Addressing the complex needs of people with severe mental health disorders in low-resource settings
Authors: Oye Gureje, Olatunde Ayinde
Journal: The Lancet Global Health (2022)

Schizophrenia is a severe mental health disorder, responsible for 12·2% of disability-adjusted life years caused by mental health and substance use disorders globally,1GBD 2019 Mental Disorders CollaboratorsGlobal, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Psychiatry. 2022; 9: 137-150Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar it is a cause of individual suffering and of caregiver burden. It is what is commonly understood as mental health disorder in much of the lay population in sub-Saharan Africa2Gureje O Ojagbemi A Applicability and future status of schizophrenia as a construct in Africa.Schizophr Res. 2022; (published online Feb 10.)https://doi.org/10.1016/j.schres.2022.01.023Crossref PubMed Scopus (2) Google Scholar because it interferes with the attainment of major life goals such as educational attainment, career development, and establishing lifelong supportive relationships, and people with the condition are exposed to human rights abuses and stigma. Most people with schizophrenia will need long-term care that includes appropriate pharmacological treatment and adjunctive psychosocial interventions. Many sub-Saharan African countries are unable to provide such a response due to a combination of a shortage of specialist mental health services and inadequately trained front-line health providers able to deliver integrated services for severe mental health disorders.3Lora A Kohn R Levav I McBain R Morris J Saxena S Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries.Bull World Health Organ. 2012; 90 (54A–54B.): 47-54Crossref PubMed Scopus (109) Google Scholar, 4Thornicroft G Ahuja S Barber S et al.Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries.Lancet Psychiatry. 2019; 6: 174-186Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar Unfortunately, the response of the research community in low and middle-income countries (LMICs), and in sub-Saharan Africa in particular, to the unique needs of people with severe mental health disorders has been inadequate. Thus, although considerable attention has been placed on how to expand services for people with common mental health disorders, such as depression and anxiety, through the integration of services into primary health or community-based platforms,5Keynejad R Spagnolo J Thornicroft G WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact.Evid Based Ment Health. 2021; 24 (ebmental-2021-300254.)Crossref Scopus (13) Google Scholar severe mental health disorders, and schizophrenia in particular, have received less focus. In The Lancet Global Health Article by Laura Asher and colleagues,6Asher L Birhane R Weiss HA et al.Community-based rehabilitation intervention for people with Schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trial.Lancet Glob Health. 2022; 10: 530-542Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar the authors describe a study designed to address some of the gaps in the literature about how to respond to the needs of people with schizophrenia living in a low-income country. Conducted in the rural Sodo district of Ethiopia, the RISE trial was designed to compare the effectiveness of routine facility-based care with a combination of facility-based care and community-based rehabilitation. The patient cohort consisted of people with schizophrenia who had been in facility-based care for at least six months before the trial, including those who did not fully engage with this service, or who had not been in facility-based care but were identified through key informants. The primary outcome was disability measured with the proxy-version of the 36-item WHO Disability Assessment Scale at 12 months. A range of equally important secondary outcomes, including clinic attendance, adherence to treatment, symptom level, experience of discrimination and physical restraint, and employment were also assessed. Overall, the results of the trial at 12-month follow-up suggest a modest effect of the facility-based care plus community-based rehabilitation approach. Although the intervention group had less overall disability at 12 months, better global clinical improvement, and less caregiver burden, the effect of the intervention was not evident on several other domains of disability, including work, self-care, symptom level, experience of discrimination, and employment. The difference between the intervention and control groups was modest, and it is possible that if correction for chance findings had been applied to the results of the multiple comparisons, the few reported differences between the groups might have been further reduced. Given that the RISE trial cohort consisted of some people who had engaged poorly with mental health services, the trial effects were not substantially different from what was reached in the PRIME task-shared facility-based cohort study in the same setting,7Hanlon C Medhin G Selamu M et al.Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study.Epidemiol Psychiatr Sci. 2019; 29: e45Crossref PubMed Scopus (9) Google Scholar which raises questions about the specific additional benefits of the RISE trial on the major rehabilitation needs of this vulnerable group of patients. People with schizophrenia living in resource-limited settings will have a range of needs. Indeed, the authors of the RISE trial identified some of these needs in the rural setting of Ethiopia, which include family conflict, difficulty participating in work and community life, and stigma.8Asher L Fekadu A Hanlon C et al.Development of a community-based rehabilitation intervention for people with schizophrenia in ethiopia.PLoS One. 2015; 10e0143572Crossref Scopus (25) Google Scholar Therefore, rehabilitation efforts in such settings should pay particular attention to how these needs might be met. The authors were aware of this and indicated that one goal of the trial was to enhance community support for people with schizophrenia and shape their social environment, and they had therefore aimed to provide employment assistance and raise community awareness. Therefore, it is disappointing that there was no benefit to employment in the facility-based care plus community-based rehabilitation group. We speculate that perhaps suboptimal community engagement activities and the apparent non-engagement with family groups was responsible for this absence of impact in some of the desired areas. Nevertheless, it is gratifying that there seems to be a growing interest in attending to the neglect of designing and testing of evidence-based interventions for severe mental health disorders in sub-Saharan Africa.9Hanlon C Medhin G Dewey ME et al.Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial.Lancet Psychiatry. 2022; 9: 59-71Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 10Gureje O Appiah-Poku J Bello T et al.Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial.Lancet. 2020; 396: 612-622Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar The needs of people with these conditions are complex and often go beyond those of people with common mental health disorders, which have received considerably more research attention.4Thornicroft G Ahuja S Barber S et al.Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries.Lancet Psychiatry. 2019; 6: 174-186Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar The valiant efforts of the RISE investigators need to be complemented by other researchers working in LMICs, particularly those working in sub-Saharan Africa where mental health resources are sparse. The RISE trial provides a good opportunity for learning about the challenges of designing and testing interventions that utilise a range of local resources to address the rehabilitation needs of people with schizophrenia. Future efforts should strive for more community mobilisation and involvement of families, and thereby will hopefully be more impactful in core areas of rehabilitation. We declare no competing interests Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trialCBR delivered by lay workers combined with task-shared facility-based care, was effective in reducing disability among people with schizophrenia. The RISE study CBR model is particularly relevant to low-income countries with few mental health specialists. Full-Text PDF Open Access