Psychoeducation for patients with Bipolar Disorder in Rwanda
2. Project period
November the 1st 2019 – October 31st 2022
Caroline J. Arnbjerg (PhD-student)*
Emmanuel (PhD-student) *
* Twin PhD model: This research will be a ‘twin model’ PhD project involving two applicants:
Caroline Juhl Arnbjerg-Nielsen and a Rwandese psychiatrist Musoni Rwililza Emmanuel. The twin
model is based on the principles of local capacity building to ensure high scientific standards and
participation by local stakeholders and prevents extractive research and scientific colonialism(1,2).
4. Supervisors and collaborative partners
Per Kallestrup - Center for Global Health (GloHau), Department of Public Health, Aarhus University
Jessica Carlsson - Competence Centre for Transcultural Psychiatry (CTP))
Darius Gishoma - College of Medicine and Health Sciences University of Rwanda
Laetitia Nyirazinyoye -College of Medicine and Health Sciences University of Rwanda
The disease burden of mental health and neurological disorders is now higher than that of infectious
and parasitic diseases in Africa(3–5).The situation has been called both a failure of humanity and
one of the most neglected global health issues of our time by some of the leading experts within
the field of global health(6).
It is estimated that severe mental disorders (i.e. severe depression, bipolar disorder, schizophrenia
and other psychotic disorders) have a two to three times higher average mortality compared to the
general population(7). Treatment rates for these disorders are low in low-and-middle-income
countries (LMICs), where treatment gaps of more than 90% have been documented(8). One of the
major barriers in decreasing the treatment gap is the lack of human resources(9). In response to the
shortage of health professionals, experts and WHO advocate that mental health care must therefore
be delegated to non-specialist health workers, who are trained to deliver interventions for specific
Bipolar disorder (BD) is characterized by periodic episodes of elevated moods and depression, which
co-occur with changes in activity or energy and is associated with cognitive, physical, and
behavioural symptoms. In western countries the efficacy of psychoeducation, as an add-on
treatment to pharmacotherapy in the treatment of symptoms and in relapse prevention initiatives
with respect to BD, is well documented(12,13).Yet, no studies on psychosocial interventions for BD
have been conducted in a low-income country(14).
In Rwanda, a Sub-Saharan country with around 12 million citizens, the total number of medical
doctors specialized in mental health is 12 in the year of 2019. So far, no treatment guidelines on
mental health disorders including BD exist in Rwanda. To date, there is no data on incidence,
prevalence or prognosis for BD in Rwanda.
In September 2014, the outpatient clinic of the Mental Health Department of Kigali Teaching
Hospital launched a psychoeducation program for BD. The manual for the program is entitled “Life
Goals Program” (LGP) and was designed back in 1996 by Bauer and McBride(15–17)LGP is a manualbased structured group psychotherapy program centred on behavioural principles from social
education and self-regulation philosophies. Nevertheless, the effect of the psychoeducation in
Rwanda is unexplored and psychoeducation is not part of the standard treatment(18).
The overall aim of the study is to determine the effect, feasibility and acceptability of
psychoeducation for patients with BD in Rwanda
The study is divided into a three-armed prospective randomized controlled trial (RCT) and a district
For the RCT study participants will be randomised to one of three arms; 1) group-psychoeducation
for patients only; 2) group-psychoeducation both for patients and relatives; 3) a waiting list. The
RCT will take place at a referral hospital and a psychiatric nurse and either a psychologist or a
psychiatric resident will conduct the group-psychoeducation.
The district trial: This trial compares the impact of psychoeducation given at district level by district
mental health nurses with the psychoeducation conducted at referral Hospital.
Intervention: Group psychoeducation structured in the manual titled “Life Goals Program” (LGP).
Bauer and McBride designed it back in 1996. The LGP is organized in two phases.
Phase 1 of the LGP psychoeducation is mandatory and entails 8 sessions of 90 minutes over the
course of 8 weeks (at one session per week) and has shown effect in western countries.
All groups will have 6-8 participants.
Moreover, Focus groups will be conducted with patients, relatives, and mental health nurses and
traditional healers. Data will be analysed to explore the perceptions of those who receive
psychoeducation, the caregiver burden, and the experience, knowledge and practice of treatment
provided at district and community level.
7.1 Number of participants (N)
50 participants will be needed for each group.
Patients with bipolar disease type I or II that meet DSM-V diagnostic criteria given by a trained
psychiatrist and age ≥ 18 years will be invited to participate. Exclusion criteria will be applied to
obtain a sample reflecting the general patient population. The exclusion criteria include:
Previous participation in any structured psychological intervention, such as psychoeducation or
cognitive remediation, mental retardation, insufficient understanding of Kinyarwanda or
7.3 Description of data and data collection
The primary outcome is reduction in symptom severity, incidence of relapse and hospitalization.
Secondary outcomes include, improved quality of life and medical adherence and knowledge,
as well as reduced self-stigmatization.
All outcomes will be assessed at baseline, immediately post-intervention and at 3 and 6 months
7.4 Application/acceptance from the National Committee on Health Research Ethics
The research protocol and study related documents will be presented to the Rwandan National
Ethical Committee (RNEC) for approval prior to study initiation. Informed consent will be
obtained from participants after oral and written information.
8. Expected results
If proven successful, this is of importance for closing the huge treatment gap in mental health
particularly affecting low- and middle-income countries and may reduce the mortality and
increase quality of life in the population suffering from bipolar disorder. Furthermore, potential
positive outcomes may be implemented in similar low-resource settings elsewhere.
9. Dissemination of results
The project aims at directing research and policy attention towards mental health at the global,
national and local level. For the dissemination of the outcomes of the project, we will: a) publish
articles in scientific journals; b) present results at international scientific meetings and
conferences; c) organise local meetings with key stakeholders during the full extent of the
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, policy and research agendas. 2017;(February):30–40.
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