Purpose

To investigate exposure to traumatic and stressful events and their association with depression, suicidal ideation, and alcohol abuse in people with severe mental disorder (SMD) in Ethiopia.

Methods

As part of the Programme for Improving Mental health carE, 300 people with SMD (84% primary psychosis, 11% bipolar disorder, and 16% depression with psychotic features) in a rural district were identified by psychiatric nurses. A cross-sectional assessment included clinical characteristics, experience of being restrained, exposure to stressful events as measured by an adapted version of the List of Threatening Experiences scale, traumatic events as measured by endorsement of 13 locally relevant potentially traumatic events that occurred since the onset of the participant's mental illness, depression symptoms measured by the Patient Health Questionnaire, the Suicidal Behavior Module of the Composite International Diagnostic Interview, and hazardous drinking which was calculated as a sum score of eight or higher on the Alcohol Use Disorders Identification Test.

Results

Almost half of participants reported being restrained since becoming ill, which was associated with more suicidal ideation and less hazardous drinking. More than one-third experienced traumatic events since becoming ill, including being assaulted, beaten, or raped. Exposure to traumatic events was associated with hazardous drinking.

Conclusions

In this rural Ethiopian setting, people with SMD experienced high levels of traumatic and stressful events which were associated with co-morbid conditions. Greater attention needs to be given to trauma prevention and integration of treatment for trauma sequelae in efforts to expand integrated mental health care.

Rationale

Little is known about the specific experience people living with bipolar disorder in rural, low resource settings, where conditions that disrupt normal social interactions are often highly stigmatized and evidence-based treatments are rare.

Objective

To explore illness experience, coping strategies, help-seeking practices, and consequences of illness among people with bipolar disorder (PBD) and their family members in rural Ethiopia as an initial step for developing psychosocial intervention grounded by the experiences of PBD.

Method

A qualitative methods using in-depth interviews were carried out with 27 individuals (15 PBD and 12 caregivers). The participants were identified on the basis of previous community-based research among people with severe mental illness. Interviews were carried out in Amharic, audio-recorded, transcribed, and translated into English. Data were analyzed using thematic analysis. Our approach was informed by phenomenological theory.

Result

Three major themes emerged: expressions and experiences of illness, managing self and living with otherness, and the costs of affliction. PBD and caregivers were concerned by different forewarnings of illness. Stigma and social exclusion were entwined in a vicious cycle that shaped both illness experience and the economic health and social life of the household. Nonetheless, PBD and caregivers learned from their experiences, developed coping strategies, and sought relief from trusted relationships, spirituality, and medication.

Conclusion

Our findings suggest that psychosocial intervention could be used to strengthen existing resources, in order to improve the lives of PBD and their family members. However, pervasive stigma may be a barrier to group and peer support approaches.

Abstract: Background: This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting. Methods: A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers. Results: Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure. Conclusions: Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI.

Background

Adjunctive psychological interventions for bipolar disorder have demonstrated better efficacy in preventing or delaying relapse and improving outcomes compared with pharmacotherapy alone.

Aims

To evaluate the efficacy of psychological interventions for bipolar disorder in low- and middle-income countries.

Method

A systematic review was conducted using PubMed, PsycINFO, Medline, EMBASE, Cochrane database for systematic review, Cochrane central register of controlled trials, Latin America and Caribbean Center on Health Science Literature and African Journals Online databases with no restriction of language or year of publication. Methodological heterogeneity of studies precluded meta-analysis.

Results

A total of 18 adjunctive studies were identified: psychoeducation (n = 14), family intervention (n = 1), group cognitive-behavioural therapy (CBT) (n = 2) and group mindfulness-based cognitive therapy (MBCT) (n = 1). In total, 16 of the 18 studies were from upper-middle-income countries and none from low-income countries. All used mental health specialists or experienced therapists to deliver the intervention. Most of the studies have moderately high risk of bias. Psychoeducation improved treatment adherence, knowledge of and attitudes towards bipolar disorder and quality of life, and led to decreased relapse rates and hospital admissions. Family psychoeducation prevented relapse, decreased hospital admissions and improved medication adherence. CBT reduced both depressive and manic symptoms. MBCT reduced emotional dysregulation.

Conclusions

Adjunctive psychological interventions alongside pharmacotherapy appear to improve the clinical outcome and quality of life of people with bipolar disorder in middle-income countries. Further studies are required to investigate contextual adaptation and the role of non-specialists in the provision of psychological interventions to ensure scalability and the efficacy of these interventions in low-income country settings.

Declaration of interest

None.

Background

In this protocol, we outline a mixed-methods randomized feasibility trial of Brief Relaxation, Education and Trauma Healing (BREATHE) Ethiopia. BREATHE Ethiopia is a culturally and contextually adapted intervention for PTSD in participants with severe mental illness. BREATHE Ethiopia maps onto the World Health Organization's guidelines for posttraumatic stress disorder (PTSD) treatment in low- and middle-income country primary care settings.

