Cost-effectiveness of implementing a digital psychosocial intervention for patients with psychotic spectrum disorders in low- and middle-income countries in Southeast Europe: Economic evaluation alongside a cluster randomised trial.

BACKGROUND: DIALOG+ is a digital psychosocial intervention aimed at making routine meetings between patients and clinicians therapeutically effective. This study aimed to evaluate the cost-effectiveness of implementing DIALOG+ treatment for patients with psychotic disorders in five low- and middle-income countries in Southeast Europe alongside a cluster randomised trial. METHODS: Resource use and quality of life data were collected alongside the multi-country cluster randomised trial of 468 participants with psychotic disorders. Due to COVID-19 interruptions of the trial's original 12-month intervention period, adjusted costs and quality-adjusted life years (QALYs) were estimated at the participant level using a mixed-effects model over the first 6 months only. We estimated the incremental cost-effectiveness ratio (ICER) with uncertainty presented using a cost-effectiveness plane and a cost-effectiveness acceptability curve. Seven sensitivity analyses were conducted to check the robustness of the findings. RESULTS: The average cost of delivering DIALOG+ was €91.11 per participant. DIALOG+ was associated with an incremental health gain of 0.0032 QALYs (95% CI -0.0015, 0.0079), incremental costs of €84.17 (95% CI -8.18, 176.52), and an estimated ICER of €26,347.61. The probability of DIALOG+ being cost-effective against three times the weighted gross domestic product (GDP) per capita for the five participating countries was 18.9%. CONCLUSION: Evidence from the cost-effectiveness analyses in this study suggested that DIALOG+ involved relatively low costs. However, it is not likely to be cost-effective in the five participating countries compared with standard care against a willingness-to-pay threshold of three times the weighted GDP per capita per QALY gained.

Improving treatment of patients with psychosis in low-and-middle-income countries in Southeast Europe: Results from a hybrid effectiveness-implementation, pragmatic, cluster-randomized clinical trial (IMPULSE).

BACKGROUND: In Southeast Europe (SEE) standard treatment of patients with psychosis is largely based on pharmacotherapy with psychosocial interventions rarely available. DIALOG+ is a digital psychosocial intervention designed to make routine care therapeutically effective. This trial simultaneously examined effectiveness of DIALOG+ versus standard care on clinical and social outcomes (Aim 1) and explored intervention fidelity (Aim 2). METHODS: A hybrid type II effectiveness-implementation, cluster-randomized trial was conducted in five SEE countries: Bosnia and Herzegovina, Kosovo*, Montenegro, North Macedonia, and Serbia. The intervention was offered to patients six times across 12 months instead of routine care. The outcomes were subjective quality of life (primary), clinical symptoms, satisfaction with services, and economic costs. Intervention fidelity was operationalized as adherence to the protocol in terms of frequency, duration, content, and coverage. Data were analyzed using multilevel regression. RESULTS: A total of 81 clinicians and 468 patients with psychosis were randomized to DIALOG+ or standard care. The intervention was delivered with high fidelity. The average number of delivered sessions was 5.5 (SD = 2.3) across 12 months. Patients in the intervention arm had better quality of life (MANSA) at 6 months (p = 0.03). No difference was found for other outcomes at 6 months. Due to disruptions caused by the COVID-19 pandemic, 12-month data were not interpretable. CONCLUSIONS: DIALOG+ improved subjective quality of life of individuals with psychosis at 6 months (after four sessions), albeit with small effect size. The intervention has the potential to contribute to holistic care of patients with psychosis.

Multifamily groups for patients with schizophrenia: an exploratory randomised controlled trial in Bosnia and Herzegovina.

