Publications by authors named "Solomon Teferra"

34 Publications

Low-coverage sequencing cost-effectively detects known and novel variation in underrepresented populations.

Am J Hum Genet 2021 Apr 25;108(4):656-668. Epub 2021 Mar 25.

Department of Psychiatry and Human Behavioral Sciences, Walter Sisulu University, Mthatha, South Africa.

Genetic studies in underrepresented populations identify disproportionate numbers of novel associations. However, most genetic studies use genotyping arrays and sequenced reference panels that best capture variation most common in European ancestry populations. To compare data generation strategies best suited for underrepresented populations, we sequenced the whole genomes of 91 individuals to high coverage as part of the Neuropsychiatric Genetics of African Population-Psychosis (NeuroGAP-Psychosis) study with participants from Ethiopia, Kenya, South Africa, and Uganda. We used a downsampling approach to evaluate the quality of two cost-effective data generation strategies, GWAS arrays versus low-coverage sequencing, by calculating the concordance of imputed variants from these technologies with those from deep whole-genome sequencing data. We show that low-coverage sequencing at a depth of ≥4× captures variants of all frequencies more accurately than all commonly used GWAS arrays investigated and at a comparable cost. Lower depths of sequencing (0.5-1×) performed comparably to commonly used low-density GWAS arrays. Low-coverage sequencing is also sensitive to novel variation; 4× sequencing detects 45% of singletons and 95% of common variants identified in high-coverage African whole genomes. Low-coverage sequencing approaches surmount the problems induced by the ascertainment of common genotyping arrays, effectively identify novel variation particularly in underrepresented populations, and present opportunities to enhance variant discovery at a cost similar to traditional approaches.
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http://dx.doi.org/10.1016/j.ajhg.2021.03.012DOI Listing
April 2021

Distribution and determinants of serum high-sensitivity C-reactive protein in Ethiopian population.

Clin Chim Acta 2021 Mar 4;517:99-107. Epub 2021 Mar 4.

National Reference Laboratory for Clinical Chemistry, Ethiopian Public Health Institute, Addis Ababa, Ethiopia.

Background: C-reactive protein (CRP) is an important inflammatory marker associated with different disease conditions, and its concentration differs among ethnicity. This study aimed to determine the distribution and determinants of serum high-sensitive method CRP (hsCRP) that can measure the typically low concentrations, among the Ethiopian population, for which there is no data.

Methods: A cross-sectional community-based study was conducted in April-June 2015. A total of 5162 individuals aged 15-69 were included. Behavioral, physical, and biochemical measurements were taken using the WHO STEPS non-communicable diseases (NCDs) risk factors assessment tool. Serum hsCRP was determined using Cobas Integra 400 Plus (Roche). Factors associated with hsCRP levels were also considered.

Results: median hsCRP was 0.80 mg/L (Interquartile range, 0.19-2.12) (males: 0.91 mg/L, females: 0.74 mg/L). More than 18% of the study participants had hsCRP greater than 3 mg/L according to the American Heart Association and Centers for Diseases Control and Preventions cut off value. Higher BMI, living in Somali and in Dire Dawa region, and not consuming of fruit or vegetables were independent risk factors for high hsCRP levels.

Conclusion: Serum hsCRP levels distribution is comparable to other studies. Until now, no data have been reported in the literature about the Ethiopian population.
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http://dx.doi.org/10.1016/j.cca.2021.02.013DOI Listing
March 2021

"Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia.

PLoS One 2021 25;16(2):e0246158. Epub 2021 Feb 25.

Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.

Background: There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries.

Methods: We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data.

Results: There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed.

Conclusion: It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246158PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906313PMC
February 2021

Adaptation and piloting of an integrated intervention model for alcohol use disorders in primary healthcare in rural Tanzania: a study protocol.

BMJ Open 2020 10 31;10(10):e038615. Epub 2020 Oct 31.

Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Introduction: Integration of evidence-based interventions for alcohol use disorders (AUDs) into primary healthcare has potential to increase coverage and reduce population burden. However, these interventions are rarely implemented in low- and middle-income countries and there is little existing guidance on how this could be achieved. The aim of the proposed study is to adapt and pilot an integrated model for AUDs in Tanzanian primary healthcare.

Methods And Analysis: The study design will include a situational analysis, a qualitative study, a series of participatory Theory of Change (ToC) workshops and pilot intervention study. The evidence-based packages of care for AUD from the WHO mental health Gap Intervention Guide will form the basis of intervention. The situation analysis will use publicly available data to identify existing resources and system functioning. In-depth interviews will be conducted with key stakeholders (people with lived experience of substance use problems, health workers, health planners and community-based organisations) to identify barriers and facilitators to integration and recommended implementation strategies. Thematic analysis will be used. Triangulation of findings will inform the ToC map for the adapted model of integrated services for AUDs. This model will then be piloted. Change in knowledge, skills and attitudes of health workers will be measured pre-implementation and post-implementation. Interrupted time series analysis will be used to identify change in the rate of identification of AUDs beyond that observed due to secular trends or by chance. The integrated model will be finalised for future implementation and larger-scale evaluation.

Ethics And Dissemination: Ethical approval was obtained from Addis Ababa University College of Health Science Institutional Review Board and Muhimbili University of Health and Allied Sciences Institutional Review Board. Findings will be disseminated to inform strategies for scale up of integrated interventions for people with AUDs in Tanzania and similar contexts.
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http://dx.doi.org/10.1136/bmjopen-2020-038615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783617PMC
October 2020

Exploring the concept of problematic khat use in the Gurage community, South Central Ethiopia: a qualitative study.

BMJ Open 2020 10 12;10(10):e037907. Epub 2020 Oct 12.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Objective: This study aimed to explore how problematic khat use is characterised in the Gurage community in South Central Ethiopia.

