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Implementation of an effective and cost-effective intervention for patients with psychotic disorders in low and middle income countries in South Eastern Europe

Periodic Reporting for period 1 - IMPULSE (Implementation of an effective and cost-effective intervention for patients with psychotic disorders in low and middle income countries in South Eastern Europe)

Reporting period: 2018-04-01 to 2019-09-30

Psychosis represents a huge burden for people that suffer with that, their carers and society. People with psychosis lose connection with reality; they complain about hearing and seeing things that others cannot, having unusual and unsettling beliefs about other people and surrounding reality, and difficulties to remember things. This has a tremendous impact not only on their quality of life, but also on their families and society with high cost for treatment and management of the illness.
Cost and access to health services for psychosis is an important issue everywhere, but particularly in low and middle income countries (LMICs) wherein lack of funds represents the main challenge to mental health care.
The IMPULSE project aim to study the effectiveness and implementation of an easy to deliver and affordable psychosocial intervention called DIALOG+ in five LMICs in South-eastern Europe: Bosnia and Herzegovina, Kosovo*, Macedonia, Montenegro and Serbia. DIALOG+ is used in routine outpatient mental health services with the support of a tablet computer and has the objective to improve the communication between patient and clinician and to empower self-efficacy and confidence in the patient. In a previous study across the UK, the adoption of DIALOG+ reduced symptoms and improved quality of life in people with psychosis. However, the uncertainties around the service context in South-Eastern Europe do not allow DIALOG’s implementation to be simply broadened to these countries. Although they shared similar socioeconomic and political background before 1990s, their individual developments in the post-communist period have led to significant differences in the organisation of mental healthcare systems. For that reason, this study will enable us to explore the implementation of DIALOG+ within different contexts that are potentially representative of other LMICs, thus increasing the generalisability and broadening impact of the results.
The IMPULSE project aims to promote the use of DIALOG+; alleviate burden of psychosis in patients and their families; strengthen public participation by actively involving patients and caregiver groups in the project and facilitating the establishment of patient organisations; and build/strengthen research capacity in participating countries. If the IMPULSE project will demonstrate that DIALOG+ can improve illness and quality of life, its use across mental health services would ultimately have a positive impact on reducing cost and improving treatment and management of psychosis.
Several activities have been carried out so far: context analysis, development of strategies and tools to implement DIALOG+, and of a dissemination and communication plan, training of researchers and clinicians on delivering DIALOG+, the clinical trial, and patients, caregivers and policy makers’ engagement in the project.
Analyses on the potential barriers and facilitators to the use of DIALOG+ were conducted. This information along with topics emerged from interviews and focus groups with patients, care givers, clinicians and policy makers, and national regulations were critically combined in developing an implementation plan.
All researchers were trained in the use of DIALOG+ and clinical measures as part of the research protocol. Refresher training and other training are being delivered in order to promote new knowledge/skills to build research capacity in participating countries.
The clinical study has a duration of 12 months and includes 81 clinicians and more than 450 patients with psychosis randomly divided into two groups, one wherein DIALOG+ is delivered and the other that maintains routine treatment. This approach will allow us to understand if the intervention is associated with improvement in quality of life and symptoms. Patients and caregivers have been involved through advisory panels to give feedback about how to put into practice DIALOG+, the methods used in the clinical study, and to promote the study using dissemination materials. Also, policy makers have been engaged with meetings during which the project was described and all potential long-term benefits from the adoption of DIALOG+ were discussed. These meetings have the ultimate goal to support the use of the intervention, and the development of new policy and regulations for the treatment of psychosis in LMICs.
Researchers and principal investigators of the IMPULSE project have regularly met to discuss progresses, challenges and next steps. A committee of experts in mental health and policy making was appointed and invited to have an external evaluation of the project and its development. Similarly, an independent ethical advisor and an external data monitoring ethics committee monitored the critical endpoints of the project and any safety issue from the clinical study (which did not happen).
Study findings about the context for the implementation of DIALOG+ at local, national and international levels have been presented at national and international conferences. Several scientific publications are in process of being published scientific journals.
The main result that we are expecting from the successful completion of the IMPULSE project is the improvement in quality of life and mental health in patients in South-Eastern Europe. We also expected the successful implementation of DIALOG+ and its long-term sustainability in the services that were involved in the project. In order to achieve this, we have been working in close collaboration with all relevant stakeholders, including patients, family members, service providers, and policy makers.
Also, several impacts for the people with psychosis, and for community and society in general are expected from the project.
From the patient perspective the study has the potential to improve quality of life and mental health condition. The adoption of DIALOG+ would have a positive effect on routine clinical meetings; since the focus is on the patient they would be more involved in the treatment process with benefit for their sense of empowerment and self-efficacy that ultimately would improve communication between patient and clinician.
At the community and society level, the IMPULSE project could potentially save costs of care and allow mental health providers in LMICs to improve services and to reach out to people who were not able to access health services before. This could contribute to reduce health inequality and treatment gap that are known to exist between women and men suffering from psychosis. A better understanding of the reasons associated with these differences would help service providers to offer a more tailored intervention based on patients’ needs. The study could also continue to strengthen research capacity across the partner organisations, thus improving the ability of researchers to undertake research in order to promote welfare and economic development of their countries. The learning from LMICs will help other countries in Europe and beyond to maximise the potential of services and increase both capacity and expertise in research. We will maximise the use of existing platforms, e.g. the WHO network, national and international clinical and academic networks, to facilitate an exchange of research findings in East Europe and globally.