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了严重的发病率和死亡率，尤其是在中低位 收入国家(LMIC)。精神障碍是最常见的主诉之一 在许多LMIC中接受专门精神卫生护理的个人。精神病通常起病于 成年早期和慢性病程，这意味着患者患有多年的功能低下，残疾， 并且失去了生产力。事实上，精神病仍然是全球导致残疾的15个主要原因之一。 尽管在LMICs中精神病的人数很多，但治疗选择极其有限 将重点放在急性、有时间限制的住院患者的稳定上。这一重点没有考虑到所演示的 需要长期的急性后门诊治疗和以社区为基础的康复以改善结果。 社区背景因素，如可靠地持续获得精神卫生保健、污名及其负面影响 影响服药依从性、支持不足和家庭冲突是后续的关键风险因素 在退伍到社区后复发。 以社区为基础的康复(CBR)是解决急性呼吸综合征后康复需求的理想选择 在低资源环境下为精神病患者提供基于社区的护理。CBR是一个普遍的证据- 以长期治疗和支持各种残疾的个人为基础的方法。CBR 特别适合适应精神病患者的需要。CBR旨在改善 通过鼓励对疾病的了解，解决功能性疾病，提高残疾人的生活质量 目标，并鼓励他们在家庭和社区中融入社会。 CBR使人们能够以人为本，强调康复而不是减少症状。传统上， 对精神病患者的大多数住院和门诊精神护理侧重于药物管理 减少阴性症状。然而，新出现的工作强调，通过加强经济复苏的重点 理解、联系、赋权和希望是优化长期生活质量的首要因素 精神病患者。由于它在家中交付，融合了家庭成员，并专注于 在职能目标和社会包容方面，CBR非常适合嵌入这一恢复方向。 因此，我们建议调整CBR模型，以将重点放在恢复方面 解决马拉维社区居住的精神病患者的需求。我们将进行 与关键利益攸关方一起进行形成性研究，以指导CBR模型的适应并完成试点 随机对照试验，以评估该方案的可行性、可接受性、保真度和初步有效性 采用CBR处理模式。这项工作将为建立证据基础提供关键的进展 对于急性住院患者以外的精神病患者的社区治疗模式 稳定，以加强康复、功能、生活质量和康复。

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.