Design: Qualitative study.

Setting: Gurage community in South Central Ethiopia.

Participants: We conducted indepth interviews with 14 khat users and 5 non-khat users, and three focus group discussions with khat users.

Methods: All participants were selected purposively based on their exposure to khat or khat use. We used an interview guide to explore the perceptions of participants about khat use and problematic khat use. We analysed the data thematically using OpenCode V.4.03 software. We used iterative data collection and analysis, triangulation of methods, and respondent validation to ensure scientific rigour.

Findings: We identified three major themes: sociocultural khat use, khat suse (khat addiction) and negative consequences of khat use. Sociocultural khat use included a broad range of contexts and patterns, including use of khat for functional, social, cultural and religious reasons. Khat addiction was mainly explained in terms of associated khat withdrawal experiences, including harara/craving and inability to quit. We identified mental health, sexual life, physical health, social and financial negative consequences of khat use. The local idiom jezba was used to label a subgroup of individuals with khat suse (khat addiction).

Conclusion: The study has identified what constitutes normative and problematic khat use in the Gurage community in South Central Ethiopia. Problematic khat use is a broad concept which includes frequency, reasons, contexts, negative consequences and addiction to khat. Insights generated can be used to inform future studies on the development of tools to measure problematic khat use.
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http://dx.doi.org/10.1136/bmjopen-2020-037907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552831PMC
October 2020

Initiating clozapine treatment service and characteristics of clozapine-treated patients in a general hospital in Addis Ababa, Ethiopia.

Authors:
Solomon Teferra

S Afr J Psychiatr 2020 24;26:1418. Epub 2020 Jun 24.

Department of Psychiatry, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.

Background: At least one-third of patients with schizophrenia suffer from treatment-resistant schizophrenia needing treatment with clozapine. This is the first report on the experience of initiating clozapine service in Ethiopia.

Aim: The aim of this study was to report the experience of setting up clozapine service and describe characteristics of patients treated with clozapine.

Setting: This study was conducted in a general hospital in Addis Ababa, Ethiopia.

Methods: Descriptive summary of the clozapine treatment service and review of characteristics of patients treated with clozapine were conducted. Clinical Global Impression (CGI) Scale and Abnormal Involuntary Movement Scale (AIMS) score were used to measure outcome. Quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) Version 24.

Results: It was possible to provide clozapine treatment in a general hospital using the national guideline. During the first year of initiation of the service, a total of 22 patients were treated. The majority were men (20/22, 90.9%) and in the age group of 30-44 years (11/22, 50%). Indications for clozapine were treatment-resistant schizophrenia (15/22, 68.2%) and tardive dyskinesia (7/22, 31.8%). The average dose of clozapine was 350 mg/day. Common side effects included sedation, constipation and excessive salivation. On CGI Scale, mean severity index score dropped from 5.18 at admission to 3.68 during discharge, and average AIMS score changed from 16.8 to 6.5. None of the patients developed agranulocytosis; however, three patients discontinued because of adverse effects.

Conclusion: Establishing clozapine treatment service was possible in a general hospital in Ethiopia where psychiatric service run by psychiatrists was available. Mechanisms should be in place to ensure adherence to the national guideline.
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http://dx.doi.org/10.4102/sajpsychiatry.v26i0.1418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343948PMC
June 2020

Prevalence of Hyperhomocysteinaemia and Associated Factors among Ethiopian Adult Population in a 2015 National Survey.

Biomed Res Int 2020 11;2020:9210261. Epub 2020 Jan 11.

Center for Food Science and Nutrition, College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Hyperhomocysteinaemia (HHcy) is an independent risk factor for major cardiovascular diseases, but data on the prevalence and predictors of HHcy in low- and middle-income countries like Ethiopia are scant. The aim of this study was to estimate the prevalence of HHcy and associated risk factors in the Ethiopian adult population. A cross-sectional survey on risks of noncommunicable diseases (NCDs) using the STEPwise approach to surveillance (STEPS) survey was conducted between April and June 2015. A total of 4,175 study participants were surveyed. Serum homocysteine (Hcy) and metabolic profile were determined using Cobas Integra 400 Plus and CardioChek PA analyzer, respectively. Factors associated with HHcy were determined using logistic regression. The mean serum tHcy concentration was 14.6 mol/L, with 16.4 mol/L in males and 13.4 mol/L in females. Overall, 38% had HHcy, with figures in males (49%) higher than females (30%). Increased age, being male, and high blood pressure and/or taking blood pressure medication, as well as low consumption of fruit and/or vegetables, were independent risk factors for HHcy. In conclusion, the prevalence of HHcy among the adult Ethiopian population is alarmingly high. Improving diets through the promotion of fruit and vegetable consumption is needed to reduce the risk of NCDs.
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http://dx.doi.org/10.1155/2020/9210261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201487PMC
February 2021

"He can send her to her parents": The interaction between marriageability, gender and serious mental illness in rural Ethiopia.

BMC Psychiatry 2019 10 26;19(1):315. Epub 2019 Oct 26.

Department of Psychiatry, Boston Medical Center, Boston, MA, USA.

Background: For women in most low- and middle-income countries, the diagnosis with serious mental illness (SMI) leads to stigma and challenges related to starting or maintaining marriages. The purpose of this qualitative study was to explore perspectives on marriage, divorce and family roles of women with SMI in rural Ethiopia.

Methods: A qualitative study was conducted in a rural setting of Butajira, South Central Ethiopia. A total of 39 in-depth interviews were carried out with service users (n = 11), caregivers (n = 12), religious leaders (n = 6), health extension workers (n = 4), police officers (n = 2), teachers (n = 2) and government officials (n = 2). Data were analyzed using a thematic approach.

