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.