THEHOPE-Traditional healers working with primary care and mental health for early intervention in psychosis in adolescent:intervention and feasibility

One-in-ten people experience a psychotic episode (delusion, hallucination) before 18 years of age. These experiences can be upsetting and, without adequate treatment, can have serious long-term effects (e.g. reduce quality of life, disrupt education, reduce long-term employment). Early treatment after a psychotic episode is vital to reduce long-term effects.

People living in Low and Middle Income Countries (LMICs) (e.g. Pakistan) experience poorer access to care compared to those in Higher Income Countries (e.g. UK, USA). It can take over two years for someone living in an LMIC to be diagnosed and treated for psychotic episodes. This is double the time it takes for someone in the UK.

We previously carried out research about psychotic episodes in the Peshawar district of Pakistan. We found that people with mental health issues often sought help from traditional and spiritual healers (TSHs). These issues are commonly linked to superstition and/or spirits. Seeking help from TSHs is a key cause of delay in treatment for psychotic episodes. Collaboration between TSHs and primary care has shown to improve healthcare provision for health conditions, such as HIV/AIDS, but the same has not been evaluated for psychotic episodes, up to now.

The proposed programme of research, called THEHOPE (Traditional healers working with primary care and mental health for early intervention in psychosis) seeks to develop a new way of detecting and treating psychotic episodes among adolescents in Peshawar, Pakistan. This research will strengthen collaboration between TSHs and primary care to improve healthcare for patients reporting these issues. By working with TSHs we will develop a new approach that is culturally-sensitive and acceptable to local populations.

We have designed a four-stage plan of research to help develop and test this new way of working:-

(1) We will work closely with people with psychotic episodes (and their carers), TSHs, and primary care practitioners to understand the healthcare context in Peshawar. We will use this information to design THEHOPE intervention and training.

(2) Experts in early intervention in psychosis will train psychiatrists who will then train primary care physicians in Peshawar. These primary care physicians will in turn train the TSH. This model of cascade training involves task shifting from mental health professionals to community health workers and lay persons and has been successfully used in resource poor settings to provide services in a cost effective way.

(3) We will test whether this new way of working helps to detect the cases of first episode psychosis at earliest possible stage in a specially designed study called feasibility cluster randomised controlled trial. In this trial small geographical clusters of Peshawar city (called Union Councils) will be randomly allocated either to proposed new way of working or to a control condition (i.e. treatment as usual). This will help us to examine whether traditional healers will engage in the study, and whether patients consent to participate in the trial and complete the follow-up. Testing the feasibility of these parameters will help us to decide the design and methodology of a much larger study to evaluate the new ways of working in more rigorous way.

(4) All of above stages of research will be closely examined and evaluated to see whether these are acceptable to all participants (e.g. patients and carers) and can be implemented in future studies.

This research will build on existing community practices and resources in a LMIC setting, to improve healthcare for people with psychotic episodes. As TSHs often have a role in mental healthcare in LMICs, findings from this research may be relevant to other countries.

The results of study will be disseminated through publications in scientific journals, meetings involving patients and carers and different stakeholders and by using the social media tools such as twitter.

First Episode Psychosis (FEP) has peak incidence in adolescent. Most patients consult traditional and spiritual healers (TSH) before seeking professional help in low and middle income countries (LMIC), which is a major factor for the long Duration of Untreated Psychosis (DUP) in these countries. We aim to develop a culturally appropriate and context-bespoke intervention (THEHOPE) for early identification, referral and management of First Episode Psychosis (FEP) in the adolescent population while working collaboratively with traditional healers and primary care physicians (PCPs). THEHOPE is an organizational/service level intervention that will consist of a cascade model of training and task shifting from psychiatrists to PCP and from PCP to traditional healers, and establishing community pathways to promote early identification and management of FEP. The study is located in Peshawar, Khyber Pakhtunkhwa, Pakistan.

The research Plan will consist of following four work packages:-

1. Qualitative and ethnographic studies to inform intervention development and training needs and methodology for the TSH and PCPs.

2. UK experts in early psychosis training two local psychiatrists who in turn train 4 PCPs. These PCPs then train 20 TSH in the intervention arm and work collaboratively with them for early detection and referral of FEP in adolescent. The Enhanced Treatment As Usual (ETAU) will be control arm.

3. A cluster feasibility RCT, randomising 92 Union Councils in 1:1 ratio to THEHOPE and ETAU arms. Key feasibility outcomes for definitive trial will include total number of cases referred by TSH and PCP with suspected FEP and likelihood of the confirmed diagnosis of FEP in these cases based on interview by psychiatrist, DUP in those meeting criteria for FEP, the willingness of TSH to work with health services, recruitment and retention at 12 weeks follow up.

4. Process evaluation of all of above study processes and acceptability of THEHOPE.

Through high-quality interdisciplinary research and community and stakeholders' involvement, THEHOPE will not only have an impact on the local populations in the Pakistan and the UK but internationally. This will include improving the care of ethnic minorities living in UK and other high income countries, who regularly use traditional healers. The findings and wide range of outputs (e.g. guidelines for working with traditional healers) will also provide significant benefit to the mental health professionals in Pakistan and UK. This will have significant impact on health services.

THEHOPE will make a significant contribution to the study of working collaboratively with traditional healers, which has rarely been systematically evaluated in mental health. This will have significant impact on developing new ways of working with traditional healers and evaluating these using the randomised controlled trial.

Working collaboratively with traditional healers and by providing effective and early treatment in the community will help reduce the stigma. Training traditional healers may help to reduce coercion and human rights abuses. This can potentially have huge societal impact.

We propose a unique model of task shifting from mental health specialists to the primary care physicians and appropriately trained traditional healers. Although task shifting is a widely established strategy in global health it has rarely been applied in adolescent mental health, nor has it utilised the TSH. Developing a potential model that can be implemented with the help of traditional healers will have wide economic and social impact and is likely to be highly acceptable to those using these services.

THEHOPE is likely to provide a cost effective way for early detection and treatment of psychosis in adolescent, which will have significant societal and economic impact.

By promoting the active partnership between patients, members of the public and researchers we will maximise impact not only during the funded period but also in future work by recognizing and supporting the unique roles users have in research prioritisation, design and management, data collection and the analysis and dissemination of findings.