Alemayehu Negash

Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia.

Background: Many studies from the Western world have reported on stigmatisation of people with mental illnesses and its negative consequences, but few studies have addressed the issue in traditional rural societies. The present study aimed to estimate the extent and socio-demographic distribution of stigma as perceived by relatives of mentally ill individuals in rural Ethiopia. Method: A total of 178 relatives of individuals who were diagnosed as suffering from schizophrenia or major affective disorders in a community-based survey were interviewed using the Family Interview Schedule. Results: About 75 % of the respondents perceived that they were stigmatised or had experienced some sort of stigma due to the presence of mental illness in the family, 42 % were worried about being treated differently and 37 % wanted to conceal the fact that a relative was ill. Those from the older age group (45+) and urban residents were more likely to perceive stigma as a major problem, but otherwise differences were few between socio-demographic groups. The illness was attributed to supernatural forces by 27 % and praying was suggested as a preferred method to deal with the problem by 65 %. Conclusion: Stigma was found to be a common problem, with few differences between socio-demographic groups or between types of mental disorder. Beliefs about causes differ from those held by professionals. Popular beliefs and attitudes must be taken into account when planning for intervention.

Onset and clinical course of schizophrenia in Butajira-Ethiopia--a community-based study.

Abstract.Background:There are reports on favourable course and outcome of schizophrenia in lowincome countries. The aim of the present study was to examine onset and clinical course of the illness in a community-based sample in rural Ethiopia based on crosssectional information.Method:A two-stage survey was carried out in Butajira-Ethiopia, a predominantly rural district. Altogether 68,378 individuals aged 15–49 years were CIDI-interviewed, of whom 2,159 were identified as cases according to the CIDI interview with regard to psychotic or affective disorders. Key informants identified another group of 719 individuals as being probable cases and a total of 2,285 individuals were SCAN-interviewed. The present paper reports on cases with schizophrenia.Results:There were 321 cases of schizophrenia giving an estimated lifetime prevalence of 4.7/1,000). Of the cases,83.2% (N = 267) were males. Mean age of first onset of psychotic symptoms for males was 23.8 (sd 8.6) compared to 21.0 (sd 7.8) for females (P = 0.037; 95 %CI 0.16–5.47). Over 80% had negative symptoms and over 67% reported continuous course of the illness. Less than 10% had a history of previous treatment with neuroleptic medication. About 7% were vagrants, 9 % had a history of assaultive behaviour,and 3.8% had attempted suicide. The male to female ratio was nearly 5:1.Conclusion:This large community-based study differs from most previous studies in terms of higher male to female ratio, earlier age of onset in females and the predominance of negative symptoms.

Schizophrenia: illness impact on family members in a traditional society - rural Ethiopia

Abstract.Background: Studies have consistently shown that both the subjective and objective dimensions of burden among family members of schizophrenia patients and other psychiatric disorders are prevalent. However, as most of these reports were from western societies, we lack information on the subject in developing countries. Method: The study was conducted within the framework of the ongoing epidemiological study of course and outcome of schizophrenia and bipolar disorders in a rural population of 15–49 years of age. Three hundred and one cases of schizophrenia and their close relatives participated in the study. Results: Family burden is a common problem of relatives of cases with schizophrenia. Financial difficulty is the most frequently endorsed problem among the family burden domains (74.4 %). Relatives of female cases suffered significantly higher social burden (Z = 2.103; p = 0.036). Work (Z = 2.180; p = 0.029) and financial (Z = 2.088; p = 0.037) burdens affected female relatives more often than males. Disorganised symptoms were the most important factors affecting the family members in all family burden domains. Prayer was found to be the most frequently used coping strategy in work burden (adj. OR = 1.99; 95 % CI = 1.08–3.67; p = 0.026). Conclusion: Negative impact of schizophrenia on family members is substantial even in traditional societies such as those in Ethiopia where family network is strong and important. The scarce existing services in the developing countries should include family interventions and support at least in the form of educating the family members about the nature of schizophrenia illness and dealing with its stigma and family burden.

Clinical Course and Outcome of Schizophrenia in a Predominantly Treatment-Naive Cohort in Rural Ethiopia

The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia.

BACKGROUND Prospective outcome studies based on a community sample of mostly neuroleptic naive cases of schizophrenia are uncommon. OBJECTIVES To describe short-term symptomatic and functional outcomes of schizophrenia, and potential predictors of outcome. METHODS After a baseline assessment, 63 incident and 208 prevalent cases of schizophrenia were followed by a yearly clinical assessment for an average of 2.5 (range 1-4) years. Scores of negative symptoms and positive symptoms were used as indicators of symptomatic outcomes. SF-36 scores of physical and social functioning, and role limitation due to mental health problems were used as indicators of functional outcomes. Several variables were evaluated as potential predictors of outcome in random coefficient models. RESULTS Functioning and other measures of health related quality of life were significantly diminished in cases as compared to the general population of the area at baseline and follow up. Of the socio-demographic and clinical factors evaluated, only lower negative and positive symptom scores were significantly associated with improvements in functioning. The level of functioning observed in cases from Butajira was lower than that reported for cases from developed countries. CONCLUSIONS Our findings are not in accord with other outcome studies that have reported better functional outcome for cases of schizophrenia from developing countries.

