Psychoeducation for patients with Bipolar Disorder in Rwanda

​1. Title 

Psychoeducation for patients with Bipolar Disorder in Rwanda 

2. Project period 

November the 1st 2019 – October 31st 2022

 3. Investigator(s) 

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 

Main-supervisor: Per Kallestrup - Center for Global Health (GloHau), Department of Public Health, Aarhus University 

Co- supervisors: 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 

5. Background 

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 mental disorders(10,11).

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). 

6. Aim 

The overall aim of the study is to determine the effect, feasibility and acceptability of psychoeducation for patients with BD in Rwanda 

7. Methods 

The study is divided into a three-armed prospective randomized controlled trial (RCT) and a district trial. 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. 

7.2 Population 

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 deafness. 

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 follow-up. 

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 project. 

10. References 

1. Schriver M, Cubaka VK, Kyamanywa P, Cotton P. Twinning Ph.D. students from south and north: towards equity in collaborative research. 2015;9879(September). 

2. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. Elsevier Ltd; 2011;378(9802):1592– 603. 

3. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Elsevier Ltd; 2019;3(February 2016):171–8. 

4. Whiteford HA, Ferrari AJ, Degenhardt L, Feigin V. The Global Burden of Mental , Neurological and Substance Use Disorders : An Analysis from the Global Burden of Disease Study 2010. 2015;1– 14. 

5. WHO D of MH and SA and. WHO. Global Health Estimates 2016: Burden of disease by cause, age, sex, by country and by region, 2000–2016. 2018. http://www.who.int/ healthinfo/global_burden_disease/estimates/en/index1.html (accessed April 28, 2018. 2018;(June). 

6. Kleinman A. The art of medicine Global mental health : a failure of humanity. Lancet. 2009;374(9690):603–4. 

7. Liu NH, Daumit GL, Dua T, Aquila R, Charlson F, Cuijpers P, et al. Excess mortality in persons with severe mental disorders : a multilevel intervention framework and priorities for clinical practice , policy and research agendas. 2017;(February):30–40. 

8. Kohn R, Saxena S, Levav I, Saraceno B. Policy and practice: The treatment gap in mental health care. Bull World Heal Organ. 2004;82(11):858–66. 

9. Sankoh O, Sevalie S, Weston M. Mental health in Africa. Lancet Glob Heal. The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license; 2018;6(9):e954–5. 

10. Keynejad RC, Dua T, Barbui C, Thornicroft G. WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: A systematic review of evidence from low and middleincome countries. Evid Based Ment Health. 2018;21(1):29–33. 

11. Patel V. Global Mental Health : From Science to Action. 2012;6–12. 

12. Colom F. The evolution of psychoeducation for bipolar disorder : from lithium clinics to integrative psychoeducation. 2014;(3):90–2. 

13. Review AS. Randomized Controlled Trials of Psychoeducation Modalities in the Management of Bipolar Disorder: A Systematic Review. 2018;(June). 

14. Demissie M, Hanlon C, Birhane R, Ng L, Medhin G, Fekadu A. Psychological interventions for bipolar disorder in low- and middle-income countries: systematic review. BJPsych Open. 2018;4(5):375–84. 

15. Bauer M ML. The life goals program: Structured group psychotherapy for bipolar disorder. 1996. 1996. 

16. Bauer, M.S., McBride, L., Williford, W.O., Glick, H., Kinosian, B., Altshuler, L., Beresford, T., Kilbourne, A.M., Sajatovic M. Long-term impact of the life goals group therapy program for bipolar patients. J Affect Disord. 2012;136(3):889–94. 

17. Unu R. Randomized trial of a population-based care program for people with bipolar disorder. 2005;13–24. 

18. Fekadu A, Hanlon C, Thornicroft G, Lund C, Kaaya S, Alem A, et al. Care for bipolar disorder in LMICs needs evidence from local settings. The Lancet Psychiatry. Elsevier Ltd; 2015;2(9):772–3.

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