Results: Three themes emerged. (1) Marriage and SMI: Chances of getting married for individuals with SMI in general was perceived to be lower: Individuals with SMI experienced various challenges including difficulty finding romantic partner, starting family and getting into a long-term relationship due to perceived dangerousness and the widespread stigma of mental illness. (2) Gendered experiences of marriageability: Compared to men, women with SMI experienced disproportionate levels of stigma which often continued after recovery. SMI affects marriageability for men with SMI, but mens' chances of finding a marital partner increases following treatment. For women in particular, impaired functioning negatively affects marriageability as ability to cook, care and clean was taken as the measure of suitability. (3) Acceptability of divorce and separation from a partner with SMI: Divorce or separation from a partner with SMI was considered mostly acceptable for men while women were mostly expected to stay married and care for a partner with SMI. For men, the transition from provider to dependent was often acceptable. However, women who fail to execute their domestic roles successfully were considered inept and would be sent back to their family of origin.

Conclusion: Women with SMI or those married to partners with SMI are at greater disadvantage. Reducing vulnerabilities through stigma reduction efforts such as community outreach and mental health awareness raising programs might contribute for better social outcomes for women with SMI.
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http://dx.doi.org/10.1186/s12888-019-2290-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815356PMC
October 2019

Gender-specific experiences of serious mental illness in rural Ethiopia: A qualitative study.

Glob Public Health 2020 02 20;15(2):185-199. Epub 2019 Oct 20.

Department of Psychiatry, Boston Medical Center, Boston, USA.

Considerable variation in the gender-specific prevalence of serious mental illness (SMI) has been reported in low- and middle-income countries (LMICs). In the rural setting of Butajira, Ethiopia, the male-to-female prevalence ratio of schizophrenia was reported to be 5:1. This qualitative study explores gender-specific experiences of SMI and the extent to which sociocultural factors may explain the observed difference in prevalence estimates. Using purposive sampling, 39 in-depth interviews were conducted with community members from Butajira, a rural district in South Central Ethiopia. Transcripts were analysed using thematic analysis to elicit community perspectives on cultural explanatory models of SMI and experiences in this region. Gender-specific experiences were reported to differ due to visibility of symptoms, community responses, and varying levels of family support towards individuals with SMI. Overall, respondents described how various sociocultural factors subject women with SMI to higher levels of physical and social isolation compared to men, greatly affecting community health workers' ability to identify and provide care to women with mental illness. Future case detection methods should involve family members as they interact with women with SMI early on in the development of their symptoms and play an essential role in their path to mental health care.
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http://dx.doi.org/10.1080/17441692.2019.1680723DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994335PMC
February 2020

Depression and social support among breast cancer patients in Addis Ababa, Ethiopia.

BMC Cancer 2019 Aug 27;19(1):836. Epub 2019 Aug 27.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Depression is a common co-morbid, disabling disorder that affects 10-25% of cancer patients. It causes substantial functional impairment and lowers survival rate of breast cancer patients. Therefore, the aim of this study is to determine the magnitude of depression and its association with social support among breast cancer patients in Addis Ababa, Ethiopia.

Methods: A cross-sectional study which included 428 breast cancer patients was conducted in seven health facilities in Addis Ababa, Ethiopia. Depression and Social Support were assessed using standard tools Patient Health Questionnaire 9 (PHQ 9) and Multidimensional Scale of Perceived Social Support (MSPSS) respectively. Descriptive statistics were done based on the standard PHQ9 cut off points (0-4, 5-9, 10-14, 15-19 and ≥ 20). Mann-Whitney and Kruskal Wallis tests were employed to compare MSPSS score among depressed and non-depressed patients and across the different levels of depression. Bivariate and multivariate logistic regression was done to identify factors associated with depression.

Result: The prevalence of depression among breast cancer patients was 25% (107/428), andaccording to the PHQ9 score categorization, 70/428 (16.4%), 30/428 (7.01%) and 7/428 (1.64%) of these patients were having moderate, moderately severe and severe depression respectively. Age, occupation, type of health facility treated, severity of pain, hormonal therapy and having problem with employer/ family were significantly associated with depression. The participants' MSPSS total score was overall found to be high (70.35 ± 16.81). Those women who had moderate and severe depression had lower mean MSPSS scores compared to women with none/ minimal depression (P = 0.002).

Conclusion: This study found that one in four breast cancer patients had depression. Depression is associated with poor social support given by family, friends and significant others. Therefore, screening for depression and psychosocial service should be integrated in the routine breast cancer care in Ethiopia.
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http://dx.doi.org/10.1186/s12885-019-6007-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712811PMC
August 2019

Definition and Validity of the Construct "Problematic Khat Use": A Systematic Review.

Eur Addict Res 2019 16;25(4):161-172. Epub 2019 Apr 16.

Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine Addis Ababa, Addis Ababa, Ethiopia.

Background: Problematic khat use, not khat use per se, is a public health and social concern for the public, researchers, and policy makers. However, the construct problematic khat use is not well-established and not fully recognized in the modern definition of substance use disorders including Diagnostic Statistic Manual (DSM-5) and international classification of diseases (ICD-10), although DSM-5 included it in the "stimulant use disorder" category. Existing scoping reviews have focused on khat use, which could not allow the differentiation of khat use from problematic khat use. Thus, the aim of this systematic review was to define and validate the construct problematic khat use.

Methods: This systematic review was reported following the PRISMA guidelines. We searched all English language studies without publication date restriction from 5 databases; PubMed, EMBASE, psychINFO, SocINDEX, and Google scholar. All studies that defined, explored, evaluated, or measured the construct problematic khat use were included. Adapted data extraction tool and criteria for quality evaluation were employed. We presented the results in tables and thematic synthesis of the major findings.

