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.

[This corrects the article DOI: 10.1371/journal.pmed.1003090.].

Low- and middle-income countries have few mental health professionals, and efforts to increase access to treatment are a global priority. A key gap is the lack of integration of psychotherapy interventions as a part of accessible evidence-based care. Current recommendations suggest that the integration of mental health treatments, including psychotherapy, into existing primary care pathways may serve as a means to address this disparity. Understanding the cultural and contextual factors that affect this process is a critical step in identifying necessary adaptations. The aim of this qualitative study was to identify contextual factors associated with integrating psychotherapy in primary care in a predominantly rural district in south-central Ethiopia. Purposive sampling was used to recruit 48 mental health service users, caregivers, health care providers, and community leaders. Semistructured interviews were conducted, recorded, and transcribed in Amharic and translated into English. Although challenges (e.g., stigma, job strain, lack of belief in formal treatments) are present, other existing strengths (e.g., openness to seeking treatment, increasing knowledge about mental health treatment, familiarity with practices similar to therapy) support subsequent psychotherapy adaptation and implementation. These findings suggest possible mechanisms to improve delivery and adaptation in the effort to lower the existing global treatment gap. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

BACKGROUND:People living in sub-Saharan Africa (SSA) are disproportionately exposed to trauma and may be at increased risk for posttraumatic stress disorder (PTSD). However, a dearth of population-level representative data from SSA is a barrier to assessing PTSD. This manuscript sought to calculate pooled PTSD prevalence estimates from nationally and regionally representative surveys in SSA. METHODS AND FINDINGS:The search was conducted in PubMed, Embase, PsycINFO, and PTSDpubs and was last run between October 18, 2019, and November 11, 2019. We included studies that were published in peer-reviewed journals; used probabilistic sampling methods and systematic PTSD assessments; and included ≥ 450 participants who were current residents of an SSA country, at least 50% of whom were aged between 15 and 65 years. The primary outcomes were point prevalence estimates of PTSD across all studies, and then within subgroups. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016029441). Out of 2,825 unique articles reviewed, 25 studies including a total of 58,887 eligible participants (54% female) in 10 out of the 48 countries in SSA were identified. Most studies enrolled any adult aged 18 years or older. However, some studies only enrolled specific age brackets or persons as young as 15 years old. Six studies were national surveys, and 19 were regional. There were 4 key findings in the meta-analysis: (1) the overall pooled prevalence of probable PTSD was 22% (95% CI 13%-32%), while the current prevalence-defined as 1 week to 1 month-was 25% (95% CI 16%-36%); (2) prevalence estimates were highly variable, ranging from 0% (95% CI 0%-0%) to 74% (95% CI 72%-76%); (3) conflict-unexposed regions had a pooled prevalence of probable PTSD of 8% (95% CI 3%-15%), while conflict-exposed regions had a pooled prevalence of probable PTSD of 30% (95% CI 21%-40%; p < 0.001); and (4) there was no significant difference in the pooled prevalence of PTSD for men and women. The primary limitations of our methodology are our exclusion of the following study types: those published in languages other than English, French, and Portuguese; smaller studies; those that focused on key populations; those that reported only on continuous measures of PTSD symptoms; and unpublished or non-peer-reviewed studies. CONCLUSIONS:In this study, PTSD symptoms consistent with a probable diagnosis were found to be common in SSA, especially in regions exposed to armed conflict. However, these studies only represent data from 10 of the 48 SSA countries, and only 6 studies provided national-level data. Given the enormous heterogeneity expected across the continent, and also within countries and regions, this review cannot speak to rates of PTSD in any regions not included in this review. Thus, substantial gaps in our knowledge of PTSD prevalence in SSA remain. More research on population-level prevalence is needed to determine the burden of trauma symptoms and PTSD in SSA and to identify acceptable and feasible approaches to address this burden given limited mental healthcare resources.