THEHOPE-Traditional healers working with primary care and mental health for early intervention in psychosis in adolescent:intervention and feasibility

十分之一的人在18岁之前经历过精神病发作（妄想，幻觉）。这些经历可能令人不安，如果没有适当的治疗，可能会产生严重的长期影响（例如降低生活质量，中断教育，减少长期就业）。精神病发作后的早期治疗对于减少长期影响至关重要。生活在低收入和中等收入国家（LMIC）（例如巴基斯坦）的人与高收入国家（例如英国，美国）的人相比，获得护理的机会较少。生活在LMIC的人可能需要两年多的时间才能被诊断和治疗精神病发作。这是英国人所需时间的两倍。我们以前在巴基斯坦白沙瓦地区进行了关于精神病发作的研究。我们发现，有心理健康问题的人经常向传统和精神治疗师（TSH）寻求帮助。这些问题通常与迷信和/或精神有关。寻求TSH的帮助是精神病发作治疗延迟的一个关键原因。TSH和初级保健之间的合作已显示出改善健康状况，如艾滋病毒/艾滋病的医疗保健提供，但到目前为止，还没有对精神病发作进行评估。拟议的研究方案名为“希望”（传统治疗师与初级保健和精神卫生部门合作，对精神病进行早期干预），旨在开发一种新的方法，检测和治疗巴基斯坦白沙瓦青少年的精神病发作。这项研究将加强TSH和初级保健之间的合作，以改善报告这些问题的患者的医疗保健。通过与TSH合作，我们将开发一种新的方法，这种方法对文化敏感，并为当地居民所接受。我们设计了一个四阶段的研究计划，以帮助开发和测试这种新的工作方式：-（1）我们将与精神病发作患者（及其护理人员），TSH和初级保健医生密切合作，以了解白沙瓦的医疗保健环境。我们将使用这些信息来设计THEHOPE干预和培训。(2)精神病早期干预专家将培训精神病医生，然后培训白沙瓦的初级保健医生。这些初级保健医生将反过来培训TSH。这种级联培训模式涉及将任务从精神卫生专业人员转移到社区卫生工作者和非专业人员，并已成功地用于资源匮乏的环境，以具有成本效益的方式提供服务。(3)我们将测试这种新的工作方式是否有助于在尽可能早的阶段发现精神病首次发作的病例，这是一项专门设计的研究，称为可行性随机对照试验。在本试验中，白沙瓦市的小地理集群（称为联合委员会）将被随机分配到拟议的新工作方式或对照条件（即照常治疗）。这将有助于我们检查传统治疗师是否会参与研究，以及患者是否同意参加试验并完成随访。测试这些参数的可行性将有助于我们决定更大规模研究的设计和方法，以更严格的方式评估新的工作方式。(4)所有上述阶段的研究将被仔细检查和评估，看看这些是否是所有参与者（如病人和照顾者）可以接受的，并可以在未来的研究中实施。这项研究将建立在现有的社区实践和资源在LMIC设置，以改善医疗保健的精神病发作的人。由于TSH通常在中低收入国家的精神卫生保健中发挥作用，因此本研究的结果可能与其他国家相关。研究结果将通过科学期刊出版物，患者和护理人员以及不同利益相关者的会议以及使用社交媒体工具（如twitter）进行传播。

One-in-ten people experience a psychotic episode (delusion, hallucination) before 18 years of age. These experiences can be upsetting and, without adequate treatment, can have serious long-term effects (e.g. reduce quality of life, disrupt education, reduce long-term employment). Early treatment after a psychotic episode is vital to reduce long-term effects. People living in Low and Middle Income Countries (LMICs) (e.g. Pakistan) experience poorer access to care compared to those in Higher Income Countries (e.g. UK, USA). It can take over two years for someone living in an LMIC to be diagnosed and treated for psychotic episodes. This is double the time it takes for someone in the UK. We previously carried out research about psychotic episodes in the Peshawar district of Pakistan. We found that people with mental health issues often sought help from traditional and spiritual healers (TSHs). These issues are commonly linked to superstition and/or spirits. Seeking help from TSHs is a key cause of delay in treatment for psychotic episodes. Collaboration between TSHs and primary care has shown to improve healthcare provision for health conditions, such as HIV/AIDS, but the same has not been evaluated for psychotic episodes, up to now. The proposed programme of research, called THEHOPE (Traditional healers working with primary care and mental health for early intervention in psychosis) seeks to develop a new way of detecting and treating psychotic episodes among adolescents in Peshawar, Pakistan. This research will strengthen collaboration between TSHs and primary care to improve healthcare for patients reporting these issues. By working with TSHs we will develop a new approach that is culturally-sensitive and acceptable to local populations. We have designed a four-stage plan of research to help develop and test this new way of working:-(1) We will work closely with people with psychotic episodes (and their carers), TSHs, and primary care practitioners to understand the healthcare context in Peshawar. We will use this information to design THEHOPE intervention and training.(2) Experts in early intervention in psychosis will train psychiatrists who will then train primary care physicians in Peshawar. These primary care physicians will in turn train the TSH. This model of cascade training involves task shifting from mental health professionals to community health workers and lay persons and has been successfully used in resource poor settings to provide services in a cost effective way.(3) We will test whether this new way of working helps to detect the cases of first episode psychosis at earliest possible stage in a specially designed study called feasibility cluster randomised controlled trial. In this trial small geographical clusters of Peshawar city (called Union Councils) will be randomly allocated either to proposed new way of working or to a control condition (i.e. treatment as usual). This will help us to examine whether traditional healers will engage in the study, and whether patients consent to participate in the trial and complete the follow-up. Testing the feasibility of these parameters will help us to decide the design and methodology of a much larger study to evaluate the new ways of working in more rigorous way.(4) All of above stages of research will be closely examined and evaluated to see whether these are acceptable to all participants (e.g. patients and carers) and can be implemented in future studies.This research will build on existing community practices and resources in a LMIC setting, to improve healthcare for people with psychotic episodes. As TSHs often have a role in mental healthcare in LMICs, findings from this research may be relevant to other countries.The results of study will be disseminated through publications in scientific journals, meetings involving patients and carers and different stakeholders and by using the social media tools such as twitter.