Result: Overall, 30 qualitative and cross-sectional design studies were included. Associated harms with khat use, an increased amount used, increased frequency of use, and withdrawal experiences were indicators of problematic khat use. Using khat on an average of 3 or more times per week and using other psychoactive substances during and after khat use were frequently used to define problematic khat use. The most frequently reported withdrawal symptoms were depressed mood, irritability, fatigue, lack of motivation, increased sleep, and appetite. The existing measures (severity of dependence scale and DSM-5) of problematic khat use had psychometrically acceptable properties in terms of construct, criterion, and convergent validity, but they are poor in terms of other domains of validity including content, conceptual, and semantic validity.

Conclusion: Problematic khat use constitutes, but is not limited to, harms, increased use over time, and frequent engagement in other psychoactive substances misuse. Khat use is different from problematic khat use since it is occasional and used for prayer, social, and functional reasons. Strong empirical studies that could establish thresholds for patterns of problematic khat use and a culturally suitable problematic khat use measures that follows a bottom-up approach of scale development are warranted.
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http://dx.doi.org/10.1159/000499970DOI Listing
November 2019

Neuropsychiatric Genetics of African Populations-Psychosis (NeuroGAP-Psychosis): a case-control study protocol and GWAS in Ethiopia, Kenya, South Africa and Uganda.

BMJ Open 2019 02 19;9(2):e025469. Epub 2019 Feb 19.

Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.

Introduction: Schizophrenia and bipolar disorder account for a large proportion of the global burden of disease. Despite their enormous impact, little is known about their pathophysiology. Given the high heritability of schizophrenia and bipolar disorder, unbiased genetic studies offer the opportunity to gain insight into their neurobiology. However, advances in understanding the genetic architecture of schizophrenia and bipolar disorder have been based almost exclusively on subjects of Northern European ancestry. The Neuropsychiatric Genetics of African Populations-Psychosis (NeuroGAP-Psychosis) project aims to expand our understanding of the causes of schizophrenia and bipolar disorder through large-scale sample collection and analyses in understudied African populations.

Methods And Analysis: NeuroGAP-Psychosis is a case-control study of 34 000 participants recruited across multiple sites within Ethiopia, Kenya, South Africa and Uganda. Participants will include individuals who are at least 18 years old with a clinical diagnosis of schizophrenia or bipolar disorder ('psychosis') or those with no history of psychosis. Research assistants will collect phenotype data and saliva for DNA extraction. Data on mental disorders, history of physical health problems, substance use and history of past traumatic events will be collected from all participants.DNA extraction will take place in-country, with genotyping performed at the Broad Institute. The primary analyses will include identifying major groups of participants with similar ancestry using the computation-efficient programme single nucleotide polymorphisms (SNP) weights. This will be followed by a GWAS within and across ancestry groups.

Ethics And Dissemination: All participants will be assessed for capacity to consent using the University of California, San Diego Brief Assessment of Capacity to Consent. Those demonstrating capacity to consent will be required to provide informed consent. Ethical clearances to conduct this study have been obtained from all participating sites. Findings from this study will be disseminated in publications and shared with controlled access public databases, such as the database of Genotypes and Phenotypes, dbGaP.
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http://dx.doi.org/10.1136/bmjopen-2018-025469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6377543PMC
February 2019

Treatment gap, help-seeking, stigma and magnitude of alcohol use disorder in rural Ethiopia.

Subst Abuse Treat Prev Policy 2019 01 18;14(1). Epub 2019 Jan 18.

Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine Addis Ababa, Addis Ababa, Ethiopia.

Background: Although alcohol use disorders contribute a high proportion of population disease burden, the treatment gap is large, especially in low- and middle-income countries. To narrow this gap, contextually relevant evidence is needed to inform service development in low- and middle-income country settings. The aim of this study was to assess the magnitude of the treatment gap for alcohol use disorder, help-seeking behavior, stigma and barriers to care among people with alcohol use disorder in rural Ethiopia.

Methods: A cross-sectional, house-to-house survey was conducted in Sodo district, south Ethiopia. A sample of 1500 adults was selected using simple random sampling from a census of households and screened for alcohol use disorder using the alcohol use disorders identification tool (AUDIT). Help-seeking, barriers to care and internalized stigma were investigated among people with moderately severe alcohol use disorder (AUDIT score ≥ 16). Poisson regression with robust variance was used to examine factors associated with alcohol use disorder.

Results: The prevalence of alcohol use disorder (AUDIT ≥8) in the past 12 months was 13.9% (25.8% in men and 2.4% in women, p-value < 0.001). People with alcohol use disorder had increased disability (adjusted prevalence ratio (aPR) 1.03, 95% confidence interval (CI) 1.01, 1.03) and higher depressive symptom scores (aPR 1.02, 95% CI 1.01, 1.04). The treatment gap was very wide, about 87.0% (only 13% sought help) of participants with an AUDIT score ≥ 16 had never sought help for their alcohol problems and 70.0% reported high internalized stigma. Major barriers to seeking help were wanted to handle the problem on their own, believing that it would get better by itself and being unsure about where to go.

Conclusions: Although alcohol use disorders are common problems in Ethiopian community, the unmet need for treatment is substantial. An integrated care approach has the potential to address this need, but stigma and low awareness may be major barriers to help-seeking. Interventions to reduce stigma and enhance community awareness are recommended.
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http://dx.doi.org/10.1186/s13011-019-0192-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6339347PMC
January 2019

The critical needs and challenges for genetic architecture studies in Africa.

Curr Opin Genet Dev 2018 12 18;53:113-120. Epub 2018 Sep 18.

Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA; Stanley Center for Psychiatric Research, Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA; Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland.

