Epidemiology of Untreated Psychoses in 3 Diverse Settings in the Global South: The International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II).

Importance: Less than 10% of research on psychotic disorders has been conducted in settings in the Global South, which refers broadly to the regions of Latin America, Asia, Africa, and Oceania. There is a lack of basic epidemiological data on the distribution of and risks for psychoses that can inform the development of services in many parts of the world. Objective: To compare demographic and clinical profiles of cohorts of cases and rates of untreated psychoses (proxy for incidence) across and within 3 economically and socially diverse settings in the Global South. Two hypotheses were tested: (1) demographic and clinical profiles of cases with an untreated psychotic disorder vary across setting and (2) rates of untreated psychotic disorders vary across and within setting by clinical and demographic group. Design, Setting, and Participants: The International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II) comprises incidence, case-control, and cohort studies of untreated psychoses in catchment areas in 3 countries in the Global South: Kancheepuram District, India; Ibadan, Nigeria; and northern Trinidad. Participants were individuals with an untreated psychotic disorder. This incidence study was conducted from May 1, 2018, to July 31, 2020. In each setting, comprehensive systems were implemented to identify and assess all individuals with an untreated psychosis during a 2-year period. Data were analyzed from January 1 to May 1, 2022. Main Outcomes and Measures: The presence of an untreated psychotic disorder, assessed using the Schedules for Clinical Assessment in Neuropsychiatry, which incorporate the Present State Examination. Results: Identified were a total of 1038 cases, including 64 through leakage studies (Kancheepuram: 268; median [IQR] age, 42 [33-50] years; 154 women [57.5%]; 114 men [42.5%]; Ibadan: 196; median [IQR] age, 34 [26-41] years; 93 women [47.4%]; 103 men [52.6%]; Trinidad: 574; median [IQR] age, 30 [23-40] years; 235 women [40.9%]; 339 men [59.1%]). Marked variations were found across and within settings in the sex, age, and clinical profiles of cases (eg, lower percentage of men, older age at onset, longer duration of psychosis, and lower percentage of affective psychosis in Kancheepuram compared with Ibadan and Trinidad) and in rates of untreated psychosis. Age- and sex-standardized rates of untreated psychoses were approximately 3 times higher in Trinidad (59.1/100 000 person-years; 95% CI, 54.2-64.0) compared with Kancheepuram (20.7/100 000 person-years; 95% CI, 18.2-23.2) and Ibadan (14.4/100 000 person-years; 95% CI, 12.3-16.5). In Trinidad, rates were approximately 2 times higher in the African Trinidadian population (85.4/100 000 person-years; 95% CI, 76.0-94.9) compared with the Indian Trinidadian (43.9/100 000 person-years; 95% CI, 35.7-52.2) and mixed populations (50.7/100 000 person-years; 95% CI, 42.0-59.5). Conclusions and Relevance: This analysis adds to research that suggests that core aspects of psychosis vary by historic, economic, and social context, with far-reaching implications for understanding and treatment of psychoses globally.

Acceptability of Peer Support for People With Schizophrenia in Chennai, India: A Cross Sectional Study Amongst People With Lived Experience, Caregivers, and Mental Health Professionals.

Introduction: Establishing structured peer support in mental health, particularly for people with schizophrenia, as a psychosocial intervention is early in low and middle-income countries like India. Before implementing and understanding the effectiveness of peer support service and which mode of peer support delivery will be suitable for our culture, our study aimed to understand if peer support would be accepted by the different participants like persons with schizophrenia, caregivers and mental health professionals in a tertiary care center in Chennai, India. Methods: The study was conducted at the outpatient department (OPD) of a tertiary psychiatric care facility in Chennai, India. A cross-sectional study method was used. Consecutive persons diagnosed with schizophrenia and caregivers of persons with schizophrenia, who attended the outpatient department, and mental health professionals within and outside the facility who met the inclusion and exclusion criteria participated in the study. A structured questionnaire purposefully developed for the study was administered to the different study participants. Descriptive statistics were used to analyze the data. Categorical variables were expressed as frequency and percentages, while the continuous variables were expressed as mean and standard deviation. Results: A total of 155 participants (52 persons with schizophrenia, 50 caregivers and 53 mental health professionals) completed the survey. The majority of the participants (90.4% of persons with schizophrenia, 86% caregivers and all mental health professionals) welcomed peer support interventions. The participants wanted peers to help persons with schizophrenia achieve personal goals to enhance their mental health and day to day living with an emphasis on independent living and interpersonal and social relationships and help them achieve medication and treatment-related goals toward recovery. Understanding the role of a peer support volunteer and transitioning from a "person with schizophrenia" to a "peer support volunteer" by persons with schizophrenia was thought most challenging. Conclusion: The results highlight the potential acceptability of peer support across several stakeholders in the care of schizophrenia in a low and middle-income country context. The results may guide the implementation of a peer support volunteer programme as an essential mechanism of delivering psychosocial interventions for persons with schizophrenia.

