Factor structure of the brief psychiatric rating scale-expanded among outpatients with psychotic disorders in five Southeast European countries: evidence for five factors.

The Brief Psychiatric Rating Scale (BPRS) is a useful tool for measuring the severity of psychopathological symptoms among patients with psychosis. Many studies, predominantly in Western countries, have investigated its factor structure. This study has the following aims: (a) to further explore the factor structure of the BPRS-Expanded version (BPRS-E, 24 items) among outpatients with psychotic disorders in Southeast European countries; (b) to confirm the identified model; and (c) to investigate the goodness-of-fit of the three competing BPRS-E factor models derived from previous studies. The exploratory factor analysis (EFA) produced a solution with 21 items grouped into five factors, thus supporting the existence of a fifth factor, i.e., Disorganization. A follow-up confirmatory factor analysis (CFA) revealed a 19-item model (with two items removed) that fit the data well. In addition, the stability of two out of three competing factor models was confirmed. Finally, the BPRS-E model with 5 factors developed in this cross-national study was found to include a greater number of items compared to competing models.

Mental Health Information Reporting Assistant (MHIRA)-an open-source software facilitating evidence-based assessment for clinical services.

Evidence-based assessment (EBA) in mental health is a critical aspect of improving patient outcomes and addressing the gaps in mental health care. EBA involves the use of psychometric instruments to gather data that can inform clinical decision-making, inform policymakers, and serve as a basis for research and quality management. Despite its potential, EBA is often hindered by barriers such as workload and cost, leading to its underutilization. Regarding low- and middle-income countries (LMIC), the implementation of EBA is recognized as a key strategy to address and close the prevalent mental health treatment gap.To simplify the application of EBA including in LMIC, an international team of researchers and practitioners from Tanzania, Kosovo, Chile, and Switzerland developed the Mental Health Information Reporting Assistant (MHIRA). MHIRA is an open-source electronic health record that streamlines EBA by digitising psychometric instruments and organising patient data in a user-friendly manner. It provides immediate and convenient reports to inform clinical decision-making.The current article provides a comprehensive overview of the features and technical details of MHIRA, as well as insights from four implementation scenarios. The experience gained during the implementations as well as the user-feedback suggests that MHIRA has the potential to be successfully implemented in a variety of clinical contexts and simplify the use of EBA. However, further research is necessary to establish its potential to sustainably transform healthcare services and impact patient outcomes.In conclusion, MHIRA represents an important step in promoting the widespread adoption of EBA in mental health. It offers a promising solution to the barriers that have limited the use of EBA in the past and holds the potential to improve patient outcomes and support the ongoing efforts to address gaps in mental health care.

The relations between socio-demographic information and negative symptoms, mental health, and quality of life: a latent profile analysis with psychotic patients in Kosovo.

The current study aims to identify meaningful psychotic patients' profiles by examining certain combinations of patient's demographic and socio-economic variables (sex, age, marital status, number of children, cohabitant and level of education). Moreover, we aim to assess whether there is any significant effect of class membership (profile) on negative symptoms, health state, and quality of life among psychotic patients. A convenience sample of 103 patients (age: M = 22, SD = 1.75), was drawn from the clinical populations of Kosovo. Demographic and socio-economic data was obtained through individual interviews, meanwhile a battery of questionnaires was used to assess negative symptoms, mental health, and quality of life of patients. The 4-class solution was selected as the best fitting model and used in subsequent analyses. Results indicated a significant effect of class membership on health state, quality of life and negative symptoms. Practical implications are discussed.

Clozapine prescription rates in Southeast Europe: A cross-sectional study.

Introduction: International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods: Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results: It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion: Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.

Prevalence of Perceived Stress, Anxiety, and Depression in HCW in Kosovo during the COVID-19 Pandemic: A Cross-Sectional Survey.

A pandemic may have a negative impact on healthcare workers' (HCW) mental health. In this cross-sectional study, we assess the self-reported prevalence of stress, anxiety, and depression and identify their predictive factors among HCW in Kosovo. The online questionnaire collected data on socio-demographics (sex, age, occupation, education, workplace) and the presence and severity of depression, anxiety, and stress through the 21-item Depression, Anxiety, and Stress Scale (DASS-21) questionnaire. Descriptive statistics, t-test, and linear logistic regression were used to analyze the data. Of the 545 respondents, the majority were male (53.0%), under 60 years of age (94.7%), and married (81.7%). Most of them were physicians (78.2%), while the remaining were nurses, midwives, and other health professionals (22%). Prevalence rates for moderate to extremely high stress, anxiety, and depressive symptoms were 21.9%, 13.0%, and 13.9%, respectively. The nurses reported significantly higher mean scores for depression and anxiety than the physicians (p < 0.05). Being married, having poor health, not exercising, and reporting "burnout" from work significantly predicted higher levels of depressive, anxiety, and stress symptoms among health workers (p < 0.05). Most HCWs (71.6%) reported a mild, moderate, or severe mental health burden, and certain factors predicted higher levels of such burden.

