Change search
ReferencesLink to record
Permanent link

Direct link
Studies on psychotic disorders in rural Ethiopia
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Studies on course and outcome of schizophrenia coming from low income countries are increasingly becoming important to challenge the existing dogma claiming good outcome in these countries. Besides clinical course and outcome, mortality is considered a very important outcome measure for schizophrenia. Culture and tradition play a significant role in the manifestations of severe mental illnesses (SMI). Khat is a culturally accepted plant endemic to Eastern Africa, which is chewed by people for its stimulating effect. It is believed that Khat influences the course and outcome of schizophrenia although systematic studies are scarce. Patients with SMI continue to chew khat despite advice from their doctors to desist. Reasons for this behavior were not fully investigated before.

Objectives             

-     To describe the 5-year clinical course and outcome and mortality of schizophrenia in Butajira.

-       To explore traditional views on psychosis in the semi-nomadic Borana population.

-       To describe the perceived causes and preferred treatment for SMI in the semi-nomadic Borana population

-       To explore reasons for khat chewing behavior in people with SMI in Butajira.

Methods The studies were done in two sites: Butajira and Borana. The Butajira study involved screening, using CIDI and Key Informants (KIs), of more than 68,000 adults aged 15-49. Of these, 321 people were diagnosed with schizophrenia and were followed-up for five years to look into their clinical course and outcome, including mortality. A qualitative study involving 37 men with SMI and 30 female caregivers was conducted in Butajira to study reasons why patients continue to chew khat despite their physicians’ advice against it. The Borana study of a remote semi-nomadic population in southern Ethiopia, used qualitative methods involving 56 KIs to identify descriptions of psychosis, perceived causes and preferred treatment in the community. Cases identified by the KIs also underwent SCAN interview for confirmatory diagnosis.

 

Results The five year follow-up of schizophrenia patients showed that 45% of participants were continuously symptomatic with 30.3% having had continuous psychotic episode. About 20% had experienced continuous remission. Being single (OR = 3.41, 95% CI = 1.08-10.82, P = 0.037), on antipsychotic treatment for at least 50% of follow up time (OR = 2.28, 95% CI = 1.12-4.62, P = 0.023), and having a diagnosis of paranoid subtype of schizophrenia (OR = 3.68, 95% CI = 1.30-10.44, P = 0.014) were associated with longer period of remission.

A total of 38 (12.4%) patients, thirty four men (11.1%) and four women (1.3%) died during the 5-year follow-up period. The mean age (SD) of the deceased for both sexes was 35 (7.35): 35.3 (7.4) for men and 32.3 (6.8) for women. The most common cause of death was infection, 18/38 (47.4%) followed by severe malnutrition, 5/38 (13.2%) and suicide 4/38 (10.5%). The overall SMR was 5.98 (95% CI = 4.09 to 7.87): 6.27 (95% C I = 4.16 to 8.38) for men and 4.30 (95% CI = 1.02 to 8.52) for women. Patients residing in rural areas had lower mortality with adjusted HR of 0.30 (95% CI = 0.12-0.69) but those with insidious onset had higher mortality with adjusted HR 2.37 (95% CI = 1.04-5.41). Treatment with antipsychotics for less than 50% of the follow-up time was also associated with higher mortality, adjusted HR 2.66 (1.054-6.72).

In the Borana study, the incongruity between local and psychiatric concepts in the CIDI lay mainly in the fact that KIs described characteristics of marata (madness) in terms of overt behavioral symptoms instead of thought disturbances. Following the focus group discussions, participants identified 8 individuals with schizophrenia and 13 with a psychotic mood disorder, confirmed by SCAN interview.

Supernatural causes such as possession by evil spirits, curse, bewitchment, ‘exposure to wind’ and subsequent attack by evil spirits in postnatal women; bio-psycho-social causes such as infections (malaria), loss, ‘thinking too much’, and alcohol and khat abuse were mentioned as causes of SMI. The preferred treatments for severe mental illness included mainly traditional approaches, such as consulting Borana wise men or traditional healers, prayer, holy water treatment and, finally, seeking modern health care.

Regarding khat and SMI in Butajira, reasons given by patients as well as caregivers were more or less congruent: social pressure, a means for survival by improving function, combating medication side effects, to experience pleasure and curbing appetite.

 Conclusion Schizophrenia runs a chronic and non-remitting course and was associated with very high premature mortality in Butajira. Continued treatment with antipsychotics has been a consistent predictor of favorable outcome and reduced mortality.

