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Bipolar disorder in rural Ethiopia: community-based studies in Butajira for screening, epidemiology, follow-up, and the burden of care
Umeå University, Faculty of Medicine, Clinical Sciences, Psychiatry.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The challenges of research in economically stunted countries’ settings remains a profound concern and is linked to socioeconomic development of these countries. More research is needed regarding psychiatric morbidity in rural areas of the developing and poverty stricken countries. The present studies were undertaken within the framework of a broader ongoing community-based project on the course and outcome of major psychiatric disorders in the rural Butajira district located in Ethiopia. This thesis treats the course and outcome of bipolar I disorder in the district.

Objectives: Through appraising mental health and population based research in a rural Ethiopian district, to evaluate the utility of modern research instruments, and to obtain baseline information relating to bipolar I disorder in the poverty stricken rural Butajira district of Ethiopia. The specific objectives were: 1. Evaluating and comparing two different screening methods of case detection and identification for schizophrenia and bipolar I disorder in the adult population of Butajira district. 2. Assesing the prevalence and clinical characteristics of of bipolar I disorder in Butajira at the community level. 3. Evaluating short-term outcome at follow-up of bipolar I disorder in the Butajira district. 4. Determining Neurological Soft Signs in community-identified cases of bipolar I disorder in Butajira district in comparison with healthy controls. 5. Assessing the burden of care among caregivers of those affected by bipolar I disorder identified in the Butajira Study.

Methods: The district’s entire adult population aged 15-49 was identified through a double-sampling design. In the first stage of screening, door-to-door interviews were conducted by lay trained high school completed individuals who knew the culture of the people. Females interviewed females whereas males interviewed males. Additionally, the key-informants method was used to identify cases that would be missed by the CIDI or otherwise. The final confirmatory diagnostic interview was conducted by clinicians using the SCAN on door-to-door basis as well. The probable cases that fulfilled the lifetime DSM-IV diagnosis of bipolar I disorder were assigned for assessment by other baseline research instruments such as Neurological Evaluation vii Scale (NES), Young Mania Rating Scale, Hamilton Rating Scale for Depression, LCSS, PANS and SANS, BISS, BII, FIS and so on. Cases so identified with bipolar I disorder were subject to a follow-up for upto 2.5 years on the average (range 1 to 4 years). Two of the main clinical outcomes assessed were relapse to a mood episode, and remission from a mood episode. Outcomes were assessed annually by the instruments, and were further assessed monthly by trained psychiatric nurses. We also did a cross-sectional study of caregivers of bipolar I disorder cases, and assessed objective burden on the caregivers as considered from social, family strain, occupational and financial domains.

Results: Information provided by the key informants was better at detecting schizophrenia or chronic psychiatric disease, whereas the CIDI was better at detecting affective disorders. Of the around 100 000 adults living in Butajira, 83.3% were found by the project’s census, of which 82% (68,378 subjects) were successfully screened by the CIDI, yielding 2,161 CIDI positive. These, together with 719 cases identified by the key informants, were invited for the SCAN interview, of which 74.7% agreed. This yielded 315 SCAN positive cases for bipolar I disorder, and complete information could be collected on 295 of these. Lifetime prevalence was estimated as 0.6% for males and 0.3% for females. The mean age of onset of the manic phase was 22.0 years and that of the depressive phase was 23.4 years. For 22.7% of the cases the illness started with a depressive episode and for the remaining 77.3% it started with a manic episode. Over half of the cases (55.9%) had never sought help from modern health care sector, and only 13.2% had ever been admitted to psychiatric hospital. At follow-up, 65.9% had exprerienced a relapse and 31.1% had persistent illness, while only 5% of the patients were in remission for most of the follow-up time. The bipolar I cases, as compared with healthy controls, performed worse on several items of NES, thus having more neurological dysfunction compared to controls. Caregives were largely (80.3%) first-degree relatives and spouses. Overall, 84% of the caregivers reported difficulties in at least one of the domains of family burden. Of these, 58.7% reported a severe degree of difficulties. Caregivers reported a high level of difficulties in intrafamilial relationships and social restrictions, disruption in earning a livelihood, and financial difficulties.