Title of the article: Sex hormones and psychopathology in drug naïve Schizophrenia.

Association of Prolactin levels & symptoms in first episode drug naïve Schizophrenia have been equivocal. This cross-sectional comparative study in a tertiary setting was conceived to examine the role of Sex hormones and symptoms in first episode untreated schizophrenia. To measure & compare the circulating estradiol, testosterone & prolactin levels in drug naïve first episode patients with Schizophrenia & healthy age matched controls. To test the association between stress, illness and psychopathology with hormone levels.In a cross-sectional Comparative study 102 subjects (Patients vs Healthy Controls)were enrolled. First episode drug naïve patients (N = 51)with International Classification of Diseases-10 (ICD-10) diagnosis of Schizophrenia were recruited by consecutive sampling. Symptom severity was measured using Positive and Negative Symptom Scale (PANSS).Sex hormone estimation was done at baseline using radioimmunoassay method (RIA) prior to antipsychotic initiation. 51 healthy controls were recruited to participate in the study. Mildly elevated prolactin levels were associated with higher total PANSS scores in women. Hallucinatory behavior and Grandiosity are positively correlated in patients with raised prolactin levels at baseline. Testosterone and estradiol were not associated with psychopathology. Women perceived more stress than men. Elevated prolactin levels in drug naïve Schizophrenia can be a putative marker for predicting gender differences in symptom severity and treatment responses in future.

What constitutes recovery in schizophrenia? Client and caregiver perspectives from South India.

BACKGROUND: Understanding the concept of recovery in severe mental illnesses such as schizophrenia from the social and cultural aspects is important as it will help in developing models of recovery and appropriate interventions. Client and caregiver perspectives on recovery play a significant role in shaping these models and interventions. Hence, the aim of this study was to understand how clients with schizophrenia and their caregivers perceive recovery and to examine the differences between male and female clients with schizophrenia. MATERIALS AND METHODS: A total of 100 clients with schizophrenia and 80 caregivers of clients with schizophrenia were included in the study after written informed consent. A semi-structured proforma was used to collect the sociodemographic profile and illness variables. A questionnaire was developed to assess the indicators of recovery from mental illness and was administered to study participants. Descriptive statistics including frequency and percentages were used along with the chi-square test for analysis. RESULTS: The most common indicators of recovery for the clients with schizophrenia were absence of symptoms (88%), no relapse (70%) and going back to work (70%), while for the caregivers were absence of symptoms (100%), becoming independent (92.5%) and no relapse (91%). Indicators of recovery were similar between male and female clients with schizophrenia except for the need to stop medication as an indicator of recovery observed significantly more in females (p = .006). Most clients used internal validation of indicators to assess their recovery (79%). CONCLUSION: Results indicate that clients and caregivers from India perceive recovery as being symptom free, able to go back to work and being independent. Clients with schizophrenia use internal validation to assess recovery. Gender does not play a role in the perceptions toward recovery in schizophrenia. These results will help in developing models of recovery for severe mental illness in Indian context leading to tailored interventions.

Medication adherence in first-episode psychosis and its association with psychopathology.

BACKGROUND: The purpose of the study was to follow-up the individuals with first-episode psychosis (FEP) for a period of 1 year to assess their medication adherence rates and to identify the association between medication adherence and psychopathology. MATERIALS AND METHODS: In a 1 year longitudinal study, 59 individuals with FEP were assessed for their sociodemographic profile and medication adherence at 1 month and 12-month follow-up period using a semi-structured per forma. Positive and negative symptoms were assessed by positive and negative syndrome scale (PANSS) while the functioning by global assessment of functioning (GAF) scale. RESULTS: Nearly 85% of the individuals were adherent with medications during the 1-month follow-up period, 32.2% were poorly adherent at the end of 12 months. Among various factors examined for association with medication adherence, positive and negative symptoms, and global functioning of the individuals at the end of 12 months were found to significant associated with poor medication adherence. CONCLUSION: There is a high rate of medication nonadherence in individuals with FEP at 12-month follow-up, and factors affecting nonadherence should be addressed specifically to improve medication adherence in these individuals.