BACKGROUND: Schizophrenia has a significant and lasting impact on the quality of life of patients and their families and is a leading cause of disability globally. Family interventions can be beneficial and may be particularly appropriate in settings with limited resources. We conducted an exploratory trial testing the effectiveness of a multifamily group intervention, which draws on the traditions of psychoeducation and trialogue, for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina. METHODS: We conducted an exploratory, randomised controlled trial with patients with schizophrenia attending an outpatient clinic in Sarajevo. Our primary outcome was improved quality of life at 6-month follow-up. Secondary outcomes included objective social outcomes, psychiatric symptoms and psychiatric hospitalisation measured at 6 and 12 months. Experiences of participants were assessed in post-intervention interviews. RESULTS: 72 patients were randomly assigned to either one of six multifamily groups or treatment as usual. Follow-up assessments were completed with 53 patients (74%) at 6 months and 55 patients (76%) at 12 months. The intervention significantly improved quality of life at 6 months (Cohen's d = 0.78, F = 6.37, p = 0.016) and 12 months (d = 1.08, F = 17.92, p < 0.001), compared with treatment as usual. Re-hospitalisation rates at 6 months and symptom levels also improved significantly whilst changes in other secondary outcomes failed to reach statistical significance. CONCLUSION: These findings suggest multifamily groups can be effective for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina. Further research is required to assess how multifamily groups may be scaled up in similar settings with limited resources.

The effectiveness of volunteer befriending for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina - an exploratory randomised controlled trial.

AIMS: Social isolation in people living with schizophrenia is associated with poor quality of life and increased symptom severity. Volunteer befriending interventions are a potential strategy for addressing social isolation, but evidence of their effectiveness is limited, particularly in low- and middle-income countries. We assessed the experiences of volunteer befriending and tested its effectiveness for improving the quality of life of patients with schizophrenia in Bosnia and Herzegovina. METHODS: Between March 2018 and July 2020, we conducted a parallel-group, randomised controlled trial in adults with schizophrenia and poor quality of life at an outpatient clinic in Sarajevo. Patients were randomised to either the intervention, in which they were matched with a volunteer befriender with whom they met fortnightly over the 6-month intervention period, or treatment as usual. The primary outcome was quality of life measured on the Manchester Short Assessment and secondary outcomes were psychiatric symptoms and objective social outcomes. Outcome measurement was conducted by blinded researchers at 6- and 12-months. RESULTS: In total, 65 patients were randomised into the intervention (n = 33) and control arms (n = 32) and 55 (85%) completed follow-up assessments at 6 months. Patients in the intervention showed a significantly more favourable quality of life at 6 months (primary outcome; mean difference: 0.7, 95% CI [0.3-1.1], p = 0.003) and 12 months (mean difference: 1.7, 95% CI [1.1-2.3], p < 0.001). They also had significantly lower symptom levels at both follow-ups, and a significantly more favourable objective social situation after 12 months. Participants reported largely positive experiences. CONCLUSION: The exploratory trial conducted at one site found sustained improvements in quality of life and reductions in psychiatric symptoms. This suggests that volunteer befriending may be a feasible and effective treatment for patients with schizophrenia in resource-limited contexts, such as Bosnia and Herzegovina.

Knowledge, attitudes, and practices towards COVID-19 among residents of Bosnia and Herzegovina during the first stage of COVID-19 outbreak.

Study design: A cross-sectional study conducted by an online questionnaire-based survey. Methods: This study was conducted by an anonymous online questionnaire based on a Chinese study during the fifth week from the beginning of outbreak of COVID-19 in Bosnia and Herzegovina. Background: In order to control the spread of COVID-19, prevent the crash of health care system and ensure well-being of its residents, Bosnia and Herzegovina has taken rigorous preventive epidemiological measures in the beginning of the pandemic. Currently the situation has dramatically changed. The aim of this study is to present knowledge, attitudes and practices at the beginning of the outbreak in Bosnia and Herzegovina when the spreading of COVID-19 was well controlled and provide useful information to policymakers at this challenging time. Results: In total 1,201 respondents, predominantly female (943 or 78.5%), with a mean age 30.57±11.26, scored very high on the knowledge test with a mean score 9.13±1.90. Being male (ß: -0.141, p<0.001) and aged >30 (ß: -0.099, p=0.030) were associated with lower knowledge scores, while education level of bachelor's degree and above (ß: 0.092, p=0.003), living in urban environment (ß: 0.062, p=0.044) and being a student (ß: 0.240, p<0.001) were associated with higher knowledge scores. Only 638 (53.1%) of the participants agreed that COVID-19 will be successfully controlled. The vast majority of the participants (1,092 or 90.9%) have not visited any crowded place and 1,043 (86.9%) wore masks when they were going out... Decreased exposure to crowded places [(OR=0.427, p<0.001);(OR=0.805, p<0.001)] and an increase of wearing a mask while leaving home [(OR=1.564, p=0.022);(OR=1.219, p<0.001)] were associated with female sex and higher knowledge scores, respectively. Age group 18-29 (OR=0.616, p=0.007) and living in rural environment (OR=0.600, p<0.025) were associated with not wearing a mask outside the home. Conclusions: Our study suggests that residents of Bosnia and Herzegovina have had good knowledge, a relatively optimistic attitudes and appropriate practices towards COVID-19 during the first period of outbreak.

Effectiveness of a structured intervention to make routine clinical meetings therapeutically effective (DIALOG+) for patients with depressive and anxiety disorders in Bosnia and Herzegovina: A cluster randomised controlled trial.

BACKGROUND: DIALOG+ is a patient-centred, solution-focused intervention, which aims to make routine patient-clinician meetings therapeutically effective. Existing evidence suggests that it is effective for patients with psychotic disorders in high-income countries. We tested the effectiveness of DIALOG â€‹+ â€‹for patients with depressive and anxiety disorders in Bosnia and Herzegovina, a middle-income country. METHODS: We conducted a parallel-group, cluster randomised controlled trial of DIALOG+ in an outpatient clinic in Sarajevo. Patients inclusion criteria were: 18 years and older, a diagnosis of depressive or anxiety disorders, and low quality of life. Clinicians and their patients were randomly allocated to either the DIALOG â€‹+ â€‹intervention or routine care in a 1:1 ratio. The primary outcome, quality of life, and secondary outcomes, psychiatric symptoms and objective social outcomes, were measured at 6- and 12-months by blinded assessors. RESULTS: Fifteen clinicians and 72 patients were randomised. Loss to follow-up was 12% at 6-months and 19% at 12-months. Quality of life did not significantly differ between intervention and control group after six months, but patients receiving DIALOG â€‹+ â€‹had significantly better quality of life after 12 months, with a medium effect size (Cohen's d â€‹= â€‹0.632, p â€‹= â€‹0.007). General symptoms as well as specifically anxiety and depression symptoms were significantly lower after six and 12 months, and the objective social situation showed a statistical trend after 12 months, all in favour of the intervention group. No adverse events were reported. LIMITATIONS: Delivery of the intervention was variable and COVID-19 affected 12-month follow-up assessments in both groups. CONCLUSION: The findings suggest DIALOG â€‹+ â€‹could be an effective treatment option for improving quality of life and reducing psychiatric symptoms in patients with depressive and anxiety disorders in a low-resource setting.

[Psychotherapeutic testimony be refugees from Bosnia-Herzegovina: a pilot study]. / Psihoterapija svjedocenjem sa izbjeglicama iz Bosne i Hercegovine: pilot studija.

GOAL: The authors wished to describe the need of the psychotherapy by the witnessing in the group of the adult refugees who have survived the genocide in B&H. METHODOLOGY: The subjects of the study were 20 refugees from B&H with the residence in Chicago, which gave the written assent for participation in the study of the psychotherapy by witnessing. All the participants were this method, what in the average were 6 sessions, the approximative duration 90 minutes, once a week or once in two weeks. The participants were tested by the application of the standardized instruments for PTSP, depression, traumatic events, the global functioning and the previous therapy, after the last seance and after 2 and 6 months. RESULT: The estimations done after the therapy showed significantly the decrease in the percentage of the diagnoses of PTSP (repeated living, escaping, increase arousing attention). The symptom of the depression have also significantly lower, and the estimation of the global functioning was significantly higher. To the testing after 2 and 6 months showed that the further significant decreasing of the symptoms and the significant increase of the functioning. CONCLUSION: This pilot study offers the preliminary proves that psychotherapy by the witnessing of the symptoms of PTSP and also the depression as well as to the improvement of the functioning in the survived political and war violence.