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Title: The impact of untreated psychosis in low and middle income (LAMI) countries and a paradigm for early intervention
Author: Farooq, Saeed
ISNI:       0000 0004 2723 4683
Awarding Body: Staffordshire University
Current Institution: Staffordshire University
Date of Award: 2012
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This thesis is based on 13 papers published in peer reviewed journals. These include studies on epidemiology and treatment of major psychotic disorders, and metanalysis of studies on Duration of Untreated Psychosis (DUP) and its relationship with the Gross Domestic Product and the outcome in Low and Middle Income (LAMI) countries. Based on this research that highlighted the extent and impact of untreated psychosis, a series of papers presented a novel approach for early intervention in psychosis in LAMI countries. The final paper presents the randomised controlled trial evaluating this approach. Seven publications on puerperal psychosis, homicide by patients suffering from Schizophrenia, and the impact of cannabis use on symptomatology and course of schizophrenia highlighted significant gaps in the care of schizophrenia in developing countries. Only 12 patients (24%), charged with homicide had received some form of treatment before the index crime, despite the fact that duration of illness was more than 5 years in most cases. In a clinical sample of 35 patients suffering from acute episode of Puerperal psychosis the mean time between the onset of symptoms and receiving psychiatric care was almost a month. Two third of mothers suffering from Puerperal psychosis could not breast feed, most showing almost total lack of concern for the baby and also other behavior which could result in harm to baby. The publications on Puerperal psychosis argued that prevention of the disorder should be feasible in developing countries in view of high incidence of the disorder following an identifiable life event (childbirth) and the fact that most of the risk factors could be screened in the antenatal period. A paper published in British Journal of Psychiatry estimated the Duration of Untreated Psychosis (DUP) and its impact on the outcome of psychosis. Based on metanalysis of 98 studies (23 from LAMI countries and 75 were from high-income countries) the DUP of LAMI countries (125 weeks) was twice as long as the DUP in high-income countries (63 weeks, p=0.012). The relationship between DUP and the gross domestic product (GDP) purchasing power parity was also examined using the data from International Monetary vii Fund (IMF) and the World Bank. There was a strong negative correlation between DUP and GDP ppp, indicating that for every thousand dollars of additional GDP (purchasing power parity), mean DUP was reduced by 8 weeks and median DUP was reduced by 5 weeks. A study published in Schizophrenia Research examined the association between DUP and at least one of the following outcome measures; psychotic symptoms, cognitive function, social disability or mortality. Patients with a longer DUP had a smaller reduction in symptom scores after treatment when compared to patients with shorter DUP. The pooled estimate indicated that longer DUP was negatively associated with the degree of reduction in symptom scores (random effects Meta analysis; r=−0.290, 95% CI=−0.483 to−0.069, z=−2.559, P < 0.011) and longer DUP was associated with greater level of disability (fixed effects Meta analysis; r=0.195, 95% CI=0.126 to 0.262, z=5.498, p<0.000; heterogeneity Q-value 1.245, p=NS, I2=0.00). These studies clearly established the case for Early Intervention in psychosis. However, an entirely different approach was needed for this in resource poor settings. This approach is described in three papers. This approach termed as ‘Supervised Treatment of Outpatient Schizophrenia’ (STOPS) was evaluated in a Randomized Controlled Trial. The paper describing this RCT which provided proof of the concept will soon be published by British Journal of Psychiatry. In this RCT, fifty five patients were recruited in each arm. Ninety five (86.36%) patients completed the study; 49 in STOPS and 46 in Treatment As Usual (TAU) group. At one year follow up, 37 (67.3%) patients in STOPS group had complete adherence with medication compared to 25 (45.5%) in the TAU group (P<.02). The patients in STOPS group also showed more improvement in symptoms (P=0.003) and functioning (P<0.011).
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: C800 Psychology