Relationship of metabolic syndrome and neurocognitive deficits in patients with schizophrenia.

This study aimed to evaluate the association of the metabolic syndrome (MS) and its components with neurocognition among patients with schizophrenia. 121 patients with schizophrenia from an outpatient service of two psychiatric centers were assessed on a neurocognitive battery and by metabolic measures. More than half (56.2%) of the patients fulfilled the consensus criteria for MS. After controlling/adjusting for various covariates (age, education in years, duration of illness, age of onset, Positive and Negative Symptom scale score and presence of smoking status), it was found that compared to patients without MS, those with MS had significantly poorer performance "in the cognitive domains" of cognitive processing and selective attention (Stroop effect percentile; p value 0.002; effect size-0.45) and auditory and verbal memory (AVLT; p value <0.001; effect size 0.68). Patients with a higher number of abnormal parameters of MS had poorer functioning in the domains of cognitive processing and selective attention, auditory and verbal memory, and executive tasks. To conclude, this two center study suggests that MS has a negative impact on neurocognition in patients with schizophrenia. There is a need to identify and monitor metabolic abnormalities among patients with schizophrenia to minimize the negative effect of metabolic parameters on neurocognition.

Psychometric properties of Tamil version of Body Weight Image and Self Esteem questionnaire (BWISE) in severe mental illness in a South Indian population.

BACKGROUND: Body weight image self-esteem questionnaire (BWISE) has been recently developed to assess psychosocial adjustment related to antipsychotic induced weight gain in Schizophrenia and related disorders. Patients have reported disturbance in body image and poor self esteem due to weight gain leading to treatment non-adherence. AIM: Assessment of psychometric properties of Tamil version of Body weight image self-esteem questionnaire (BWISE) in our population. METHODOLOGY: In a cross sectional, validation study conducted at Schizophrenia Research Foundation (SCARF), 203 consenting outpatients with DSM IV diagnosis of Schizophrenia and related psychotic disorder fulfilling inclusion/exclusion criteria were administered BWISE. RESULTS: The mean age of the sample was 38.21 ±â€¯10.32 years. BWISE ratings showed that patients (54%) reported weight gain with current medications and were aware of increase in weight. Only three percent reported to have severe psychosocial adjustment to the weight gain while remaining reported moderate (55%) and mild (42%) psychosocial adjustment. Validation of Tamil version of BWISE was found to be of moderate range (internal consistency 0.55-0.72). Principal Component analysis of BWISE identified 3 components with a 50.36% variance. CONCLUSIONS: BWISE could be used as a useful screening instrument to assess the psychosocial consequences of weight gain in patients.

Objective psychosocial function vs. subjective quality-of-life in schizophrenia within 5-years after diagnosis: A study from southern India.

There is increasing interest from treaters and patients alike in subjective quality-of-life (sQOL) and objective psychosocial function as indices of treatment outcome in studies of schizophrenia. With the emergence of evidence-based treatment protocols (e.g., NIMH-funded Recovery after Initial Schizophrenia Episode Initiative) these outcomes are of particular significance in treatment studies of samples early in the course of their illness. Few studies have investigated demographic, clinical and cognitive factors associated with sQOL in samples early in the course of their illness and compared these factors to objective measures. We administered measures of sQOL or satisfaction with life, and objective psychosocial function to 59 people with schizophrenia within 5-years of diagnosis, along with standardized measures of symptoms and cognition. Results revealed that symptoms, rather than cognitive or demographic variables, were the best independent predictors of both subjective QOL and objective functioning. Positive symptoms were independent predictors of sQOL, while positive and negative symptoms were independent predictors of objective psychosocial status. Depression and cognition were also linked to sQOL. These findings point to the importance of attending to residual positive symptoms early in the treatment of schizophrenia as a means of possibly enhancing both subjective and objective outcome in early course schizophrenia.

Role of Novel Dietary Supplement N-acetyl Cysteine in Treating Negative Symptoms in Schizophrenia: A 6-Month Follow-up Study.

