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，扰乱教育，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。与高收入国家（如英国、美国）相比，生活在低收入和中等收入国家（如巴基斯坦）的人们获得医疗服务的机会更少。对于生活在LMIC中的人来说，诊断和治疗精神病发作可能需要两年多的时间。这是英国人所需时间的两倍。我们之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（TSHs）寻求帮助。这些问题通常与迷信和/或精神有关。向TSHs寻求帮助是精神病发作治疗延迟的一个关键原因。TSHs与初级保健之间的合作已证明可以改善针对艾滋病毒/艾滋病等健康状况的医疗保健服务，但到目前为止还没有对精神病发作进行同样的评估。拟议的研究项目名为THEHOPE（传统治疗师与初级保健和精神卫生合作，对精神病进行早期干预），旨在开发一种检测和治疗巴基斯坦白沙瓦青少年精神病发作的新方法。这项研究将加强TSHs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TSHs合作，我们将开发一种对文化敏感并为当地居民所接受的新方法。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)我们将与精神病患者（及其护理人员）、TSHs和初级保健从业人员密切合作，以了解白沙瓦的医疗保健环境。我们将利用这些信息来设计THEHOPE的干预和培训。(2)精神病早期干预专家将培训精神科医生，然后由精神科医生培训白沙瓦的初级保健医生。这些初级保健医生将依次培训TSH。这种梯级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，并已成功地在资源匮乏的环境中使用，以具有成本效益的方式提供服务。(3)我们将在一项特别设计的可行性集群随机对照试验中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首发精神病病例。在这项试验中，白沙瓦市的小地理集群（称为联盟理事会）将被随机分配到拟议的新工作方式或控制条件（即照常处理）。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与试验并完成随访。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)上述所有阶段的研究都将被仔细检查和评估，以确定这些是否为所有参与者（例如患者和护理人员）所接受，并可以在未来的研究中实施。这项研究将建立在低收入和中等收入国家现有社区实践和资源的基础上，以改善精神病患者的医疗保健。由于TSHs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上的出版物、患者、护理人员和不同利益相关者参加的会议以及使用twitter等社交媒体工具传播。

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.