Methods

Specifically, this study includes a non-randomized pre-pilot (n = 5) and a randomized feasibility trial comparing BREATHE Ethiopia to Treatment as Usual (n = 40) to assess trial procedures, acceptability, and feasibility of intervention delivery, and investigate potential effectiveness and implementation. In a process evaluation, we will collect data that will be critical for a future fully randomized controlled trial, including the numbers of participants who are eligible, who consent, who engage in treatment, and who complete the assessments, as well as the feasibility and acceptability of assessments and the intervention. Qualitative data on facilitators and barriers to intervention delivery and quantitative data on provider fidelity to the intervention and participant and provider satisfaction will also be collected. Quantitative assessments at baseline, post-treatment, 1-month follow-up, and 3-month follow-up will assess change in mental health symptoms and functional impairment and hypothesized intervention mechanisms, including knowledge about PTSD, stigma, trauma-related cognitions, and physiological arousal.

Discussion

Findings from this study will inform a future fully-powered randomized controlled trial, and if found to be effective, the intervention has the potential to be integrated into mental healthcare scale-up efforts in other low-resource settings.

Trial registration

Registered with ClinicalTrials.gov (NCT04385498) first posted May 13^th, 2020; https://www.clinicaltrials.gov/ct2/show/NCT04385498?term=ethiopia&cond=PTSD&draw=2&rank=1 .

Background:

In this protocol, we outline a mixed-methods randomized feasibility trial of Brief Relaxation, Education and Trauma Healing (BREATHE) Ethiopia. BREATHE Ethiopia is a culturally and contextually adapted intervention for PTSD in participants with severe mental illness. BREATHE Ethiopia maps onto the World Health Organization’s guidelines for posttraumatic stress disorder (PTSD) treatment in low- and middle-income country primary care settings. MethodsSpecifically, this study includes a non-randomized pre-pilot (n=5) and a randomized feasibility trial comparing BREATHE Ethiopia to Treatment as Usual (n=40) to assess trial procedures, acceptability and feasibility of intervention delivery, and investigate potential effectiveness and implementation. In a process evaluation we will collect data that will be critical for a future fully randomized controlled trial, including the numbers of participants who are eligible, who consent, who engage in treatment, and who complete the assessments, as well as the feasibility and acceptability of assessments and the intervention. Qualitative data on facilitators and barriers to intervention delivery and quantitative data on provider fidelity to the intervention and participant and provider satisfaction will also be collected. Quantitative assessments at baseline, post-treatment, one-month follow-up, and three-month follow-up will assess change in mental health symptoms and functional impairment and hypothesized intervention mechanisms, including knowledge about PTSD, stigma, trauma-related cognitions, and physiological arousal. DiscussionFindings from this study will inform a future fully-powered randomized controlled trial, and if found to be effective, the intervention has the potential to be integrated into mental healthcare scale-up efforts in other low-resource settings. Trial RegistrationRegistered with ClinicalTrials.gov (NCT04385498) first posted May 13 th , 2020; https://www.clinicaltrials.gov/ct2/show/NCT04385498?term=ethiopia&cond=PTSD&draw=2&rank=1.

Traumatic events and ensuing stress are not widely studied in individuals with severe mental illness (SMI) despite their increased vulnerability to both. Far less is known about traumatic events and posttrauma reactions in people with SMI in low-resourced settings.

Objective

To address this gap in knowledge, our study focused on trauma and its effects for individuals with SMI and their caregivers in rural Ethiopia. Study aims were to identify events that were considered traumatic by stakeholders; characterize the mental health effects of such events; and discern events and posttrauma symptoms most relevant for SMI.

Method

Qualitative interviews were gathered from 48 participants in Ethiopia who included individuals with SMI, their caregivers, health care providers, and community and religious leaders.

Results

Based on a combined emic and etic approach, major traumatic events included those commonly experienced in rural Ethiopia (e.g., lost property, forced marriage) and endorsed by individuals with SMI (e.g., restraining or chaining, SMI illness in a low-resourced setting). In addition, traumatic events were identified consistent with Western medical criteria (e.g., physical assault, sexual assault). Posttrauma symptoms that were commonly reported included emotions like anger and sadness; thinking too much; crying; and somatic (e.g., burning sensation) and physiological (e.g., shortness of breath) symptoms. As for symptoms consistent with the Diagnostic and Statistical Manual, we found the presence of all four symptom clusters.

Conclusions

Overall, results point to the common occurrence of traumatic events and trauma-linked symptoms for individuals with SMI and their caregivers, including as a result of SMI. (PsycInfo Database Record (c) 2022 APA, all rights reserved).