Improving psychotherapies offered in public hospitals in Nairobi, Kenya: extending practice-based research model for LMICs

BackgroundPsychotherapy and mental health services in Nairobis public hospitals are increasing. Rather than prematurely imposing psychotherapy protocols developed in Western countries to Kenya, we argue that first studying psychological interventions as they are practiced may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems in a lower and middle income country like Kenya.MethodWe present preliminary findings from a process-outcome study involving 345 patients from two public institutions, Kenyatta National and Mathare National Hospitals. We asked our patients to fill out a brief personal information questionnaire, Clinical Outcomes in Routine Evaluation-Outcome Measure (Evans et al. in Br J Psychiatry 180:51-60, 2002, and the Session Alliance Inventory (Falkenstrom et al. in Psychol Assess 27:169-183, 2015) after each session. We present descriptives for CORE-OM, patient-therapist concordance on the SAI, and using longitudinal mixed-effects model, test change in CORE-OM over time with various therapy and patient factors as predictors in regression analyses.ResultsThe majority of patients who attended the outpatient care clinics were young males. Our regression analysis suggested that patients with depression reported higher initial distress levels (2.75 CORE-OM scores, se=1.11, z=2.48, p=0.013, 95% CI 0.57-4.93) than patients with addictions, anxiety, or psychosis. Older clients improved slower (0.08 CORE-OM scores slower improvement per session per year older age; se=0.03, z=3.02 p=0.003, 95% CI 0.03, 0.14). Female patients reported higher initial distress than men (2.62 CORE-OM scores, se=1.00, z=2.61, p=0.009, 95% CI 0.65, 4.58). However, interns had patients who reported significantly higher initial distress (3.24 CORE-OM points, se=0.90, z=3.60, pamp;lt;0.001, 95% CI 1.48, 5.00), and improved more over time (-1.20 CORE-OM scores per session, se=0.51, z=-2.35, p=0.019, 95% CI -2.20, -0.20) than patients seeing mental health practitioners. The results showed that at average alliance, CORE-OM decreased by 1.74 points per session (se=0.21, pamp;lt;0.001). For each point higher on the SAI at session 2, the CORE-OM decreased by an additional 0.58 points per session (se=0.25, p=0.02).DiscussionOur objective was to study psychotherapies as they are practiced in naturalistic settings. The overall significant finding is that our participants report improvement in their functioning mental health condition and distress reduced as psychotherapy progressed. There were many more male than female participants in our sample; younger patients improved more than older ones; and while interns had patients with higher distress, their patients improved better than those patients attended by professionals.ConclusionsThese are preliminary observations to consider for a larger sample follow-up study. Before changing practices, evaluating the existing practices by mapping clinical outcomes is a helpful route.Funding Agencies|Center for Clinical Research Sormland; US National Institutes of Health [1R24TW008889]</p

Neurocognitive correlates of the use of combined Antiretroviral Therapy among HIV-infected adults attending care and treatment center at Muhimbili National Hospital, Dar es Salaam, Tanzania: An analytical crosssectional study

Background: The discovery of the highly active antiretroviral therapy has improved the life span of people living with HIV/AIDS (PLWHA) to almost that of the general population. This, however, has been coupled with increased incidences of HIVassociated dementia, especially mild cognitive impairment. Combined antiretroviral therapy (cART) has been observed to improve neurocognitive functions but the ART regimen that is best suited for improvement of neurocognitive functions is still largely unknown. This study was aimed at determining how neurocognitive deficits in patients on cART were related to ART regimen.Methods: This was a cross-sectional analytical study. A sample of 351 adult patients attending care and treatment center (CTC) at Muhimbili National Hospital (MNH) in Dar es salaam, Tanzania were screened for HIV-associated neurocognitive deficits (HAND) against the ART regimens the patients were using. The study that was conducted from July to August 2012 and employed a standardized tool known as International HIV Dementia Scale (IHDS). Analysis was done using SPSS version 18. Frequency distribution, Chi-square, Fisher’s exact test and multivariate regression analysis were calculated to determine the levels of risk which was set at 5% significance level (p &lt; 0.05).Results: Two hundred and forty of the 351 (68.4%) patients screened positive for neurocognitive deficits. Under descriptive statistics, factors such as age, years of formal education, central nervous system penetration effectiveness (CPE) score and the use of efavirenz containing regimens showed statistically significant association with HAND at p=0.03, p=0.038, p&lt;0.001 and p=0.039, respectively, while on multivariate analysis only ART combination with CPE based on 2010 scoring system showed significant association system (p=0.02, AOR=0.449 and C.I=0.27-0.748) with HAND.Conclusion: These findings support the hypothesis that specific ART factors such as CPE may be protective against neurocognitive deficits. The study also highlights the need to choose appropriate ART regimen with special consideration to their potential neurotoxic side effect. Individual assessment for best therapeutic response is crucial for the patients’ cognitive wellbeing.Keywords: HIV-associated neurocognitive deficits (HAND), Antiretroviral, Central nervous system penetration, Muhimbili National Hospital, Dar es Salaam, Tanzani

Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis

Background: Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extending youth-friendly services. Methods: Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18-25 years about their mental health condition for which they were undergoing treatment. Each interview took 30-45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions. Results: We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting intervention, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emotions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy. Conclusion: Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya.Funding Agencies|NIMH; NIH [1R24TW008889]</p