Saeed Farooq

The relationship between the duration of untreated psychosis and outcome in low-and-middle income countries: A systematic review and meta analysis

BACKGROUND The duration of untreated psychosis (DUP) is defined as the period between the onset of symptoms of psychosis and the start of antipsychotic treatment. Delay in the initiation of treatment, resulting in a long DUP, is associated with a poor prognosis in high-income (HI) countries. It is not known if longer DUP is associated with poor outcomes in Low and Middle Income (LAMI) countries, where schizophrenia might have a more benign course. METHODS A systematic review and meta-analysis of studies from LAMI countries that reported an association between DUP and response to treatment, measures of disability and mortality. The association between DUP, symptoms and cognitive function at presentation were also examined. FINDINGS Meta analysis of five studies that reported the association between DUP and the reduction in total symptoms scores after treatment found a significant negative correlation between DUP and improvement in symptoms after treatment (r=-0.290, 95% CI=-0.483 to -0.069, z=-2.559, p<0.011). Prolonged DUP was also associated with increased levels of disability. One study reported that longer DUP was associated with a higher mortality in the following decade. CONCLUSIONS Delay in the initial initiation of treatment for psychosis is associated with a poorer response to treatment and increased levels of disability in LAMI countries.

Relationship between gross domestic product and duration of untreated psychosis in low- and middle-income countries.

BACKGROUND The duration of untreated psychosis (DUP), the period between the first onset of psychotic symptoms and treatment, has an important influence on the outcome of schizophrenia. AIMS To compare the published studies of DUP in low- and middle-income (LAMI) countries with the DUP of high-income countries, and examine a possible association between DUP and per capita income. METHOD We used six search strategies to locate studies of the DUP from LAMI countries published between January 1975 and January 2008. We then examined the relationship between DUP and measures of economic activity, which was assessed using the LAMI classification of countries and gross domestic product (GDP) purchasing power parity. RESULTS The average mean DUP in studies from LAMI countries was 125.0 weeks compared with 63.4 weeks in studies from high-income countries (P=0.012). Within the studies from LAMI countries, mean DUP fell by 6 weeks for every

Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial

1000 of GDP purchasing power parity. CONCLUSIONS There appears to be an inverse relationship between income and DUP in LAMI countries. The cost of treatment is an impediment to care and subsidised antipsychotic medication would improve the access to treatment and the outcome of psychotic illness in LAMI countries.

Clozapine: dangerous orphan or neglected friend?

Importance The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. Objective To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. Design, Setting, and Participants A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Interventions Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. Main Outcomes and Measures Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). Results Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help (AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder (AMD, -3.41; 95% CI, -4.49 to -2.34). Conclusions and Relevance Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. Trial Registration anzctr.org.au Identifier: ANZCTR12614001235695.

Schizophrenia medication adherence in a resource-poor setting: randomised controlled trial of supervised treatment in out-patients for schizophrenia (STOPS)

Evidence concerning the superior efficacy and effectiveness of clozapine has not fully informed routine clinical practice. This is possibly because of the perception that clozapine is a dangerous therapeutic agent. Clozapine use may actually promote longevity, and earlier use of clozapine in adequate dosages represents a neglected therapeutic opportunity in this age of stagnated antipsychotic innovation.

Brief culturally adapted CBT for psychosis (CaCBTp): A randomized controlled trial from a low income country

BACKGROUND Most people with schizophrenia in low- and middle-income (LAMI) countries receive minimal formal care, and there are high rates of non-adherence to medication. AIMS To evaluate the effectiveness of an intervention that involves a family member in supervising medication administration - supervised treatment in out-patients for schizophrenia (STOPS) - in improving treatment adherence and clinical outcomes. METHOD Individuals (n = 110) with schizophrenia or schizoaffective disorders were allocated to STOPS or to treatment as usual (TAU) and followed up for 1 year. The primary outcome was adherence to the treatment regimen. Positive and Negative Syndrome Scale for Schizophrenia and Global Assessment of Functioning scores were also assessed. RESULTS Participants in the STOPS group had better adherence (complete adherence: 37 (67.3%) in STOPS v. 25 (45.5%) in TAU; P<0.02) and significant improvement in symptoms and functioning. CONCLUSIONS STOPS may be useful in enhancing adherence to treatment for schizophrenia in LAMI countries.

