Electroconvulsoterapia em pacientes psicóticos : interface entre o stress percebido, ansiedade e depressão e resultado clínico

Dissertação de mestrado em Ciências da SaúdeElectroconvulsive therapy (ECT) continues to be considered an effective treatment of psychotic patients with hallucinatory and delusional symptoms resistant to antipsychotic medication. Several studies have evaluated the effectiveness of ECT in major depression as well as the effect of cortisol in the evolution and prognosis of those patients. However, studies that evaluate the evolution of the delusional and hallucinatory schizophrenic patients, psychotic depression and schizoaffective psychotic patients treated with ECT and its correlation with the salivary cortisol are scarce. Moreover, stress plays a significant role in modulation of mental disorders, and the hypothalamic-pituitary-adrenal (HPA) axis regulates the biological mechanisms of stress. In this project we have assessed the clinical evolution of patients in three diagnostic groups, namely patients psychotic depression, schizoaffective disorder and schizophrenia before and after ECT. The Positive and Negative Syndrome Scale (PANSS) was used to evaluate psychotic symptoms, the Perceived Stress scale (PSS) to evaluate perceived stress, the Hospital Anxiety and Depression Scale (HADS) to evaluate anxiety and depression and salivary cortisol levels to evaluate the HPA axis function. The results of our study demonstrate that ECT is effective and a valuable therapeutic option which could be useful as adjunctive therapy in psychotic patients refractory to antipsychotics agents. There was a noticeable improvement in the PANSS, HADS and PSS scores after ECT in all psychotic patients in our study. Moreover, this study shows the effectiveness of ECT in chronic psychotic patients, while most studies have studied first psychotic episodes. The decrease of salivary cortisol after ECT in our study suggests that it may impact in the HPA axis, improving its function. However, the mechanism by which it can improve HPA axis function remains unclear. Finally, the correlations between variables revealed that the HADS score may predict the rate of response to ECT. In conclusion, the present study has confirmed the role of ECT in the treatment of psychotic disorders. Importantly, a relation between HPA axis function and ECT was revealed specifically in patients with schizophrenia and psychotic depression but not in schizoaffective disorder, suggesting a distinct involvement of this key neurobiological factor.A eletroconvulsoterapia (ECT) continua a ser considerada um tratamento eficaz para pacientes psicóticos com sintomatologia delirante e alucinatória resistente à medicação antipsicótica. Vários estudos têm avaliado a eficácia da ECT na depressão major, bem como o efeito do cortisol na evolução e prognóstico desses pacientes. No entanto, estudos que avaliam a evolução em pacientes com esquizofrenia , depressão psicótica e psicose esquizoafetiva tratados com ECT e sua correlação com o cortisol salivar são escassos. Além disso, o stress desempenha um papel significativo na modulação de perturbações mentais sendo regulado pelo eixo hipotálamohipófise- adrenal (HPA).Neste projeto, avaliamos a evolução clínica dos pacientes em três grupos diagnósticos, nomeadamente pacientes com depressão psicótica, perturbação esquizoafetiva e esquizofrenia, antes e depois da ECT. A escala de sintomas positivos e negativos (PANSS) foi utilizada para avaliar sintomas psicóticos, a escala de stress percebido (PSS) para avaliar a percepção de stress, a escala de ansiedade e depressão hospitalar (HADS) para avaliar a ansiedade e a depressão e os níveis de cortisol salivar para avaliar a função do eixo HPA. Os resultados do nosso estudo demonstram que a ECT é eficaz e uma valiosa opção terapêutica que pode ser útil como terapia adjuvante em pacientes psicóticos refratários a agentes antipsicóticos. Observou-se uma melhoria significativa nas pontuações PANSS, HADS e PSS após ECT em todos os grupos de pacientes psicóticos no nosso estudo. Além disso, este estudo demonstrou a eficácia da ECT em pacientes psicóticos crónicos, enquanto a maioria dos trabalhos têm estudado primeiros episódios psicóticos. A diminuição do cortisol salivar após ECT no nosso estudo sugere que esta tem um impacto sobre o eixo HPA, melhorando a sua função. No entanto, o mecanismo pelo qual ela modula a função do eixo HPA permanece desconhecido. Finalmente, as correlações entre as variáveis revelaram que os niveis de HADS podem predizer a taxa de resposta à ECT. Em conclusão, o presente estudo confirmou o papel da ECT no tratamento de perturbações psicóticas. De realçar, a relação entre a função do eixo HPA e ECT foi revelada especificamente em pacientes com esquizofrenia e depressão psicótica, mas não na perturbação esquizoafetiva, sugerindo um envolvimento distinto deste factor neurobiológico

