Studies on psychotic disorders in rural Ethiopia

Sammanfattning: 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.