Case identification in studies of psychotic disorders in traditional communities are likely to benefit from combining structured interviews with the key informant method. Planning mental health care in traditional communities needs to involve influential people and traditional healers to increase acceptability of modern mental health care. Patients with SMI chewed khat for some important reasons that clinicians need to consider in their management.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2011. , 47 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1427
Keyword [en]
Attribution, caregivers, course and outcome, key informant method, khat, longitudinal study, mortality, psychotic disorders, qualitative methods, schizophrenia, semi-nomadic, severe mental illness, treatment, Ethiopia, sub-Saharan Africa
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-43826ISBN: 978-91-7459-226-9OAI: oai:DiVA.org:umu-43826DiVA: diva2:416226
Public defence
2011-06-07, Sal A, våning 0, Psykiatriska kliniken, by 23, NUS, Umeå, 12:00 (English)
Opponent
Supervisors
Available from: 2011-05-12 Created: 2011-05-11 Last updated: 2011-05-14Bibliographically approved
List of papers
1. Five-year clinical course and outcome of schizophrenia in rural Ethiopia
Open this publication in new window or tab >>Five-year clinical course and outcome of schizophrenia in rural Ethiopia
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-43821 (URN)
Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2011-05-14Bibliographically approved
2. Five-year mortality in a cohort of people with schizophrenia in rural Ethiopia
Open this publication in new window or tab >>Five-year mortality in a cohort of people with schizophrenia in rural Ethiopia
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-43823 (URN)
Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2011-05-14Bibliographically approved
3. Exploring the apparent absence of psychosis amongst the Borana pastoralist community of Southern Ethiopia. A mixed method follow-up study.
Open this publication in new window or tab >>Exploring the apparent absence of psychosis amongst the Borana pastoralist community of Southern Ethiopia. A mixed method follow-up study.
2010 (English)In: World psychiatry : official journal of the World Psychiatric Association (WPA), ISSN 1723-8617, Vol. 9, no 2, 98-102 p.Article in journal (Refereed) Published
Abstract [en]

There are few reports of the prevalence of psychotic disorders among isolated population groups. Where present, variations in prevalence estimates raise questions about the validity of methods of case ascertainment in such settings. In a previous population-based survey of the Borana pastoralist community in Ethiopia using the Composite International Diagnostic Interview, no cases of schizophrenia were identified. In order to further explore this finding and investigate how serious mental disorder is conceptualized, we conducted focus group discussions with key members of the Borana pastoralist community. Subsequently, focus group participants were used as key informants to identify cases with possible psychotic disorder, based on their conceptualization. Cases identified by key informants were interviewed by a trained psychiatrist using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), to confirm presence of disorder. Focus group discussions were subjected to thematic analysis. The incongruity between local and psychiatric concepts lay mainly in the fact that key informants described characteristics of marata ("madness") in terms of overt behavioural symptoms. Following the focus group discussions, participants identified eight individuals with schizophrenia and 13 with a psychotic mood disorder, confirmed through SCAN interview. Studies of psychotic disorders in such communities are likely to benefit from combining structured interviews with the key informant method.

Keyword
Psychotic disorders, Borana community, key informant method
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-41128 (URN)20671898 (PubMedID)
Available from: 2011-03-18 Created: 2011-03-18 Last updated: 2012-10-29Bibliographically approved
4. Perceived causes of severe mental illnesses and preferred treatment for the mentally ill among the Borana semi-nomadic community, southern Etiopia
Open this publication in new window or tab >>Perceived causes of severe mental illnesses and preferred treatment for the mentally ill among the Borana semi-nomadic community, southern Etiopia
(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-43824 (URN)
Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2011-05-14Bibliographically approved
5. Khat-chewing in persons with severe mental illness in Ethiopia: A qualitative study exploring perspectives of patients and caregivers
Open this publication in new window or tab >>Khat-chewing in persons with severe mental illness in Ethiopia: A qualitative study exploring perspectives of patients and caregivers
Show others...
2011 (English)In: Transcultural Psychiatry, ISSN 1363-4615, E-ISSN 1461-7471, Vol. 28, no 4, 455-472 p.Article in journal (Refereed) Published
Abstract [en]

People with severe mental illness (SMI) in Ethiopia chew khat despite advice from their physicians to desist. We wanted to better understand their reasons for khat chewing, including any benefits that they might gain. A qualitative study was conducted involving patients with SMI and their caregivers in Butajira. Reasons given by patients as well as caregivers were more or less congruent: social pressure, a means for survival by improving function, combating medication side effects, to experience pleasure and curbing appetite. These findings will be of value to health workers, caregivers and policymakers alike in improving care and understanding for this patient group. Furthermore, our study indicates a role for future research to explore potentially beneficial effects of khat in this population.

Place, publisher, year, edition, pages
London: Sage Publications on behalf of McGill University, 2011
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-43825 (URN)10.1177/1363461511408494 (DOI)
Available from: 2011-05-11 Created: 2011-05-11 Last updated: 2011-10-26Bibliographically approved

Open Access in DiVA

fulltext(1067 kB)3956 downloads
File information
File name FULLTEXT01.pdfFile size 1067 kBChecksum SHA-512
02f7019a8984264f5b8a08161239dd84f2fde9a08bdcdb72a21d7e1b9e42525435e62e75b853ffbafea1f2853bfa4202d0e963952377dab0ada2b59abbc68f58
Type fulltextMimetype application/pdf

Search in DiVA

By author/editor
Teferra Abebe, Solomon
By organisation
Psychiatry
Psychiatry

Search outside of DiVA

GoogleGoogle Scholar
Total: 3956 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

Total: 883 hits
ReferencesLink to record
Permanent link

Direct link