Technology and implementation science to forge the future of evidence-based psychotherapies: the PRIDE scale-up study

Objective: To report the interim results from the training of providers in evidence-based psychotherapies (EBPs) and use of mobile applications. Design and setting: The Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications. Main outcome measures: We examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPs PARTICIPANTS: Psychiatric technicians and primary care providers trained in the EBPs. Results: PRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment. Conclusions: The future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications. Keywords: adult psychiatry; anxiety disorders; depression & mood disorders; schizophrenia & psychotic disorders; substance misuse. © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ

Community health workers as potential providers of mental health care for people with psychosis in rural areas of Mozambique

Introdução: Os transtornos psicóticos contribuem significativamente para a carga global de doenças, causando incapacidade, comprometimento da qualidade de vida e maior mortalidade nas pessoas afetadas em comparação com a população em geral. Os Trabalhadores Comunitários de Saúde (TCS) são provedores importantes de serviços comunitários de saúde mental, e ajudam a mitigar as lacunas de acesso e tratamento na África. No entanto, há uma escassez de conhecimento sobre o papel e desempenho desses trabalhadores, bem como sobre até que ponto as intervenções psicológicas por eles oferecidas, são culturalmente adaptadas ao contexto. Em contextos rurais, onde o acesso aos cuidados de saúde é limitado ou inexistente, as pessoas com transtornos psicóticos procuram frequentemente o apoio dos TCS. No entanto, pouco se sabe sobre a perceção dos TCS, sobre psicose em Moçambique. Objetivos: Explorar o conteúdo e os aspetos relativos à adaptação cultural e sustentabilidade das intervenções psicológicas oferecidas por TCS, para pessoas com transtornos mentais na África. Explorar a perceção geral dos TCS sobre psicose e sobre os fatores facilitadores e barreiras para o acesso aos cuidados de saúde mental em zonas rurais de Moçambique. Métodos: para o primeiro estudo, realizamos uma análise de escopo da literatura revisada por pares publicada de janeiro de 2000 a dezembro de 2018 para identificar intervenções psicológicas oferecidas pelos TCS para pessoas com transtornos mentais na África. Procuramos sistematicamente no PubMed, Google scholar e Hinari por publicações relevantes. Os artigos foram avaliados quanto ao risco de viés utilizando a Ferramenta de Avaliação de Qualidade do National Heart, Lung and Blood Institute (NHLBI). A consulta de especialistas foi realizada de acordo com o modelo de Arksey & O’Malley, a análise de adaptação cultural foi realizada de acordo com o modelo de Bernal. Para o segundo estudo qualitativo foi realizado nos distritos rurais de Maputo, através de seis grupos de discussão, envolvendo no total 79 TCS. Utilizou-se a análise temática, informada pelo modelo de Capacidades, Oportunidades, Motivação e Comportamento (COM-B). Resultados: de cerca de 14.549 artigos, identificamos dez artigos revisados por pares conduzidos no Zimbábue, Uganda, África do Sul e Zâmbia. Seis eram ensaios clínicos randomizados; nenhum abordou os resultados da implementação. Terapia interpessoal baseada em grupo (n = 5), terapia cognitivo-comportamental focada no trauma (n = 1), terapia de resolução de problemas (n = 3) e terapia de exposição narrativa (n = 1) surgiram como intervenções psicológicas oferecidas pelos TCS para pessoas com depressão, ansiedade, trauma e comportamento suicidários. As intervenções psicológicas oferecidas por TCS em África foram todas adaptadas culturalmente para atender às competências dos TCS. Todas as intervenções foram associadas à melhora dos sintomas, mas a qualidade da evidência variou amplamente com o desenho do estudo. Quanto a percepção dos TCS sobre as barreiras e facilitadores do acesso aos cuidados de saúde mental em zonas rurais em Moçambique, foram identificados nove temas. No geral, os TCS percebem a doença mental como uma condição médica tratável e mantêm uma atitude positiva, estão preparados para fazer parte do processo de cuidado de pessoas com psicose nas zonas rurais. A parceria com outros atores interessados, como praticantes de medicina tradicional, profissionais de saúde e famílias, foi considerada pelos TCS, como facilitador para melhoria do acesso aos cuidados de saúde mental nas zonas rurais. O estigma, os mitos e a falta de habilidades para tratar pessoas com psicose foram percebidos como principais barreiras para o acesso aos cuidados. Conclusões: As intervenções psicológicas oferecidas pelos TCS, após a adaptação cultural apropriada, mostram-se promissoras para atender às necessidades de saúde mental na África Sub-Sahariana. São necessárias mais evidências sobre a eficácia e implementação, de intervenções psicológicas fornecidas por TCS para adolescentes, idosos, pessoas com transtornos mentais graves e comportamentos suicidários. Os TCS, com suporte adequado, podem desempenhar um papel importante na continuidade do cuidado ao paciente com psicose em zonas rurais de Moçambique. A formação dos TCS deve considerar a inclusão de competências básicas em matérias de saúde mental.D43T Grant Columbia Universit