Human genetic studies have long been vastly Eurocentric, raising a key question about the generalizability of these study findings to other populations. Because humans originated in Africa, these populations retain more genetic diversity, and yet individuals of African descent have been tremendously underrepresented in genetic studies. The diversity in Africa affords ample opportunities to improve fine-mapping resolution for associated loci, discover novel genetic associations with phenotypes, build more generalizable genetic risk prediction models, and better understand the genetic architecture of complex traits and diseases subject to varying environmental pressures. Thus, it is both ethically and scientifically imperative that geneticists globally surmount challenges that have limited progress in African genetic studies to date. Additionally, African investigators need to be meaningfully included, as greater inclusivity and enhanced research capacity afford enormous opportunities to accelerate genomic discoveries that translate more effectively to all populations. We review the advantages, challenges, and examples of genetic architecture studies of complex traits and diseases in Africa. For example, with greater genetic diversity comes greater ancestral heterogeneity; this higher level of understudied diversity can yield novel genetic findings, but some methods that assume homogeneous population structure and work well in European populations may work less well in the presence of greater heterogeneity in African populations. Consequently, we advocate for methodological development that will accelerate studies important for all populations, especially those currently underrepresented in genetics.
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http://dx.doi.org/10.1016/j.gde.2018.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494470PMC
December 2018

The critical needs and challenges for genetic architecture studies in Africa.

Curr Opin Genet Dev 2018 12 18;53:113-120. Epub 2018 Sep 18.

Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA; Stanley Center for Psychiatric Research, Broad Institute of Harvard and MIT, Cambridge, MA 02142, USA; Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland.

Human genetic studies have long been vastly Eurocentric, raising a key question about the generalizability of these study findings to other populations. Because humans originated in Africa, these populations retain more genetic diversity, and yet individuals of African descent have been tremendously underrepresented in genetic studies. The diversity in Africa affords ample opportunities to improve fine-mapping resolution for associated loci, discover novel genetic associations with phenotypes, build more generalizable genetic risk prediction models, and better understand the genetic architecture of complex traits and diseases subject to varying environmental pressures. Thus, it is both ethically and scientifically imperative that geneticists globally surmount challenges that have limited progress in African genetic studies to date. Additionally, African investigators need to be meaningfully included, as greater inclusivity and enhanced research capacity afford enormous opportunities to accelerate genomic discoveries that translate more effectively to all populations. We review the advantages, challenges, and examples of genetic architecture studies of complex traits and diseases in Africa. For example, with greater genetic diversity comes greater ancestral heterogeneity; this higher level of understudied diversity can yield novel genetic findings, but some methods that assume homogeneous population structure and work well in European populations may work less well in the presence of greater heterogeneity in African populations. Consequently, we advocate for methodological development that will accelerate studies important for all populations, especially those currently underrepresented in genetics.
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http://dx.doi.org/10.1016/j.gde.2018.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494470PMC
December 2018

"I cry every day and night, I have my son tied in chains": physical restraint of people with schizophrenia in community settings in Ethiopia.

Global Health 2017 07 11;13(1):47. Epub 2017 Jul 11.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mental illness and their families, are rarely heard. The aim of this study was to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions.

Methods: A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions (n = 35) with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Thematic analysis was used.

Results: Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint.

Conclusion: Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment. The scale up of accessible and affordable mental health care may go some way to address the issue of restraint.

Trial Registration: Clinicaltrials.gov NCT02160249 Registered 3rd June 2014.
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http://dx.doi.org/10.1186/s12992-017-0273-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5504711PMC
July 2017

What constitutes problematic khat use? An exploratory mixed methods study in Ethiopia.

Subst Abuse Treat Prev Policy 2017 03 21;12(1):17. Epub 2017 Mar 21.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Khat is a psycho-stimulant herb, which has been in use in traditional societies in East Africa and the Middle East over many centuries. Although khat is reported to cause various health problems, what constitutes problematic khat use has never been systematically investigated. This study explored the acceptable and problematic uses of khat from the perspective of users.

Methods: The study used a mixed methods design (exploratory sequential) in which qualitative (emic) data were collected to develop a framework to define problematic khat use. The qualitative data were gathered through in-depth interviews (N = 13) and focus group discussions (N = 34). By supplementing the emic experiences considered to constitute problematic khat use with an etic definition, DSM-5 criteria for stimulant related disorders, a structured questionnaire was developed. Subsequently a cross-sectional evaluation of 102 respondents was carried out. Respondents both for qualitative and quantitative study were selected through purposive sampling and snowballing methods. Qualitative data were transcribed and subjected to thematic analysis whereas quantitative data were analyzed using descriptive and nonparametric statistics.

Results: Khat use was acceptable socio-culturally and for functional purposes. However, even in these acceptable contexts there was a restriction to the amount, frequency and type of khat used, and in relation to the experience of the individual using khat and other personal characteristics. More specifically, khat use was considered problematic if there was: 1) Impairment (in social and occupational functioning); 2) loss of control in the use of khat; and 3) withdrawal symptoms when not using khat. Among the participants who use khat (n = 102), 45.1% (n = 46) used khat on a daily basis. The commonest indicators of problematic khat use endorsed by the khat users were loss of control over chewing (73.5%), continuing use of khat despite harm (72.5%) and efforts to avoid withdrawal from khat (61.8%).

Conclusion: Despite reported religious, sociocultural and functional benefits to the use of khat, those with defined problematic khat use have impaired mental health, and social and occupational performance. Comparison of these respondent defined indicators of problem behavior matched almost completely to the DSM-5 (etic-defined) understanding of problematic stimulant use. Although the findings have relevant clinical, research and policy implications, the study focused on users purposively identified. Future larger scale definitive studies are required to make concrete policy recommendations.
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http://dx.doi.org/10.1186/s13011-017-0100-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5361726PMC
March 2017

What constitutes problematic khat use? An exploratory mixed methods study in Ethiopia.

