Alex S. Cohen

Treatment and prevention of mental disorders in low-income and middle-income countries

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Barriers to improvement of mental health services in low-income and middle-income countries

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.

Social Anhedonia and Schizotypy in a Community Sample: The Maryland Longitudinal Study of Schizotypy

Social anhedonia has been employed in psychometric high-risk studies to identify putative schizotypes. To date, this research has focused almost exclusively on college samples. The current study sought to examine the validity of social anhedonia as an indicator of risk for schizophrenia-spectrum disorders within a community sample. Furthermore, we evaluated the role of other individual difference variables in accounting for variable clinical severity within the social anhedonia group including trait affectivity, social support, and family environment. Following the mailed questionnaire screening of 2434 eighteen-year olds, laboratory assessments were conducted with individuals identified as being high in social anhedonia (n=86) and a comparison sample (n=89). Compared with the control group, individuals in the social anhedonia group were found to have higher rates of mood disorders, elevated schizophrenia-spectrum personality disorder characteristics, greater negative symptom characteristics, and lower global functioning. Individuals within the social anhedonia group also reported greater trait negative affectivity, lower positive affectivity, less social support, and more family conflict. Low social support and problematic family environment were found to be related to elevations in spectrum personality disorder characteristics and poorer functioning within the social anhedonia group. These cross-sectional findings from a community sample provide further support for social anhedonia as a possible indicator of schizotypy.

TOWARD A MORE PSYCHOMETRICALLY SOUND BRIEF MEASURE OF SCHIZOTYPAL TRAITS: INTRODUCING THE SPQ-BRIEF REVISED

Psychometric case identification of individuals at risk for developing schizophrenia-spectrum disorders is an important enterprise. Unfortunately, current instruments for this purpose are limited. The present studies sought to improve the Schizotypal Personality Questionnaire-Brief (SPQ-Brief), a measure of schizotypal traits that has come under recent criticism. In the first study, we conducted exploratory factor analysis on the SPQ-Brief using a Likert-style scoring format in a large sample of nonclinical adults. Although acceptable internal consistency was found, the original factor structure was not supported. In the second study, we administered the full version of the SPQ to a separate large nonclinical adult sample and employed exploratory and confirmatory factor analysis to identify critical items that could be used to revise the SPQ-Brief. The end product of these studies is the SPQ-Brief Revised, which offers a subordinate seven-factor and super-ordinate three or four factor solution, employs a Likert-scale format to improve sensitivity, and is brief (34 items).

Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India

Background There is little evidence of the feasibility, acceptability and impact of services for the care of people with psychotic disorders in low- and middle-income countries. Aims To describe the scaling up and impact of a community-based rehabilitation programme for people with psychotic disorders in a very-low-resource setting. Methods Longitudinal study of people with psychotic disorders who had been ill for an average of 8 years in a rural Indian community. All individuals received a community-based intervention package comprising psychotropic medications, psychoeducation, adherence management, psychosocial rehabilitation and support for livelihoods. The primary outcome was change in disability scores. Results The cohort consisted of 256 people with psychotic disorders (schizophrenia, bipolar affective disorder and other psychosis) of whom 236 people completed the end-point assessments (92%), with a median follow-up of 46 months. There were significant reductions (P<0.05) in the levels of disability for the cohort, the vast majority (83.5%) of whom engaged with the programme. On multivariate analyses, lower baseline disability scores, family engagement with the programme, medication adherence and being a member of a self-help group were independent determinants of good outcomes. Lack of formal education, a diagnosis of schizophrenia and dropping out of the programme were independent determinants of poor outcomes. Conclusions Community-based rehabilitation is a feasible and acceptable intervention with a beneficial impact on disability for the majority of people with psychotic disorders in low-resource settings. The impact on disability is influenced by a combination of clinical, programme and social determinants.