Family reintegration of homeless in Maputo and Matola: a descriptive study

Abstract Background Homelessness is a global and local social problem with underestimated prevalence. It has been shown to increase the risk of mental illness, raising concerns from mental health providers about the need for effective interventions targeting this population. Objectives The aim of this paper is to describe the mental health status of the homeless people in two urban setting in a low-income country, through using standardised clinical and socio-demographic assessments as well assessing potential predictors of family integration versus non-family integration among a group of homeless individuals receiving psychiatric and psychosocial treatment. Methods A descriptive study was performed in Maputo and Matola cities between 2008 and 2010. Homeless people with apparent mental illness were mapped and recruited. The participants were referred from community to hospital, using a multidisciplinary treatment model, according to their clinical condition and later entered a family reintegration process. Results Seventy-one homeless people were recruited (93.0% male; 80.3% unemployed). The most common diagnosis was schizophrenia and other psychosis (46; 64.8%), followed by mental and behaviour disorder related to substance misuse (21; 29.6%), and intellectual disability (4; 5.6%). Family reintegration was achieved for 53.5% (38 patients). Patients with intellectual disability were less reintegrated and those with disorders related to substance use had better reinsertion in their families (Chi square (2)  = 6.1; p = 0.047). Conclusions Family reintegration was achieved in more than half of participants after hospitalization. Integration was higher in cases of substance misuse, with those with associated intellectual disability being more difficult to reintegrate. Trial registration Trial Registration Number: NCT02936141, date of registration: 14/10/2016, retrospectively registered

Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: scoping review and expert consultation

Background Lay Health Workers (LHW) are important providers of community mental health services and help mitigate access and treatment gaps in Africa. However, there is a paucity of knowledge about the role and performance of these workers, as well as about the extent to which the interventions delivered are culturally adapted to the African context. Aims This scoping review aimed to explore the content and aspects concerning the cultural adaptation and sustainability of psychological interventions delivered by LHW to people with mental disorders in Africa. Methods We conducted a scoping review of the peer-reviewed literature published from January 2000 to December 2018 to identify psychological interventions delivered by LHW for people with mental disorders in Africa. We systematically searched PubMed, Google scholar and Hinari to select relevant publications. The articles were evaluated for risk of bias according to study design with the National Heart, Lung, and Blood Institute’s (NHLBI) Quality Assessment Tools. Expert consultation was performed according to Arksey & O’Malley framework and cultural adaptation analysis was performed according to Bernal framework. Results Out of 14,549 retrieved records, we identified ten peer-reviewed articles conducted in Zimbabwe, Uganda, South Africa and Zambia describing four distinct interventions. Six were randomized controlled trials; none addressed implementation outcomes. Group-based interpersonal therapy (n = 5), trauma-focused cognitive behaviour therapy (n = 1), problem solving therapy (n = 3) and narrative exposure therapy (n = 1) emerged as psychological interventions delivered by LHW for people with depression, anxiety, trauma and suicidal behavior. Psychological interventions delivered by LHW in Africa were all culturally adapted to meet the competence of LHW. All the interventions were associated with symptom improvement, but the quality of this evidence varied widely with study design. Conclusion Task-shifting psychological interventions delivered by LHW after appropriate cultural adaptation show promise for addressing unmet mental health care needs in Africa. More effectiveness and implementation evidence is needed, especially with regard to psychological interventions delivered by LHW for adolescence, older people and those with severe mental disorders and suicidal behaviors