An Evaluation of Two Screening Methods to Identify Cases with Schizophrenia and Affective Disorders in a Community Survey in Rural Ethiopia

Background: Detecting cases with psychiatric disorders in the general population is costly and it is not clear which is the method of choice for community surveys in low-income countries. Aim: To compare the performance of a standardized diagnostic layman interview instrument-the Composite International Diagnostic Interview (CIDI 2.1) versus the Key Informant method in identifying cases with schizophrenia and major affective disorders in a community survey. Method: Both screening methods were tested against an expert interview the Schedule for Clinical Assessment in Neuropsychiatry (SCAN 2.1) in a rural district in Ethiopia with 25,632 inhabitants. Result: CIDI identified 524 and key informants 192 individuals as probable cases who were invited for a further SCAN interview. Seventy-two individuals were identified by both methods. Of those identified as probable cases by either method, a total of 481 volunteered the SCAN interviews. The Key Informant method alone detected more cases of schizophrenia, 59 vs. 29 for CIDI, whereas CIDI alone detected more cases of affective disorders, 45 vs. 30. Key informants performed better in detecting chronic cases. Conclusion: For community surveys, which aim at identifying cases with major mental disorders in low-income countries like Ethiopia, the combined use of both CIDI and the Key Informant method is recommended.

Neurological soft signs (NSS) in 200 treatment-naïve cases with schizophrenia: a community-based study in a rural setting

Several studies have reported neurological soft signs (NSS) to be common in individuals with schizophrenia. The majority of these studies are based on clinical samples exposed to neuroleptic treatment. The present study reports on 200 treatment-naïve and community-identified cases of schizophrenia and 78 healthy individuals from the same area, evaluated using the Neurological Evaluation Scale (NES). The median NES score was 5.0 for cases of schizophrenia and 1.5 for healthy subjects. The impairment rate of NSS in cases with schizophrenia was 65.0% against 50.0% in healthy subjects, and the difference was statistically significant ( h 2 = 5.30; df = 1; P < 0.021). NSS abnormality is as common in treatment-naïve cases as reported in many studies in those on neuroleptic medication. There was no significant relation between the NSS impairment and duration of illness, remission status, positive symptoms, negative symptoms and disorganized symptoms.

Clinical outcome in bipolar disorder in a community‐based follow‐up study in Butajira, Ethiopia

Objective:  To determine the clinical outcome of bipolar disorder in a developing country setup.

Bipolar disorder among an isolated island community in Ethiopia

BACKGROUND Psychiatric data on population groups of geographic and social isolates are rare, but can potentially give insights into factors of aetiological importance. The Zeway islanders have lived in geographic and cultural isolation for over three centuries. AIM To determine the prevalence of major psychiatric disorders among the adult population of Zeway islands. METHODS A three stage screening design that included the use of structured interview instruments (CIDI and SCAN), key informants, and clinical assessment by psychiatrists was employed for case identification. RESULTS Prevalence of bipolar disorders among the adult population (n = 1691) was 1.83% (n = 31) with 66% of the cases originating from one of the islands that constitutes only 17.33% of the study population. Only one subject was identified with schizophrenia. CONCLUSIONS A pattern of differential prevalence for bipolar disorders and schizophrenia appears to exist in this isolated population, which also seems shared by other isolated population groups. The high prevalence of bipolar disorders with clustering of cases on one island may represent an environmental or genetic factor of etiologic relevance that deserves further exploration.

The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia

OBJECTIVES To describe the major sociodemographic correlates of schizophrenia, and their interactions, in a rural population of Ethiopia. METHODS We have recently completed a study in Butajira to identify cases of major mental disorders for description of course and outcome. A total of 318 cases of schizophrenia were identified by a door-to-door survey of a predominantly rural population of close to 68,500 individuals. Cases were confirmed by use of the SCAN and clinical assessment. FINDINGS The study showed that being male, under 35 years of age, unmarried, educated and living in an urban area were factors all associated with schizophrenia independently of each other. The risk of schizophrenia associated with being male was much higher in those aged 35 and over compared to those under 35 years of age. The risk of schizophrenia among males was higher in those not married (never married, separated, divorced or widowed) compared to those who were married. The association of marital status with schizophrenia was also more pronounced among those aged 35 year or over compared to those under 35. The association between schizophrenia and being unmarried was higher in urban than in rural areas. CONCLUSION The sociodemographic correlates of schizophrenia in this rural population were similar to those described for the developed world. Furthermore, there were significant interactions between sex, age, marital status, area of residence and education as correlates of schizophrenia.