Subst Abuse Treat Prev Policy 2017 03 21;12(1):17. Epub 2017 Mar 21.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Khat is a psycho-stimulant herb, which has been in use in traditional societies in East Africa and the Middle East over many centuries. Although khat is reported to cause various health problems, what constitutes problematic khat use has never been systematically investigated. This study explored the acceptable and problematic uses of khat from the perspective of users.

Methods: The study used a mixed methods design (exploratory sequential) in which qualitative (emic) data were collected to develop a framework to define problematic khat use. The qualitative data were gathered through in-depth interviews (N = 13) and focus group discussions (N = 34). By supplementing the emic experiences considered to constitute problematic khat use with an etic definition, DSM-5 criteria for stimulant related disorders, a structured questionnaire was developed. Subsequently a cross-sectional evaluation of 102 respondents was carried out. Respondents both for qualitative and quantitative study were selected through purposive sampling and snowballing methods. Qualitative data were transcribed and subjected to thematic analysis whereas quantitative data were analyzed using descriptive and nonparametric statistics.

Results: Khat use was acceptable socio-culturally and for functional purposes. However, even in these acceptable contexts there was a restriction to the amount, frequency and type of khat used, and in relation to the experience of the individual using khat and other personal characteristics. More specifically, khat use was considered problematic if there was: 1) Impairment (in social and occupational functioning); 2) loss of control in the use of khat; and 3) withdrawal symptoms when not using khat. Among the participants who use khat (n = 102), 45.1% (n = 46) used khat on a daily basis. The commonest indicators of problematic khat use endorsed by the khat users were loss of control over chewing (73.5%), continuing use of khat despite harm (72.5%) and efforts to avoid withdrawal from khat (61.8%).

Conclusion: Despite reported religious, sociocultural and functional benefits to the use of khat, those with defined problematic khat use have impaired mental health, and social and occupational performance. Comparison of these respondent defined indicators of problem behavior matched almost completely to the DSM-5 (etic-defined) understanding of problematic stimulant use. Although the findings have relevant clinical, research and policy implications, the study focused on users purposively identified. Future larger scale definitive studies are required to make concrete policy recommendations.
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http://dx.doi.org/10.1186/s13011-017-0100-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5361726PMC
March 2017

Hazardous alcohol use and associated factors in a rural Ethiopian district: a cross-sectional community survey.

BMC Public Health 2016 Mar 3;16:218. Epub 2016 Mar 3.

Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Alcohol related health and social problems are on the rise in sub-Saharan Africa. This survey reports the prevalence and associated factors for hazardous drinking in rural Sodo district, southern Ethiopia. The survey was part of a multi-center study, Programme for Improving Mental Health Care (PRIME), which is a consortium of research institutions and ministries of health of five low and middle income countries, namely Ethiopia, India, Nepal, South Africa and Uganda in partnership with UK institutions and World Health Organization (WHO).

Methods: A cross-sectional community survey was conducted involving 1500 adults, age 18 and above, recruited using multi-stage random sampling. Data on alcohol use was collected using the Fast Alcohol Screening Test (FAST). Standardised instruments were used to measure potential associated factors, including a validated adaptation of the Kessler 10 (psychological distress), the List of Threatening Experiences (number of adverse life events). Exploratory multivariable logistic regression was conducted to examine factors associated with hazardous alcohol use.

Results: The overall prevalence of hazardous alcohol use was found to be 21 %; 31 % in males and 10.4 % in females, P < 0.05. Factors independently associated with hazardous alcohol use were being male (adjusted OR = 4.0, 95 % CI = 2.44, 6.67), increasing age, having experienced one or more stressful life events (adjusted OR = 1.71, 95 % CI = 1.18, 2.48, and adjusted OR = 2.12, 95 % CI = 1.36, 3.32 for 1-2 and 3 or more adverse life events, respectively) and severe psychological distress (adjusted OR = 2.96, 95 % CI = 1.49, 5.89). High social support was found to be protective from hazardous alcohol use (adjusted OR = 0.41, 95 % CI = 0.23, 0.72).

Conclusion: High level of hazardous alcohol use was detected in this predominantly rural Ethiopian setting. The finding informed the need to integrate services for hazardous alcohol use such as brief intervention at different levels of primary care services in the district. Public health interventions to reduce hazardous alcohol use also need to be launched.
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http://dx.doi.org/10.1186/s12889-016-2911-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778336PMC
March 2016

Large Scale Genetic Research on Neuropsychiatric Disorders in African Populations is Needed.

EBioMedicine 2015 Oct 9;2(10):1259-61. Epub 2015 Oct 9.

Stanley Center for Psychiatric Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA ; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA ; Psychiatric and Neurodevelopmental Genetics Unit and Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.ebiom.2015.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634677PMC
October 2015

Development of a scalable mental healthcare plan for a rural district in Ethiopia.

Br J Psychiatry 2016 Jan 7;208 Suppl 56:s4-12. Epub 2015 Oct 7.

Abebaw Fekadu, MD, PhD, MRCPsych, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia, Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience and Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Charlotte Hanlon, PhD, MRCPsych, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia and Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Girmay Medhin, PhD, Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia; Atalay Alem, MD, PhD, Medhin Selamu, MA, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia; Tedla W. Giorgis, PhD, Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia; Teshome Shibre, MD, PhD, Solomon Teferra, MD, PhD, Teketel Tegegn, MD, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia; Erica Breuer, MPH, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Vikram Patel, PhD, MRCPsych, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK, Centre for Mental Health, the Public Health Foundation of India and Sangath, Alto-Porvorim, Goa India; Mark Tomlinson, PhD, Stellenbosch University and University of Cape Town, Cape Town, South Africa; Graham Thornicroft, PhD, FRCPsych, Martin Prince, MD, FRCPsych, Centre for Global Mental Health, Health Services and Population Research Department, King's College London, London, UK; Crick Lund, PhD, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa, and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.