Using Treatment Response to Subtype Schizophrenia: Proposal for a New Paradigm in Classification

Evidence for the effectiveness of Culturally adapted CBT for psychosis in Low And Middle Income Countries (LAMIC) is limited. Therefore, brief Culturally adapted CBT for psychosis (CaCBTp) targeted at symptoms of schizophrenia for outpatients plus treatment as usual (TAU) is compared with TAU. A total of 116 participants with schizophrenia were recruited from 2 hospitals in Karachi, Pakistan, and randomized into two groups with 1:1 allocation (CaCBTp plus TAU=59, TAU=57). A brief version of CaCBTp (6 individual sessions with the involvement of main carer, plus one session for the family) was provided over 4months. Psychopathology was measured using Positive and Negative Syndrome Scale of Schizophrenia (PANSS), Psychotic Symptom Rating Scales (PSYRATS), and the Schedule for Assessment of Insight (SAI) at baseline and end of therapy. Participants in treatment group, showed statistically significant improvement in all measures of psychopathology at the end of the study compared with control group. Participants in treatment group showed statistically significant improvement in Positive Symptoms (PANSS, Positive Symptoms Subscale; p=0.000), Negative Symptoms (PANSS, Negative Symptoms subscales; p=0.000), Delusions (PSYRATS, Delusions Subscale; p=0.000), Hallucinations (PSYRATS, Hallucination Subscale; p=0.000) and Insight (SAI; p=0.007). The results suggest that brief, Culturally adapted CBT for psychosis can be an effective treatment when provided in combination with TAU, for patients with schizophrenia in a LAMIC setting. This is the first trial of CBT for psychosis from outside the western world. These findings need replicating in other low and middle income countries.

Brief Culturally adapted CBT (CaCBT) for depression: A randomized controlled trial from Pakistan

Phenomenology and Diagnosis The treatment and classification of schizophrenia continue to represent an enormous challenge. Phenomenology and outcome remain the basis of present classification systems although both are heterogeneous and overlap with other psychiatric disorders.1,2 Efforts are in place for change; eg, the Working Group on Classification of Psychotic Disorders for ICD-11 has recommended omitting the traditional subtypes such as paranoid, catatonic, etc., in accordance with DSM-5, the major argument being lack of clinical utility in routine clinical practice.3,4 We believe the changes advocated do not go far enough because classification still relies heavily on symptom clusters. Adding severity and course specifiers, as is the case in the ICD-11 draft, or multiple dimensions (DSM-V) may represent more of a challenge than benefit for clinicians in their busy daily practices. Moreover, the reliability and predictive validity of these specifiers and domains are not well established and, possibly, not substantively better than the subtypes that have been abandoned.

A systematic review of explanatory models of illness for psychosis in developing countries

OBJECTIVES To determine the efficacy of brief Culturally adapted CBT (CaCBT) for depression when added to Treatment As usual (TAU)-delivered by trained therapists using a manual compared with alone TAU. METHODS This was an assessor-blinded, randomised controlled clinical trial. Particpants with a diagnosis of depression, attending psychiatry departments of three teaching hospitals in Lahore, Pakistan, were included in the study. We screened a total of 280 patients and randomly allocated 137 of them to CaCBT plus Treatment As Usual (TAU) [Treatment group] or to TAU alone [Control group]. Assessments were completed at baseline, at 3 months and at 9 months after baseline. Reduction in depression score (Hospital Anxiety and Depression-Depression Subscale) at 3 months was primary outcome measure. The secondary outcome measures included anxiety scores (Hospital Anxiety and Depression-Anxiety Subscale), somatic symptoms (Bradford Somatic Inventory), disability (Brief Disability Questionnaire) and satisfaction with the treatment. FINDINGS A total of 69 participants were randomised to Treatment group and 68 to Control group. Participants in Treatment group showed statistically significant improvement in depression (p=0.000), anxiety (p=0.000), somatic symptoms (p=0.005) and disability (p=0.000). This effect was sustained at 9 months after baseline (Except for disability). Participants in Treatment group also reported higher satisfaction with treatment compared with those in Control group. CONCLUSION Brief CaCBT can be effective in improving depressive symptoms, when compared with treatment as usual. This is the first report of a trial of Culturally adapted CBT from South Asia and further studies are needed to generalise these findings.

Clozapine prescribing in the UK: views and experience of consultant psychiatrists.

Abstract Background: Explanatory models of illness, held by patients and treating clinicians, offer justifications and propose explanations for sickness, treatment evaluations and choice. These have been studied in relation to common mental disorders but research on explanatory models of psychosis (EMOP) has received scant attention. Adequately understanding patients’ explanatory models for psychosis has important clinical implications. Method: We systematically examined studies on EMOP in the developing world to report on the nature of explanatory models, their relationship with help-seeking, duration of untreated psychosis (DUP), perceived stigma and any differences in the explanatory models between first and subsequent episodes. Results: 14 studies examining EMOP in developing countries were identified. The majority of studies reported predominantly supernatural and psychosocial EMOP. Holding supernatural and psychosocial explanatory models affected help-seeking behaviour, treatment modalities used and DUP. Discussion: EMOP in developing countries are rich and varied. The literature reports on a variety of populations using different methods and suffers from methodological limitations. Some recent studies have also attempted to modify explanatory models by using educational interventions; however, this was not examined in patient populations. Further research is needed to examine the impact of different explanatory models on DUP and help-seeking behaviours.