BACKGROUND: Abnormal metabolism of dopamine and glutamate in schizophrenia induces oxidative stress that is exacerbated by brain glutathione (GSH) deficiency. N-acetyl cysteine (NAC) increases brain GSH levels and is being used as an adjunctive agent in patients with schizophrenia. This open-label exploratory study in a naturalistic setting was conceived to examine the efficacy of NAC augmentation in treating negative syndrome in schizophrenia. AIMS: To examine the efficacy of add-on NAC (1200 mg) in treating negative symptoms measured using Scale for the Assessment of Negative Symptoms (SANS) and clinical global impression (CGI) at baseline and 24 weeks. SUBJECTS AND METHODS: In a 24-week feasibility study with open-label design, thirty patients with the International Classification of Diseases-Tenth Edition diagnosis of schizophrenia were recruited. Eligible patients were required to have been treated with stable dose of clozapine or amisulpride for negative symptoms for a minimum period of 8 weeks were selected for the study. The subjects were assigned to receive NAC (1.2 g/day) as an add-on treatment. Severity of negative symptoms was measured using SANS and CGI-severity at baseline and improvement with NAC measured using CGI-improvement at 24 weeks. Serum interleukin-6 was assessed before NAC initiation at baseline. RESULTS: NAC augmentation showed a significantly greater improvement in negative symptoms on total SANS and CGI scores at 24 weeks. CONCLUSIONS: NAC may be effective as an adjunct for the treatment of negative symptoms in schizophrenia.

Cognition, social cognition and functional disability in early-stage schizophrenia: A study from southern India.

In high-income countries a wealth of studies has revealed cognitive and social cognitive deficits in schizophrenia and a close relationship of these deficits to psychosocial functioning. Studies examining these illness features in middle and low-income countries are rare, particularly in early-stage samples. Sixty adult participants within 5 years of diagnosis with schizophrenia and 53 matched, healthy control were assessed with the MATRICS Consensus Cognitive Battery and the PEAT emotion identification task at study entry, and the WHODAS functioning scale one year later. Deficits on cognitive instruments ranged from d = 0.64-1.04 and were consistent with those reported in Western samples. Negative symptoms were linked to function longitudinally. Deficits in social cognitive skills and longitudinal links between cognition and functioning were not evident. These findings suggest a highly consistent magnitude of neurocognitive deficits in people with schizophrenia across widely varying cultures, but with limited evidence of social cognitive skill deficits using Western-based instruments. There was little evidence of a relationship between cognition and psychosocial disability in people with early-stage schizophrenia in this sample.

Sexual dysfunctions in schizophrenia: Professionals and patients perspectives.

BACKGROUND: Sexual dysfunction (SD) is not commonly reported by persons with schizophrenia unless an enquiry is made by a doctor or staff during routine clinical visits. MATERIALS AND METHODS: A cross-sectional study was carried out to determine reporting of drug-induced sexual side-effects and the attitude of the treating team in clarifying or detecting this issue. RESULTS: A vast majority of professionals (73.2%) did not enquire about SDs in routine clinical setting and admitted that they lack expertise based on the Attitude Survey Questionnaire. More than one-third of the patients (35.3%) attributed sexual side-effects to medications. Many patients (91.7%) reported good to fair tolerance to sexual side-effects according to the Psychotropic Related Sexual Dysfunction Questionnaire. CONCLUSION: The treating team plays a crucial role. Sexual side-effects are often under-reported and need to be addressed by the treating physician.

Psychiatric advance statements: an Indian experience.

BACKGROUND: The psychiatric advance statement (PAS) is a document that outlines the preferences of patients in their future treatment. Formulating and writing a PAS has not been studied in low- and middle-income (LAMI) countries. AIM: To study the feasibility of writing a PAS in an Indian population. METHODS: Patients' diagnosed with schizophrenia or schizoaffective psychosis attending the outpatient clinic at the Schizophrenia Research Foundation (SCARF) or its community centres in 2011 were screened using the study criteria. After obtaining informed consent, stratified sampling was used to derive the final sample. RESULTS: Most patients consented to participate in the study (122/123 patients). Following interviews with research assistants, 93 patients were assessed to have the capacity to write a PAS and 92 completed one. The patients were mostly able to complete the PAS on their own. Major themes included choice of treatment facility, type of treatment and nomination of others to take decisions on their behalf. A third of the sample were either from rural areas or not exclusively urban. At the time of the study, about 45% of the sample was rated as being symptomatic. CONCLUSION: Psychotic patients with a long-term illness, a third of them from non-urban areas, were able to write a valid PAS.