Background: Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority.

Aims: To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia.

Method: A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation).

Results: The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability.

Conclusions: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.
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http://dx.doi.org/10.1192/bjp.bp.114.153676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698551PMC
January 2016

International Clinical Trial Day and clinical trials in Ethiopia and Africa.

Trials 2014 Dec 19;15:493. Epub 2014 Dec 19.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Zambia Street, PO Box 9086, Addis Ababa, Ethiopia.

Low income countries like Ethiopia are underrepresented in clinical research. As a major public commitment to clinical research, Ethiopia celebrated the International Clinical Trial Day (ICTD) for the first time on 20 May 2014 under the auspices of Addis Ababa University. The motto for the day was 'Clinical Trials for Excellence in Patient Care'. The celebration offered an opportunity to inform academic staff, researchers, students and the leadership about clinical trials being conducted and to discuss the future of clinical trials in the country. Although clear challenges to the conduct of trials abound, clinical trials registered from Ethiopia in trial registration databases is increasing. Cross-country collaborations, international funding support, motivation of academic staff to conduct clinical trials and the commitment and engagement of the leadership in research are all improving. The overall impact of clinical trials is also encouraging. For example, some of the trials conducted in Ethiopia have informed treatment guidelines. However, administrative capacity, research infrastructure as well as financial support remain weak. There is a need for enhanced university-industry linkage and translation of research findings into locally relevant evidence. Ethiopia, as well as the whole of Africa, has an unparalleled opportunity to lead the way in clinical trials, given its prospect of development and the need to have locally relevant evidence for its growing population. In this commentary we reflect on the celebration of ICTD, the status and opportunities for conducting clinical trials and the way forward for facilitating clinical trials in Ethiopia and Africa.
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http://dx.doi.org/10.1186/1745-6215-15-493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4300613PMC
December 2014

Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population-based cohort.

Schizophr Res 2015 Feb 22;161(2-3):414-20. Epub 2014 Nov 22.

Addis Ababa University, Ethiopia; King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK.

Background: Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far.

Methods: A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome.

Result: About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia.

Conclusion: This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.
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February 2015

Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population-based cohort.

Schizophr Res 2015 Feb 22;161(2-3):414-20. Epub 2014 Nov 22.

Addis Ababa University, Ethiopia; King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK.

Background: Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far.

Methods: A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome.

Result: About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia.

Conclusion: This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.
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February 2015

Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population-based cohort.

Schizophr Res 2015 Feb 22;161(2-3):414-20. Epub 2014 Nov 22.

Addis Ababa University, Ethiopia; King's College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK.

Background: Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far.

Methods: A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome.

Result: About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia.

Conclusion: This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.
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February 2015

Adjuvant therapy with minocycline for schizophrenia (The MINOS Trial): study protocol for a double-blind randomized placebo-controlled trial.

Trials 2013 Nov 27;14:406. Epub 2013 Nov 27.

Department of psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Schizophrenia is understood to be a heterogeneous brain condition with overlapping symptom dimensions. The negative symptom dimension, with its protean cognitive manifestations, responds poorly to treatment, which can be a particular challenge in countries where clozapine therapy is not available. Preliminary data indicate that minocycline may be beneficial adjunct in the treatment of schizophrenia: positive, negative, and cognitive symptoms.In this study we aim to assess the efficacy of adjunctive minocycline to alleviate symptoms of schizophrenia in patients who have failed to respond to a therapeutic trial of antipsychotic medications.

Methods: The study is a parallel group, double-blind, randomized, placebo-controlled trial. Participants will be adults (aged 18 years and above) with first episode or relapse episode of schizophrenia of under 5 years' duration. Patients who failed to show adequate therapeutic response to at least one antipsychotic medication given for a minimum of 4 weeks will be recruited from a psychiatry hospital in Addis Ababa and a psychiatry clinic in Butajira, Ethiopia. A total of 150 participants (75 in each arm) will be required to detect a five-point mean difference between the intervention arms adjusting for baseline symptom severity, at 90% power and 95% confidence. Patients in the intervention arm will receive minocycline (200 mg/day orally) added on to the regular antipsychotic medications participants are already on. Those in the placebo arm will receive an inactive compound identical in physical appearance to minocycline. Intervention will be offered for 12 weeks. Diagnosis will be established using the operational criteria for research (OPCRIT). Primary outcome measure will be a change in symptom severity measured using the positive and the negative syndrome scale for schizophrenia (PANSS). Secondary outcome measures will include changes in severity of negative symptoms, proportion achieving remission, and level of functioning. Whether changes are maintained post intervention will also be measured (PANSS). Key assessment for the primary outcome will be conducted at the end of trial (week 12). One post-intervention assessment will be conducted 4 weeks after the end of intervention (week 16) to determine sustainability of change.

Trial Registration: Clinicaltrials.gov identifier: NCT01809158.
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http://dx.doi.org/10.1186/1745-6215-14-406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222697PMC
November 2013

Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers.

BMC Psychiatry 2013 Jun 17;13:168. Epub 2013 Jun 17.

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Levels of non-adherence to antipsychotic medication in persons with schizophrenia in rural African settings have been shown to be comparable to those found in high-income countries. Improved understanding of the underlying reasons will help to inform intervention strategies relevant to the context.

Methods: A qualitative study was conducted among persons with schizophrenia (n = 24), their caregivers (n = 19), research field workers (n = 7) and health workers (n = 1) involved in the ongoing population-based cohort study, 'The Butajira Study on Course and Outcome of Schizophrenia and Bipolar Disorder', based in rural Ethiopia. Six focus group discussions and 9 in-depth interviews were conducted to elicit perspectives on non-adherence to antipsychotic medication. Thematic analysis was used to identify prominent perspectives.

