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

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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.