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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 2 - 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: 2019-10-01 to 2021-12-31

Psychosis represents a huge burden for affected individuals, their carers and society. Individuals with psychosis can suffer from unrealistic beliefs, distorted perceptions of reality, and confusion. Effective treatment strategies can be particularly scarce in low- and middle-income countries (LMICs) wherein lack of funds is a challenge.

The main goal of the IMPULSE project was to improve the treatment of individuals diagnosed with psychosis in five low-and-middle income countries of South East Europe (SEE): Bosnia and Herzegovina, Kosovo* UN Resolution, North Macedonia, Montenegro, and Serbia. The project focused on i) bridging the gap between research and policy, ii) facilitating community-based mental health care, iii) facilitating user-led involvement by actively involving service users and caregiver groups in the project and facilitating the establishment of service users organisations, and iv) building research capacity in the participating countries.

The IMPULSE clinical trial focused on exploring effectiveness, implementation and economic costs of delivering a digital psychosocial intervention (DIALOG+) in the mental health services of participating countries. DIALOG+ (a tablet supported tool) is used in routine outpatient appointments to make them more therapeutically effective. A previous trial in the UK showed that DIALOG+ reduced symptoms, improved quality of life of people with psychosis and reduced treatment costs. However, SEE countries have a very different organisation of mental healthcare systems that do not simply allow the adoption of the DIALOG+ intervention. Instead, this project focused on working collaboratively with all relevant stakeholders to understand the wider context and address implementation barriers. The IMPULSE trial demonstrated that DIALOG+ can improve the mental health of individuals with psychosis with an easy-to-deliver and relatively cheap instrument. Its use across services of LMICs will have a positive impact on improving the treatment of psychosis.
IMPULSE showed that DIALOG+ improved the quality of life of people with psychosis, and that it could be implemented in mental health services across LMICs in SEE. Among the facilitators to implementation of the intervention there was the structure of DIALOG+, an improved therapeutic relationship and patient’s empowerment.

Different core activities were carried out:
• A pre-trial phase to explore contextual factors (i.e. facilitators and barriers to the intervention) to support the development of an implementation strategy
• A clinical trial to evaluate effectiveness and cost-effectiveness of DIALOG+. This enrolled 468 individuals with psychosis, 41 clinicians; the intervention, was delivered 6 times across 12 months while assessment was conducted at baseline, 6- and 12-month follow-up.
• In-depth interviews after completion of the trial explored the experience that clinicians and patients had in using DIALOG+.
• 40 Lived Experience Advisory Panels (with patients and caregivers) were established and run throughout the project. They were involved in all stages of the project (i.e. trial progression, feedback on results).
• Building research capacity: several trainings were delivered to support researchers in accomplishing projects tasks as well as in improving their research skillset.
• Dissemination and exploitation of findings:
o Twenty-two peer-reviewed publications originated from the project, two booklets, and one book (up to 31/12/21; more publications are expected to be published in the coming months);
o The project/results were presented at 35 events (conferences, workshops);
o A webinar was organised;
o A promotional video was created;
o Social media channels were used to promote the study;
o A main website with information about the study was created and regularly updated, a Serbian website for national audience;
o A collaboration (i.e. a symposium at international conference in schizophrenia and development of a policy brief) with another EC funded project was established.
IMPULSE is a successfully completed 45 month-long mental health research project. The project improved knowledge of psychosis, contributed to the evidence-base of effective treatment for psychosis, contributed to research methodology during public health crisis, contributed to the methodology of hybrid trials, and advanced understanding of service user involvement.

Major advances and successes include:

• IMPULSE clearly showed that individuals with psychosis and health care professionals can successfully engage in a digital psychosocial intervention which is a step toward providing collaborative and holistic care. The DIALOG + intervention can be delivered with high fidelity in mental health services with limited budgets. The intervention can significantly improve the quality of life of individuals with psychosis after four sessions. The intervention now has strong evidence base for improving the quality of life of patients with psychosis in mental health services.
• The IMPULSE clinical trial is the largest ever non-pharmacological randomised-controlled trial involving individuals with psychosis conducted in SEE, and among few such trials globally. Implementation barriers were successfully addressed through a data-driven implementation strategy and continued stakeholders’ engagement. This approach remains rare in mental health research and findings from IMPULSE can be used to guide future developments. The trial was successfully completed during the COVID-19 pandemic, thus allowing insights into delivering complex research under public health crisis restrictions.
• IMPULSE allowed new insights into clinical presentations of individuals with psychosis in SEE, prescribing strategies in SEE countries, use of clinical guidelines, and utilisation of services and associated economic costs. One important insight is that women’s mental health care is unmet in SEE countries which should be addressed in future work.
• IMPULSE improved service user involvement in SEE by setting up standards for including service users in research; training service users and professionals in effective service users involvement in mental health research/service delivery/policies; and increasing awareness of the importance of a collaborative approach.
• IMPULSE improved research capacity. Researchers attended training linked to key project’s objectives (i.e. hybrid trial methodology, implementation science, mixed methods) as well as the general skillset (i.e. academic writing, dissemination and public engagement, research integrity).
• IMPULSE employed innovative and effective dissemination and public engagement by continued involvement of service users, carers, clinicians, and policy makers. The social media strategy, multi-media presentation of key project findings and multi-language approach allowed good reach and communication with a wide audience.
• IMPULSE facilitated research networks across Europe and links with organisations such WHO, GACD, EC to disseminate the findings and facilitated future collaborations.
Logo of the IMPULSE project