Results: Predominant reasons for non-adherence specific to a low-income country setting included inadequate availability of food to counter appetite stimulation and the perceived strength of antipsychotic medications. The vital role of the family or other social support in the absence of a statutory social safety net was emphasised. Expectations of cure, rather than need for continuing care, were reported to contribute to non-adherence in the longer-term. Many of the factors associated with non-adherence in high-income countries were also considered important in Ethiopia, including lack of insight, failure to improve with treatment, medication side effects, substance abuse, stigma and dissatisfaction with the attitude of the care provider.

Conclusion: This study identifies additional barriers to medication adherence faced by persons with schizophrenia in Ethiopia compared to those in high-income countries. In this era of scaling up of mental health care, greater attention to provision of social and financial assistance will potentially improve adherence and thereby enable patients to benefit more fully from medication.
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http://dx.doi.org/10.1186/1471-244X-13-168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686587PMC
June 2013

Predictors of carer-burden in schizophrenia: a five-year follow-up study in Butajira, Ethiopia.

Ethiop Med J 2012 Apr;50(2):125-33

Addis Ababa University, Faculty of Medicine, Department of Psychiatry, Addis Ababa, Ethiopia.

Objective: We assessed carer-burden and its predictors in a traditional rural Ethiopian community in order to establish the longitudinal course of carer-burden and factors predicting changes.

Methods: Using a 5-year follow-up data from the ongoing Butajira outcome study on SMI, carer-burden was assessed annually with the Family Interview Schedule (FIS). Multilevel modeling was used to identify clinical predictors of severity and rate of change of burden.

Results: Scores in all domains of carer burden decreased over time, although the greatest reduction was seen in the first year. In a univariate analyses, longitudinal reduction in burden score was predicted by longer period in remission during follow-up, while negative and positive symptom severity scores predicted higher burden score. In the fully adjusted model, poor social support predicted higher burden score (beta=0.38, 95%CI 0.04, 0.72), and longer period in remission predicted lower level of carer-burden (beta = -0.49, 95%CI = -0.89, - 0.10). Reduction in positive symptoms was associated with the instantaneous rate of reduction of burden score (beta = -0.03, 95%CI - 0.05, -0.01).

Conclusion: There is a significant reduction in carer-burden over the years in all burden domains. Providing accessible mental health care has the potential to alleviate carer-burden, as positive symptoms are believed to be more amenable to intervention. The study also indicates that remission is associated with reduction in carer-burden.
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April 2012

Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study.

BMC Psychiatry 2012 Jul 12;12:79. Epub 2012 Jul 12.

Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Background: Culture affects the way people conceptualize causes of severe mental disturbance which may lead to a variation in the preferred intervention methods. There is a seemingly dichotomous belief regarding what causes severe mental disturbance: people living in western countries tend to focus mainly on biological and psychosocial risk factors; whereas, in non-western countries the focus is mainly on supernatural and religious factors. These belief systems about causation potentially dictate the type of intervention preferred. Studying such belief systems in any society is expected to help in planning and implementation of appropriate mental health services.

Methods: A qualitative study was conducted among the Borana semi-nomadic population in southern Ethiopia to explore perceived causes of severe mental disturbance and preferred interventions. We selected, using purposive sampling, key informants from three villages and conducted a total of six focus group discussions: three for males and three for females.

Results: The views expressed regarding the causes of mental disturbance were heterogeneous encompassing supernatural causes such as possession by evil spirits, curse, bewitchment, 'exposure to wind' and subsequent attack by evil spirit in postnatal women and biopsychosocial causes such as infections (malaria), loss, 'thinking too much', and alcohol and khat abuse. The preferred interventions for severe mental disturbance included mainly indigenous approaches, such as consulting Borana wise men or indigenous healers, prayer, holy water treatment and seeking modern mental health care as a last resort.

Conclusions: These findings will be of value for health care planners who wish to expand modern mental health care to this population, indicating the need to increase awareness about the causes of severe mental disturbance and their interventions and collaborate with influential people and indigenous healers to increase acceptability of modern mental health care. It also provides information for further research in the area of mental health in this semi-nomadic population.
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http://dx.doi.org/10.1186/1471-244X-12-79DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3416742PMC
July 2012

Disclosure of diagnosis by parents and caregivers to children infected with HIV: prevalence associated factors and perceived barriers in Addis Ababa, Ethiopia.

AIDS Care 2012 9;24(9):1097-102. Epub 2012 Feb 9.

Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.

Vertical transmission of HIV from infected mothers to children is a common phenomenon. After the introduction of highly active antiretroviral treatment (HAART), most children live longer than before. Recently, HAART has become widely available to children living in sub-Saharan African countries, and this makes disclosure of HIV status an important issue. We conducted a cross-sectional survey involving 172 parents/caregivers of HIV-infected school-age children who had follow-up at the Pediatric Infectious Disease Clinic of the Yekatit 12 Hospital, Addis Ababa. Only 16.3% of HIV-infected schoolchildren knew their diagnosis. The child's age was the main predictor of disclosure (OR: -0.25; 95% CI: -0.35, -0.09; p<0.05). The main reason for nondisclosure was fear of negative emotional consequences for the child. More than half of the parent/caregivers agreed that they need to tell the children their diagnosis, but 86% reported that they needed health care providers to help them at the event. The low rate of disclosure found in this study shows the need for awareness creation and training of health professionals, and this should be supported by appropriate guidelines to be followed by health professionals working in pediatric ART clinics. Caregivers need to be provided with the necessary knowledge and skills on how to look after children who know their HIV status.
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http://dx.doi.org/10.1080/09540121.2012.656565DOI Listing
November 2012