Challenges faced by university students during the COVID-19: An international study in five countries during the early phase of the pandemic.

This study focused on the specific challenges of university students in the face of the COVID-19 pandemic and examined similarities and differences in COVID-related concerns and difficulties in functioning in samples of undergraduate students in five countries. A sample of 4306 undergraduate university students (43.8% males, 56.2% females) from Israel, Kosovo, Ukraine, Cyprus and Germany participated in an anonymous online survey during the first wave of the pandemic, between March and June 2020. Study variables included the assessment of the exposure to COVID-19, perceived health status, specific COVID-related concerns and functional difficulties, social support, and the perceived level of coping. Similar concerns about the uncertainty regarding the termination of the health crisis and worry for the health of family members were identified as the most common concerns in the five countries. Challenges in online learning and financial difficulties were rated as the most central difficulties. Both COVID-related concerns and COVID-related difficulties predicted lower levels of perceived coping. Greater social support was associated with better perceived coping. Policymakers should be informed by the accumulating research showing the substantive relationships between academic difficulties and perceived COVID-related distress and coping.

Corrigendum: Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

[This corrects the article DOI: 10.3389/fpsyt.2021.785144.].

Structure of Negative Symptoms in Schizophrenia: An Unresolved Issue.

Background: Negative symptoms are core features of schizophrenia and very challenging to be treated. Identification of their structure is crucial to provide a better treatment. Increasing evidence supports the superiority of a five-factor model (alogia, blunted affect, anhedonia, avolition, and asociality as defined by the NMIH-MATRICS Consensus); however, previous data primarily used the Brief Negative Symptoms Scale (BNSS). This study, including a calibration and a cross-validation sample (n = 268 and 257, respectively) of participants with schizophrenia, used the Clinical Assessment Interview for Negative Symptoms (CAINS) to explore the latent structure of negative symptoms and to test theoretical and data-driven (from this study) models of negative symptoms. Methods: Exploratory factor analysis (EFA) was carried out to investigate the structure of negative symptoms based on the CAINS. Confirmatory factor analysis (CFA) tested in a cross-validation sample four competing theoretical (one-factor, two-factor, five-factor, and hierarchical factor) models and two EFA-derived models. Result: None of the theoretical models was confirmed with the CFA. A CAINS-rated model from EFA consisting of five factors (expression, motivation for recreational activities, social activities, vocational, and close/intimate relationships) was an excellent fit to the data (comparative fix index = 0.97, Tucker-Lewis index = 0.96, and root mean square error of approximation = 0.07). Conclusions: This study cannot support recent data on the superiority of the five-factor model defined by the NMIH-MATRICS consensus and suggests that an alternative model might be a better fit. More research to confirm the structure of negative symptoms in schizophrenia, and careful methodological consideration, should be warranted before a definitive model can put forward and shape diagnosis and treatment of schizophrenia.

Implementing a digital mental health intervention for individuals with psychosis - a multi-country qualitative study.

BACKGROUND: Implementation of psychosocial interventions in mental health services has the potential to improve the treatment of psychosis spectrum disorders (PSD) in low- and middle-income countries (LMICs) where care is predominantly focused on pharmacotherapy. The first step is to understand the views of key stakeholders. We conducted a multi-language qualitative study to explore the contextual barriers and facilitators to implementation of a cost-effective, digital psychosocial intervention, called DIALOG+, for treating PSD. DIALOG+ builds on existing clinician-patient relationships without requiring development of new services, making it well-fitting for healthcare systems with scarce resources. METHODS: Thirty-two focus groups were conducted with 174 participants (patients, clinicians, policymakers and carers), who were familiarized with DIALOG+ through a presentation. The Southeast European LMICs included in this research were: Bosnia and Herzegovina, Kosovo, (Kosovo is referred throughout the text by United Nations resolution) North Macedonia, Montenegro and Serbia. Framework analysis was used to analyse the participants' accounts. RESULTS: Six major themes were identified. Three themes (Intervention characteristics; Carers' involvement; Patient and organisational benefits) were interpreted as perceived implementation facilitators. The theme Attitudes and perceived preparedness of potential adopters comprised of subthemes that were interpreted as both perceived implementation facilitators and barriers. Two other themes (Frequency of intervention delivery; Suggested changes to the intervention) were more broadly related to the intervention's implementation. Participants were exceedingly supportive of the implementation of a digital psychosocial intervention such as DIALOG+. Attractive intervention characteristics, efficient use of scarce resources for its implementation and potential to improve mental health services were seen as the main implementation facilitators. The major implementation barrier identified was psychiatrists' time constrains. CONCLUSIONS: This study provided important insights regarding implementation of digital psychosocial interventions for people with PSD in low-resource settings by including perspectives from four stakeholder groups in five LMICs in Southeast Europe - a population and region rarely explored in the literature. The perceived limited availability of psychiatrists could be potentially resolved by increased inclusion of other mental health professionals in service delivery for PSD. These findings will be used to inform the implementation strategy of DIALOG+ across the participating countries. The study also offers insights into multi-country qualitative research.

