Enhancing post-acute mental health outcomes for patients with psychosis in Malawi through nurse-delivered community-based rehabilitation: The ENHANCE Pilot Trial

摘要 精神病在世界范围内造成严重的发病率和死亡率，特别是在中低收入国家， 低收入国家（LMIC）。精神障碍是最常见的投诉之一， 在许多低收入国家接受专业精神卫生保健的个人。精神障碍通常在 成年早期和慢性病程，意味着患者遭受多年的功能差，残疾， 失去了生产力。事实上，精神障碍仍然是全球15个主要残疾原因之一。 尽管中低收入国家的精神病患者人数众多，但治疗选择极其有限， 重点关注急性、有时限的住院稳定。这一重点没有考虑到已证明的 需要长期的急性期后门诊治疗和社区康复，以改善结果。 背景社区因素，如可靠的持续获得精神卫生保健，耻辱及其负面影响， 对药物依从性的影响、支持不足和家庭冲突是随后的主要风险因素。 出院后重返社区。 基于社区的康复（CBR）是理想的定位，以解决急性后 为资源匮乏地区的精神病患者提供社区护理。CBR是一个通用的证据- 为各种残疾人提供长期治疗和支助的一种基于基础的方法。CBR 特别适合适应精神病患者的需要。CBR旨在改善 提高残疾人的生活质量，鼓励他们了解疾病， 目标，并鼓励在家庭和社区内的社会包容。 CBR能够以人为本地强调恢复，而不是减少症状。传统上， 对精神病患者的大多数住院和门诊精神病护理侧重于药物管理， 减少负面症状。然而，新的工作强调，通过加强 理解、联系、赋权和希望对于优化长期生活质量至关重要， 精神病患者。由于其在家中分娩，融合家庭成员，并注重 功能目标和社会包容，社区康复非常适合嵌入这种恢复方向。 因此，我们建议调整CBR模型，以采用以恢复为重点的方法， 解决马拉维社区居住的精神病患者的需求。我们会进行 与关键利益相关者进行形成性研究，以指导CBR模型的适应并完成试点 随机对照试验，以评估的可行性，可接受性，保真度，和初步的有效性， 适应CBR处理模式。这项工作将为建立证据基础提供重要的进展 为急性住院患者以外的精神病患者提供社区治疗模式， 稳定，以加强康复、功能、生活质量和恢复。

ABSTRACT Psychosis exacts a heavy morbidity and mortality toll worldwide, but especially in low- and middle- income countries (LMICs). Psychotic disorders are one of the most common presenting complaints for individuals admitted to specialty mental health care in many LMICs. Psychotic disorders typically have onset in early adulthood and a chronic course, meaning patients suffer from many years of poor functionality, disability, and lost productivity. Indeed, psychotic disorders remain among the 15 leading causes of disability globally. Despite the significant toll of psychosis in LMICs, treatment options are extremely limited and focus heavily on acute, time-limited inpatient stabilization. This focus fails to consider the demonstrated need for long-term post-acute outpatient treatment and community-based rehabilitation to improve outcomes. Contextual community factors such as reliable continued access to mental health care, stigma and its negative impact on medication adherence, inadequate support, and family conflict are key risk factors for subsequent relapse upon discharge into the community. Community-based rehabilitation (CBR) is ideally positioned to address the need for post-acute community-based care for people with psychosis in low-resource settings. CBR is a general evidence- based approach for the long-term treatment and support of individuals with a broad range of disabilities. CBR is particularly well suited for adaptation to address the needs of those with psychosis. CBR aims to improve the quality of life of individuals living with disability by encouraging understanding of illness, addressing functional goals, and encouraging social inclusion within their families and communities. CBR enables a person-focused emphasis on recovery rather than symptom reduction. Traditionally, most inpatient and outpatient psychiatric care for people with psychosis focuses on medication management to reduce negative symptoms. Yet emerging work underscores that a focus on recovery through strengthening understanding, connection, empowerment, and hope is paramount to optimize long-term quality of life for individuals with psychosis. Due to its delivery in the home, integration of family members, and focus on functional goals and social inclusion, CBR is ideally suited to embed this recovery orientation. Accordingly, we propose to adapt the CBR model to bring a recovery-focused approach to addressing the needs of community-dwelling individuals with psychosis in Malawi. We will conduct formative research with key stakeholders to guide the adaptation of the CBR model and complete a pilot randomized controlled trial to evaluate the feasibility, acceptability, fidelity, and preliminary effectiveness of the adapted CBR treatment model. This work will provide a critical advance toward establishing the evidence base for community-based treatment models for people living with psychosis outside of the context of acute inpatient stabilization so as to enhance rehabilitation, functioning, quality of life, and recovery.