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

摘要 精神病在全世界范围内造成严重的发病率和死亡率，特别是在低收入和中收入国家 收入国家（LMIC）。精神障碍是最常见的主诉之一 许多中低收入国家接受专业精神卫生保健的个人。精神障碍通常发病于 成年早期和慢性病程，意味着患者多年来遭受功能不良、残疾、 并失去了生产力。事实上，精神障碍仍然是全球导致残疾的 15 个主要原因之一。 尽管中低收入国家精神病患者人数众多，但治疗选择极其有限，而且 重点关注急性、有时限的住院患者稳定。这个重点没有考虑到已证明的 需要长期的急性后门诊治疗和社区康复以改善结果。 社区背景因素，例如可靠、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后续的关键风险因素 出院后复发。 基于社区的康复 (CBR) 非常适合满足急性后康复的需求 为资源匮乏地区的精神病患者提供社区护理。 CBR 是一个普遍的证据—— 为患有广泛残疾的个人提供长期治疗和支持的基础方法。社区商业银行 特别适合适应精神病患者的需求。 CBR 旨在改善 通过鼓励了解疾病、解决功能问题，提高残疾人的生活质量 目标，并鼓励家庭和社区的社会包容。 社区康复能够以人为本，强调康复而不是减轻症状。传统上， 大多数精神病患者的住院和门诊精神科护理侧重于药物管理，以 减少阴性症状。然而，新出现的工作强调，要通过加强 理解、联系、赋权和希望对于优化长期生活质量至关重要 患有精神病的人。由于是在家分娩，融入家庭成员，并且注重 功能目标和社会包容性，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，以采取以恢复为重点的方法 满足马拉维社区居住的精神病患者的需求。我们将进行 与主要利益相关者进行形成性研究，以指导社区康复模型的调整并完成试点 随机对照试验评估该方案的可行性、可接受性、保真度和初步有效性 适应CBR治疗模式。这项工作将为建立证据基础提供关键的进展 针对急性住院患者之外的精神病患者的社区治疗模式 稳定，以增强康复、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.