Anxiety and depression among Kosovar university students during the initial phase of outbreak and lockdown of COVID-19 pandemic.

Background and Purpose: Measures taken to prevent COVID-19 infections, aside from causing disruptions in many facets of our daily life, have impeded education, including the higher education process, as never seen before on a global scale. Recent studies have indicated the potential negative impact of the COVID-19 pandemic on the mental health trajectory of university students. Anxiety and depression can seriously hamper students' quality of life and educational achievement. This study explored anxiety and depression among university students in Kosovo during the lockdown as a result of COVID-19 pandemics. The study was implemented during the initial phase of the pandemic. This study also explored the impact of selected determinants on the reported mental health of students. Methods: In total, 904 university students from the largest public university in Kosovo were enrolled in a web-based cross-sectional study during the early phase of the national lockdown due to the COVID-19 pandemic. Results: The first and second hierarchical regression models indicated that the anxiety and depression scores of students were predicted by gender, knowing someone who was infected with COVID-19, concerns about the potential financial impact of measures taken by governments to respond to the COVID-19 pandemic and excessive information seeking about COVID-19. The third model improved significantly when the variables concerns about family members' health, concerns about being lonely, problems with online lectures and requests for help from the university related to online lectures were added to the model. Overall, the findings indicated that situational variables associated with measures taken to respond to the COVID-19 pandemic appeared to predict anxiety and depression among students. Conclusion: These findings indicate that universities and public health institutions need to support students, especially the more vulnerable students, in enhancing their skills to cope with mental health problems and distress related to the pandemic and the shift to online learning.

Conducting research on building psychosocial support for Syrian refugee families in a humanitarian emergency.

BACKGROUND: This case study describes research, which is located in Turkey, where more than 750,000 Syrian refugees reside autonomously in Istanbul. The research developed and pilot tested a novel model for helping urban refugee families with limited to no access to evidence-based mental health services, by delivering a transdiagnostic family intervention for common mental disorders in health and non-health sector settings using a task-sharing approach. This case study addresses the following question: What challenges were encountered in developing and piloting a low intensity trans-diagnostic family support intervention in a humanitarian emergency setting? DISCUSSION: The rapidly growing scale of humanitarian crises requires new response capabilities geared towards addressing populations with prolonged high vulnerability to mental health consequences and limited to no access to mental health, health, and social resources. The research team faced multiple challenges in conducting this research in a humanitarian emergency setting including: 1) Non-existent or weak partnerships geared towards mental health research in a humanitarian emergency; 2) Lack of familiarity with task-sharing; 3). Insufficient language and cultural competency; 3) Fit with families' values and demands; 4) Hardships of urban refugees. Through the research process, the research team learned lessons concerning: 1) building a coalition of academic and humanitarian organization partners; 2) investing in the research capacity building of local researchers and partners; 3) working in a community-collaborative and multi-disciplinary approach. CONCLUSION: Conducting research in humanitarian emergency settings calls for innovative collaborative and multidisciplinary approaches to understanding and addressing many sociocultural, contextual, practical and scientific challenge.

Building Online and Telephone Psychological First Aid Services in a Low Resource Setting During COVID-19: The Case of Kosovo.

The COVID-19 pandemic and the measures brought for prevention of infections are associated with considerable psychosocial and psychological morbidity in the general population. Providing continuous mental health services during the pandemics is a challenge worldwide, especially in low- and middle-income countries (LMICs). This paper reports on the strategies and activities taken to protect public mental health during the COVID-19 pandemic in Kosovo. This included establishing online and phone psychological first aid services and developing psychoeducational videos and webinars. The paper concludes with several lessons learned during the process of establishing and maintaining these interventions, such as: initial political endorsement is crucial to gain and maintain the momentum of services; continuous training of volunteers is crucial for both addressing the needs/problems, which arise during the process of work and maintain the motivation of volunteers; promotion of the services is crucial; academic curricula training mental health professionals should include digital mental health related courses and manualization on how to establish this kind of services in midst of crisis is crucial in order to ensure quick operationalization when needed again especially in LMIC settings. The interventions developed provide opportunity for further research especially by evaluating the impact of the services and exploring how online and provision of mental health and psychoeducation services online could help to cover services gap in times of isolation, limited movement and situations similar to pandemics in settings with limited mental health services and resources. The situation with pandemics with COVID 19 is still far from ending. Future waves of infections and restriction could again spike the mental health and psychosocial and psychological strain of the general population, therefore being prepared in provisions of psychological first aid and other mental health services online is crucial.