Specific cognitive deficits and differential domains of social functioning impairment in schizophrenia

There is considerable inconsistency in findings regarding the relationship between specific cognitive deficits and social impairment in patients with schizophrenia. This inconsistency may relate to variability across studies in how social functioning is measured and preliminary evidence suggests that different indices of social functioning (e.g., laboratory test, community assessment) may have different cognitive correlates. The present study examined this issue by evaluating the relationships between cognitive deficits (including social cognitive deficits), role-play test performance, and community social functioning in 28 inpatients with schizophrenia. We expected the two measures of social functioning to have only modest convergence with each other. Moreover, informed by the literature on cognitive functioning in schizophrenia, we identified specific cognitive processes that were hypothesized to be associated with role-play performance (delayed verbal memory and attentional vigilance) and social functioning in the community (delayed verbal memory and executive functioning). As expected, the two measures of social functioning were modestly correlated with each other. Community social functioning was associated with a relatively constrained pattern of cognitive deficits and received a significant contribution (Deltar2=0.24) from specific cognitive processes beyond that of general cognitive functioning and symptom severity. In contrast to our hypotheses, role-play test performance was associated with a wide range of cognitive impairments and received little contribution from the specific cognitive processes beyond the effects of general cognitive functioning. Community social functioning, but not role-play test performance, was significantly associated with social cognition. These findings highlight the importance of conceptualizing social functioning as a multidimensional construct for schizophrenia research.

Cognition and Brain Function in Schizotypy: A Selective Review

Schizotypy refers to a set of personality traits thought to reflect the subclinical expression of the signs and symptoms of schizophrenia. Here, we review the cognitive and brain functional profile associated with high questionnaire scores in schizotypy. We discuss empirical evidence from the domains of perception, attention, memory, imagery and representation, language, and motor control. Perceptual deficits occur early and across various modalities. While the neural mechanisms underlying visual impairments may be linked to magnocellular dysfunction, further effects may be seen downstream in higher cognitive functions. Cognitive deficits are observed in inhibitory control, selective and sustained attention, incidental learning, and memory. In concordance with the cognitive nature of many of the aberrations of schizotypy, higher levels of schizotypy are associated with enhanced vividness and better performance on tasks of mental rotation. Language deficits seem most pronounced in higher-level processes. Finally, higher levels of schizotypy are associated with reduced performance on oculomotor tasks, resembling the impairments seen in schizophrenia. Some of these deficits are accompanied by reduced brain activation, akin to the pattern of hypoactivations in schizophrenia spectrum individuals. We conclude that schizotypy is a construct with apparent phenomenological overlap with schizophrenia and stable interindividual differences that covary with performance on a wide range of perceptual, cognitive, and motor tasks known to be impaired in schizophrenia. The importance of these findings lies not only in providing a fine-grained neurocognitive characterization of a personality constellation known to be associated with real-life impairments, but also in generating hypotheses concerning the aetiology of schizophrenia.

Is the outcome of schizophrenia really better in developing countries

That schizophrenia has a better prognosis in non-industrialized societies has become an axiom in international psychiatry; the evidence most often cited comes from three World Health Organization (WHO) cross-national studies. Although a host of socio-cultural factors have been considered as contributing to variation in the course of schizophrenia in different settings, we have little evidence from low-income countries that clearly demonstrates the beneficial influence of these variables. In this article, we suggest that the finding of better outcomes in developing countries needs re-examination for five reasons: methodological limitations of the World Health Organization studies; the lack of evidence on the specific socio-cultural factors which apparently contribute to the better outcomes; increasing anecdotal evidence describing the abuse of basic human rights of people with schizophrenia in developing countries; new evidence from cohorts in developing countries depicting a much gloomier picture than originally believed; and, rapid social and economic changes are undermining family care systems for people with schizophrenia in developing countries. We argue that the study of the long-term course of this mental disorder in developing countries is a major research question and believe it is time to thoroughly and systematically explore cross-cultural variation in the course and outcome of schizophrenia.

Stability of formal thought disorder and referential communication disturbances in schizophrenia.

This study examined the degree to which different types of communication disturbances in the speech of 48 schizophrenia patients and 28 controls were variable and state related versus stable and traitlike. Clinically rated formal thought disorder and 5 types of referential disturbance showed substantial stability within participants over time. The sixth type of referential disturbance, the vague reference, was not stable over time. Formal thought disorder was associated with the severity of core psychotic symptoms in patients. whereas referential disturbances showed little or no association with positive or negative symptom severity. Furthermore, changes in psychotic symptoms over time were accompanied by corresponding changes in formal thought disorder but not referential disturbances. These results support the idea that some types of referential disturbances are traitlike and may be reflective of vulnerability as well as manifest illness.

Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India

Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low resource settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials.