Barriers and facilitators to treatment seeking behaviors for depression, epilepsy, and schizophrenia in low- and middle-income countries: A systematic review.

Despite the severe consequences, the treatment gap for depression, epilepsy, and schizophrenia continues to be a major concern in low and middle-income countries (LMICs). We conducted a systematic review of literature on barriers and facilitators of treatment-seeking behaviors from the perspective of individuals living with depression, epilepsy, and schizophrenia and stakeholders in LMICs. Knowledge deficits, beliefs, and stigma were barriers to treatment-seeking across disorders. The most cited facilitators were demographics, socioeconomic status, and collaboration with traditional healers. Culturally sensitive interventions in collaboration with stakeholders within the community can facilitate treatment-seeking behaviors among people living with depression, epilepsy, and schizophrenia.

Predictors of disability: a 5-year cohort study of first-episode schizophrenia.

BACKGROUND: There is a dearth of information about the predictors of disability in schizophrenia from low and middle-income countries. This study attempted to investigate the impact of socio-demographic and clinical variables on disability in a cohort of first episode schizophrenia. METHOD: Patients diagnosed to have DSM IV schizophrenia (n=131) were assessed prospectively for psychopathology, functioning, insight and explanatory models of illness at baseline, 6, 12 and 60 months using standard instruments. Disability was assessed at 5 years. Multiple linear regression was employed to adjust for common confounders. RESULTS: We could follow-up 95 (72.5%) patients. Sixty-five of these patients (68.4%) achieved remission. Disability scores at 5 years were associated negatively with episodic nature of illness at baseline, functional assessments at 6 and 12 months and return to pre-morbid level function. Disability correlated positively with psychopathology at 6 and 12 months and time spent in psychotic episodes. It was also associated with psychopathology, remission, insight and patient perspectives at the 5th year cross-sectional evaluation. While employment status at recruitment was not associated with disability, it was associated with unemployment at follow-up. CONCLUSIONS: Disability at 5 years was associated with illness variables - episodic nature of illness at baseline, psychopathology and functioning, duration in psychotic episode and return to pre-morbid function. Patient perspectives about their illness (insight and patient explanatory models) were only associated cross-sectionally at 60 months but not earlier and are more suggestive of a coping response rather than being predictive of outcome. The relationship between unemployment and disability suggests that they are products of the same disease process.

Predictors of insight in first-episode schizophrenia: a 5-year cohort study from India.

BACKGROUND AND AIMS: There is a dearth of data on the predictors of insight in schizophrenia. This study attempted to assess the predictors of insight in a cohort of first-episode schizophrenia followed up over 5 years. METHODS: Patients diagnosed to have Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) schizophrenia (n = 131) were assessed prospectively for insight, psychopathology and explanatory models of illness over a 5-year period using standard instruments. Multiple linear regression and generalized estimating equations (GEE) were employed to assess predictors of insight. RESULTS: We could follow up 95 (72.5%) patients, 5 years after recruitment. A total of 65 of these patients interviewed at 60 months (68.4%) achieved remission. Cross-sectional evaluations suggest a relationship between insight, psychosis rating and explanatory models of illness with good insight and medical models associated with good outcome. However, baseline and early illness data do not predict insight scores at 5 years. Serial longitudinal assessment of insight is negatively associated with Brief Psychiatric Rating Scale (BPRS) scores and positively associated with the number of nonmedical explanatory models of illness held by patients. CONCLUSION: These findings argue that insight and explanatory models of illness are secondary to psychopathology, course and outcome. They are dependent on the trajectory of the person's illness, are not independent of the condition and call for multifaceted understanding of the issues.

Insight, psychopathology, explanatory models and outcome of schizophrenia in India: a prospective 5-year cohort study.

BACKGROUND: The sole focus of models of insight on bio-medical perspectives to the complete exclusion of local, non-medical and cultural constructs mandates review. This study attempted to investigate the impact of insight, psychopathology, explanatory models of illness on outcome of first episode schizophrenia. METHOD: Patients diagnosed to have DSM IV schizophrenia (n = 131) were assessed prospectively for insight, psychopathology, explanatory models of illness at baseline, 6, 12 and 60 months using standard instruments. Multiple linear and logistic regression and generalized estimating equations (GEE) were employed to assess predictors of outcome. RESULTS: We could follow up 95 (72.5%) patients. Sixty-five of these patients (68.4%) achieved remission. There was a negative relationship between psychosis rating and insight scores. Urban residence, fluctuating course of the initial illness, and improvement in global functioning at 6 months and lower psychosis rating at 12 months were significantly related to remission at 5 years. Insight scores, number of non-medical explanatory models and individual explanatory models held during the later course of the illness were significantly associated with outcome. Analysis of longitudinal data using GEE showed that women, rural residence, insight scores and number of non-medical explanatory models of illness held were significantly associated with BPRS scores during the study period. CONCLUSIONS: Insight, the disease model and the number of non-medical model positively correlated with improvement in psychosis arguing for a complex interaction between the culture, context and illness variables. These finding argue that insight and explanatory models are secondary to psychopathology, course and outcome of the illness. The awareness of mental illness is a narrative act in which people make personal sense of the many challenges they face. The course and outcome of the illness, cultural context, acceptable cultural explanations and the prevalent social stigma interact to produce a complex and multifaceted understanding of the issues. This complexity calls for a nuanced framing of insight.