and snowballing techniques. RESULTS: The structure of the mental health systems in each catchment area was similar, but the content (i.e., type, extent, and nature) differed. Tunapuna-Piarco (Trinidad), for example, has the most comprehensive and accessible professional services. By contrast, Ibadan (Nigeria) has the most extensive folk (traditional) sector. We identified and engaged in our detection system-(a) all professional mental health services in each site (in- and outpatient services-Chengalpet, 6; Ibadan, 3; Trinidad, 5); (b) a wide range of folk providers (Chengalpet, 3 major healing sites; Ibadan, 19 healers; Trinidad: 12 healers); and c) a number of key informants, depending on need (Chengalpet, 361; Ibadan, 54; Trinidad, 1). CONCLUSIONS: Marked differences in mental health systems in each catchment area illustrate the necessity of developing tailored systems for the detection of representative samples of cases with untreated and first-episode psychosis as a basis for robust, comparative epidemiological studies.