Conclusions: The prevalence of bipolar I disorder is comparable to the prevalences reported from other countries, and our findings support the cross-cultural validity of the concept of bipolar I disorder. Majority of the cases are not treated in contrast to that in the developed countries. The burden of care for the caregivers is substantial in the population studied.

Place, publisher, year, edition, pages
Umeå: Institutionen för klinisk vetenskap , 2009. , 77 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1260
Keyword [en]
Butajira, bipolar 1 disorder, screening, epidemiology, neurological soft signs, burden of care
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-21743ISBN: 978-91-7264-775-6 (print)OAI: oai:DiVA.org:umu-21743DiVA: diva2:211781
Public defence
2009-05-07, Psykiatriska klinikens föreläsningssal A, Norrlands universitetssjukhus, by 23, 0-planet, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2009-04-20 Created: 2009-04-17 Last updated: 2010-01-18Bibliographically approved
List of papers
1. An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia
Open this publication in new window or tab >>An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia
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2002 (English)In: International Journal of Social Psychiatry, ISSN 0020-7640, E-ISSN 1741-2854, Vol. 48, no 3, 200-208 p.Article in journal (Refereed) Published
Abstract [en]

Background: Detecting cases with psychiatric disorders in the general population is costly and it is not clear which is the method of choice for community surveys in low-income countries.

Aim: To compare the performance of a standardized diagnostic layman interview instrument-the Composite International Diagnostic Interview (CIDI 2.1) versus the Key Informant method in identifying cases with schizophrenia and major affective disorders in a community survey.

Method: Both screening methods were tested against an expert interview the Schedule for Clinical Assessment in Neuropsychiatry (SCAN 2.1) in a rural district in Ethiopia with 25,632 inhabitants.

Result: CIDI identified 524 and key informants 192 individuals as probable cases who were invited for a further SCAN interview. Seventy-two individuals were identified by both methods. Of those identified as probable cases by either method, a total of 481 volunteered the SCAN interviews. The Key Informant method alone detected more cases of schizophrenia, 59 vs. 29 for CIDI, whereas CIDI alone detected more cases of affective disorders, 45 vs. 30. Key informants performed better in detecting chronic cases.

Conclusion: For community surveys, which aim at identifying cases with major mental disorders in low-income countries like Ethiopia, the combined use of both CIDI and the Key Informant method is recommended.

Place, publisher, year, edition, pages
Sage Publications, 2002
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-21746 (URN)10.1177/002076402128783244 (DOI)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-12-13Bibliographically approved
2. Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: a community-based study
Open this publication in new window or tab >>Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: a community-based study
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2005 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 87, no 2/3, 193-201 p.Article in journal (Refereed) Published
Abstract [en]

Background Bipolar disorders have been extensively studied in the high-income countries but community-based studies from low-income countries are very rare. The main objectives of the current study are to estimate the lifetime prevalence of bipolar I disorder in the general population of the Butajira district in Ethiopia and to characterize the onset and course of the disorder in a predominantly treatment naïve population.

Method Cases were identified by a door-to-door screening of the district's entire adult population aged 15 to 49 years (N = 83,387), where 68,378 were successfully screened. CIDI and key informant method were used in the first stage of screening followed by confirmatory SCAN interviews.

Results Three hundred fifteen cases were identified and complete information could be collected for 295 individuals. Of these, 55.3% were males, 83.1% were from a rural area, and 70.2% were illiterate. Lifetime prevalence of bipolar I disorder was estimated to be 0.6% for males and 0.3% for females. The mean age of cases was 29.5 years, with no significant sex difference. The mean age of first recognition of illness was 22.0 years; for men 22.3 years and for women 21.2 years. The mean age at onset of manic phase of the illness was found to be 22.0 years (22.5 for men and 21.4 for women). The mean age at onset of depressive phase was 23.4 years (24.1 for men and 22.5 for women). There was no significant sex difference in the age of onset of manic or depressive phases. In 22.7% of the cases bipolar I illness started with a depressive episode and in 77.3% of the cases it started with a manic episode. Two or more episodes of the illness were reported by 64.1%. Over half of the study subjects (55.9%) had never sought any help from modern healthcare sector, and only 13.2% had ever been admitted to psychiatric hospital. During the survey 7.1% of the cases were undergoing treatment. A previous suicide attempt was reported by 8.1% of the males and 5.4% of the females.