Lowering costs for large-scale screening in psychosis:A systematic review and meta-analysis of performance and value of information for speech-based psychiatric evaluation

Objective: Obstacles for computational tools in psychiatry include gathering robust evidence and keeping implementation costs reasonable. We report a systematic review of automated speech evaluation for the psychosis spectrum and analyze the value of information for a screening program in a healthcare system with a limited number of psychiatrists (Maputo, Mozambique). Methods: Original studies on speech analysis for forecasting of conversion in individuals at clinical high risk (CHR) for psychosis, diagnosis of manifested psychotic disorder, and first-episode psychosis (FEP) were included in this review. Studies addressing non-verbal components of speech (e.g., pitch, tone) were excluded. Results: Of 168 works identified, 28 original studies were included. Valuable speech features included direct measures (e.g., relative word counting) and mathematical embeddings (e.g.: word-to-vector, graphs). Accuracy estimates reported for schizophrenia diagnosis and CHR conversion ranged from 71 to 100% across studies. Studies used structured interviews, directed tasks, or prompted free speech. Directed-task protocols were faster while seemingly maintaining performance. The expected value of perfect information is USD 9.34 million. Imperfect tests would nevertheless yield high value. Conclusion: Accuracy for screening and diagnosis was high. Larger studies are needed to enhance precision of classificatory estimates. Automated analysis presents itself as a feasible, low-cost method which should be especially useful for regions in which the physician pool is insufficient to meet demand

Conhecimentos, atitudes e prácticas dos agentes comunitários de saúde sobre a epilepsia em Sofala, centro de Moçambique

Abstract: Background: Epilepsy is the most common neurological disease in the world, affecting 50 million people, with the majority living in low- and middle-income countries (LMICs). A major focus of epilepsy treatment in LMICs has been task-sharing the identification and care for epilepsy by community health workers (CHWs). The present study aimed to assess the knowledge, attitudes, and practices (KAPs) of CHWs towards epilepsy in Mozambique. Methods: One hundred and thirty-five CHWs completed a questionnaire that included socio-demographic characteristics and 44-items divided into six subscales pertaining to KAPs towards epilepsy (QKAP-EPI) across nine districts of Sofala, Mozambique. The internal consistency was examined to evaluate the reliability of the instrument (QKAP-EPI). The association between sociodemographic variables and QKAP-EPI subscales was examined using linear regression models. Results: The internal consistency was moderate for two subscales (causes of epilepsy, α = 0.65; medical treatment, α = 0.694), acceptable for cultural treatment (α = 0.797) and excellent for 2 subscales (safety and risks, α = 0.926; negative attitudes, α = 0.904). Overall, CHWs demonstrated accurate epilepsy knowledge (medical treatment: mean = 1.63, SD = 0.28; safety/risks: mean = 1.62, SD = 0.59). However, CHWs reported inaccurate epilepsy knowledge of the causes, negative attitudes, as well as culturally specific treatments for epilepsy, such as: “if a person with epilepsy burns when set on fire they cannot be treated”. Knowl- edge about how to manage epileptic seizures varied across the different emergency care practices, from the accurate belief that it is not advisable to place objects in the individual’s mouth during an epileptic seizure, to the wrong perception of the need to hold the person in seizures to control seizures. Heterogeneity in the level of epilepsy knowledge was observed among CHWs, when consid- ering epilepsy according to the local names as treatable (“Dzumba”) and other forms as untreatable (“Nzwiti”). Conclusion: CHWs knowledge of medical treatment and epilepsy safety/risks were adequate. However, information on the causes of epilepsy, stigmatizing attitudes, cultural treatment, and some knowledge of epileptic seizure management were low. These areas of poor knowledge should be the focus of educating CHWs in increasing their ability to provide quality care for patients with epilepsy in Mozambique.Project 41—8th Call from the National Fund of Investigation in Mozambique (FNI), 2017