War and displacement stressors and coping mechanisms of Syrian urban refugee families living in Istanbul.

The overall purpose of this study was to achieve a contextual understanding of war and displacement stressors and coping mechanisms among urban refugee families from Syria living in Istanbul. This study was informed primarily by Walsh's family resilience framework and Weine's Family Consequences of Refugee Trauma empirical model. Qualitative family interviews were conducted with a purposive sample of 30 Syrian refugee families from the Çapa and Esenler neighborhoods of Istanbul. Data were analyzed using a grounded theory approach and Atlas/ti software. The analysis identified a total of 21 war and displacement stressors for families across 3 categories: (a) Surviving war and border crossing; (b) Living as urban refugees, and; (c) Parenting children in refuge. The analysis also identified a total of 16 coping mechanisms for families across 4 themes: (a) Flexible and reciprocal family organization; (b) Hopeful family beliefs and communication; (c) Staying connected with family in Syria and in exile, and; (d) Making the best of living in a new country. These findings underlie the need for several practice and policy priorities including: (a) Increasing the number of children attending Turkish schools and decreasing child labor; (b) Incorporating faith into psycho-social and mental health interventions, and; (c) Developing family focused interventions conducted by community-based lay providers that draw upon empirical models of family stressors and coping. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Posttraumatic Growth Among Family Members With Missing Persons From War in Kosovo: Association With Social Support and Community Involvement.

There is almost no data on the role of social support and in general on posttraumatic growth among people who have missing family member(s) as result of war and who experience ambiguous loss. This study explores relationship between reported posttraumatic growth and perceived social support and social activism in community-based organizations dealing directly with issues of missing persons. Family members who reported higher levels of social support from family, friends, and important others reported significant higher levels of posttraumatic growth. Family members that reported being active in community-based organizations reported significant higher averages in posttraumatic growth scores in total and its subscales. Regression analyses indicates that factors associated posttraumatic growth were as follows: being active in community organization dealing with missing person's issues and higher levels of social support from friends and family. Findings provide insight for clinicians working with this population and psycho social experts working in postconflict contexts.

Global mental health and the National Institute of Mental Health Research Domain Criteria.

BACKGROUND: The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project presents innovative ways of investigating mental illness based on behavioral and neurobiological measures of dimensional processes. Although cultural psychiatrists have critiqued RDoC's implications and limitations for its under-developed focus on context and experience, RDoC presents opportunities for synergies with global mental health. It can capture aspects of clinical or sub-clinical behavior which are less dependent upon Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and perhaps better elucidate the role of culture in disease expression and resilience. Aim/Results: This article uses the example of migration to describe several starting points for new research: (1) providing components for building an investigable conceptual framework to understand individual's mental health, resilience and adjustment to migration challenges or social adversities in low- and middle-income countries (LMICs) and (2) identifying measurable factors which determine resilience or vulnerability, to guide development and evaluation of targeted prevention, treatment and recovery strategies for mental health in LMICs. CONCLUSION: In such ways, RDoC frameworks could help put the new cutting edge neurobiological dimensional scientific advances in a position to contribute to addressing mental health problems amid social adversities in LMICs. However, this would require a much-expanded commitment by both RDoC and global mental health researchers to address contextual and experiential dimensions.

Social networks and mental health in post-conflict Mitrovica, Kosova.

BACKGROUND: To investigate the relation between social networks and mental health in the post-conflict municipality of Mitrovica, Kosovo. METHODS: Using a three-stage stratified sampling method, 1239 respondents aged 16 years or above were recruited in the Greater Mitrovica region. Social network depth was measured by the frequency of contacts with friends, relatives and strangers. Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression was used to examine the association between social network depth and mental health. RESULTS: The analytical sample consisted of 993 respondents. The prevalence of depression (54.3%) and anxiety (64.4%) were extremely high. In multiple regression analysis, a lower depth of social network (contact with friends) was associated with higher levels of both depression and anxiety. CONCLUSIONS: This study has shown that only one variety of social network--contact with friends--was important in terms of mental health outcomes in a population living in an area heavily affected by conflict. This suggests that the relation between social networks and mental health may be complex in that the effects of different forms of social network on mental health are not uniform and may depend on the way social networks are operationalised and the particular context in which the relationship is examined.