Conclusion The overall lifetime prevalence and age of onset are within the range of findings from other studies in Western countries. In contrast to most previous studies, prevalence of the disorder among females was half of that among males. Our finding that prevalence of this disorder among males and females appeared to be different from many other studies warrants further research.

Keyword
bipolar I disorder, rural Ethiopia, onset and course, epidemiology
Identifiers
urn:nbn:se:umu:diva-21739 (URN)10.1016/j.jad.2005.03.011 (DOI)
Available from: 2009-04-17 Created: 2009-04-17 Last updated: 2017-12-13Bibliographically approved
3. Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia
Open this publication in new window or tab >>Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia
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2006 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 114, no 6, 426-434 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To determine the clinical outcome of bipolar disorder in a developing country setup.

Method: After assessing 68 378 individuals, aged 15–49 years, in a double-sampling design in a rural community in Ethiopia, 312 patients with bipolar disorder were prospectively monitored with symptom rating scales and clinically for an average of 2.5 years.

Results: Overall, 65.9% of the cohort experienced a relapse – 47.8% manic, 44.3% depressive and 7.7% mixed episodes – and 31.1% had persistent illness. Female gender predicted depressive relapse, while male gender predicted manic relapse. Being on psychotropic medication was associated with remission.

Conclusion: This large community-based study confirms the relapsing nature of bipolar disorder and a tendency for chronicity. This may be partly because of lack of appropriate interventions in this setting; however, it may also indicate the underlying severity of the disorder irrespective of setting.

Keyword
antipsychotics, bipolar disorder, developing country, remission
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-21747 (URN)10.1111/j.1600-0447.2006.00825.x (DOI)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-12-13Bibliographically approved
4. Neurological soft signs in bipolar I disorder patients
Open this publication in new window or tab >>Neurological soft signs in bipolar I disorder patients
Show others...
2004 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 80, no 2/3, 221-230 p.Article in journal (Refereed) Published
Abstract [en]

Background: Neurological soft signs (NSS) have been reported to be more prevalent in patients with schizophrenia compared to other psychiatric and non-psychiatric controls. However, this issue in bipolar I disorder seems to be understudied.

Aims: The aims of the study were to examine the extent to which NSS are associated with bipolar I disorder cases compared to healthy controls, to assess the possible relationship between NSS and clinical dimensions of the disorder, and to explore the association of sociodemographic characteristics with the occurrence of NSS in cases with this disorder.

Methods: Predominantly treatment naïve cases of bipolar I disorder from rural communities were assessed for NSS using the Neurological Evaluation Scale (NES).

Results: This study showed that patients with bipolar I disorder performed significantly worse on two NES items from the sensory integration subscale, on one item from motor coordination and on four items from the ‘others’ subscale, the highest difference in performance being in items under the sequencing of complex motor acts subscale. Clinical dimensions and sociodemographic characteristics appeared to have no relationship with NES total score.

Conclusions: Bipolar I disorder patients seem to have more neurological dysfunction compared to healthy controls particularly in the area of sequencing of complex motor acts. In addition, the finding suggests that NSS in bipolar I disorder are stable neurological abnormalities established at its onset or may be essential characteristic features of the disorder representing stable disease process that existed long before its onset.

Keyword
bipolar disorder, neurological soft signs, treatment naïve, Ethiopia
Identifiers
urn:nbn:se:umu:diva-21741 (URN)10.1016/S0165-0327(03)00116-2 (DOI)
Available from: 2009-04-17 Created: 2009-04-17 Last updated: 2017-12-13Bibliographically approved
5. Burden of care of bipolar I disorder: perception of caregiver relatives in rural Ethiopia
Open this publication in new window or tab >>Burden of care of bipolar I disorder: perception of caregiver relatives in rural Ethiopia
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(English)Manuscript (Other (popular science, discussion, etc.))
Identifiers
urn:nbn:se:umu:diva-21742 (URN)
Available from: 2009-04-20 Created: 2009-04-17 Last updated: 2010-01-14Bibliographically approved

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