Pathways to care for psychosis in Malawi.

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Postpartum psychosis: a public involvement perspective across three continents.

Postpartum psychosis is a psychiatric emergency that is currently not represented in diagnostic systems, to the detriment of people with lived experience. Engaging with stakeholders offers an important avenue to improve clinical practice and make research more impactful, by providing perspectives based on first-hand, expert experience. There is a paucity of reports on stakeholders' engagement in psychiatry. Activities have thus far been limited to Western countries and there are few reports on postpartum psychosis. We report the results of public involvement activities (in the form of discussion groups) with key stakeholders in India, Malawi and the UK. These discussions centred around the clinical picture of postpartum psychosis and the terminologies used to describe these episodes. Seven major areas were highlighted: how postpartum psychosis is handled within services, common symptoms and characteristics, impact of episode, barriers to care, non-medical approaches, terminology and research areas of interest. According to the discussions, postpartum psychosis presents similarly across countries, although there are differences in access to services, approaches to mental health and terminologies used within and across countries. With this understanding comes the foundation for cross-cultural assessment, service improvement and a stakeholder-informed research agenda.

Changes in rates of psychiatric beds and prison populations in sub-Saharan Africa from 1990 to 2020.

Background: Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020. Methods: We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels. Results: Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries. Conclusions: SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.

The relationship between adverse childhood experiences and common mental disorders among pregnant women living with HIV in Malawi.

INTRODUCTION: Adverse childhood experiences (ACEs) have been linked to common mental disorders (CMDs) such as anxiety and depressive thoughts. We examined the prevalence of ACEs and their association with CMDs among pregnant women living with HIV (PWLHIV) in Malawi-an HIV endemic resource-limited setting. METHODS: This is a cross-sectional study of 798 PWLHIV enrolled in the VITAL Start trial in Malawi (10/2018 to 06/2021) (NCT03654898). ACE histories were assessed using WHO's Adverse Childhood Experiences International Questionnaire (ACE-IQ) tool. Depressive symptoms (somatic complaints, reduced vital energy, anxiety, and depressive thoughts) were assessed using WHO's Self Reporting Questionnaire 20-Item (SRQ-20) tool. Log-binomial regressions were used to examine the association between cumulative ACEs and each depressive symptom, as well as identify ACEs driving this association. RESULTS: The mean age of our sample was 27.5 years. Over 95 % reported having experienced ≥1 ACE. On average, each participant reported four ACEs; 11 % reported sexual abuse. About 52 % and 44 % reported anxiety and depressive thoughts, respectively. In regressions, cumulative ACE scores were significantly associated with depressive symptoms-even after adjusting for multiple testing. This association was primarily driven by reports of sexual abuse. LIMITATIONS: Data on maternal ACEs were self-reported and could suffer from measurement error because of recall bias. CONCLUSIONS: ACEs are widespread and have a graded relationship with depressive symptoms in motherhood. Sexual abuse was found to be a primary driver of this association. Earlier recognition of ACEs and provision of trauma-informed interventions to improve care in PWLHIV may reduce negative mental health sequelae.

Epidemiology and bacterial colonization of burn injuries in Blantyre.

Forty-nine patients from the Burns Unit at the QECH had swabs taken from various sites in order to determine the bacterial profile and antibiotic susceptibilities in burn wounds colonized by bacteria. The mean age was 16 years (range 1-70 years); 27 (55 %) of the study population were female and 22 (45%) were male. Twenty-four (49%) patients were epileptic. Open fire (41%) was the most common cause of burn injuries among epileptics while hot water burns (29%) were commonest among non-epileptics. Burn injury and percentage total burn surface area (% TBSA) injuries decreased with age, and the upper and lower limbs, trunk, head and neck were the most commonly affected sites. Staphylococcus aureus was the commonest isolate (23%), followed by Proteus mirabilis (22.7%), Streptococci spp (15.9%), Pseudomonas aeruginosa (4.5%) and 3.4% for Escherichia coli, Salmonella and Klebsiella spp. There was a significant trend of bacterial growth with increasing % TBSA (p<0.001). Bacterial growth was significantly more common in more recent burns of less than 20 days compared to burns of longer duration (OR 4.1 [95% CI 1.58-10.99]). Broad-spectrum antibiotics are required as first-line therapy for burns-related sepsis but there is need for surveillance of antibiotic susceptibility to help determine appropriate therapy.

Epidemiology and Bacterial Colonization of Burn Injuries in Blantyre

Forty-nine patients from the Burns Unit at the QECH had swabs taken from various sites in order to determine the bacterial profile and antibiotic susceptibilities in burn wounds colonized by bacteria. The mean age was 16 years (range 1-70 years); 27 (55 ) of the study population were female and 22 (45) were male. Twenty-four (49) patients were epileptic. Open fire (41) was the most common cause of burn injuries among epileptics while hot water burns (29) were commonest among non-epileptics. Burn injury and percentage total burn surface area (TBSA) injuries decreased with age; and the upper and lower limbs; trunk; head and neck were the most commonly affected sites. Staphylococcus aureus was the commonest isolate (23); followed by Proteus mirabilis (22.7); Streptococci spp (15.9); Pseudomonas aeruginosa (4.5) and 3.4 for Escherichia coli; Salmonella and Klebsiella spp. There was a significant trend of bacterial growth with increasing CI 1.58-10.99]). Broad-spectrum antibiotics are required as first-line therapy for burns-related sepsis but there is need for surveillance of antibiotic susceptibility to help determine appropriate therapy