Abstract
Purpose
Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low- and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting.
Methods
A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing community-ascertained cohort of people with SMD (n = 218), and attendees at the Butajira General Hospital psychiatric clinic (n = 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding 2 years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS) were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment.
Results
Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects, and internalized stigma were associated with functional impairment across self-reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment.
Conclusion
To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects, and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted.
Similar content being viewed by others
References
Bowie CR, Depp C, McGrath JA, Wolyniec P, Mausbach BT, Thornquist MH, Luke J, Patterson TL, Harvey PD, Pulver AE (2010) Prediction of real-world functional disability in chronic mental disorders: a comparison of schizophrenia and bipolar disorder. Am J Psychiatry 167:1116–1124
McFarlane WR, Levin B, Travis L, Lucas FL, Lynch S, Verdi M, Williams D, Adelsheim S, Calkins R, Carter CS, Cornblatt B, Taylor SF, Auther AM, McFarland B, Melton R, Migliorati M, Niendam T, Ragland JD, Sale T, Salvador M, Spring E (2015) Clinical and functional outcomes after 2 years in the early detection and intervention for the prevention of psychosis multisite effectiveness trial. Schizophr Bull 41(1):30–43
Waghorn G, Chant D, Jaeger J (2007) Employment functioning and disability among community residents with bipolar affective disorder: results from an Australian community survey. Bipolar Disord 9:166–182
Dickerson F, Boronow JJ, Ringel N, Parente F (1999) Social functioning and neurocognitive deficits in outpatients with schizophrenia: a 2-year follow-up1. Schizophr Res 37:13–20
Honkonen T, Saatinen S, Salokangas RKR (1999) Deinstitutionalization and schizophrenia in Finland II: discharged patients and their psychosocial functioning. Schizophr Bull 25(3):543–551
Martínez-Arán A, Vieta E, Reinares M, Colom F, Torrent C, Sánchez-Moreno J, Benabarre A, Goikolea JM, Comes M, Salamero M (2004) Cognitive function across manic or hypomanic, depressed, and euthymic states in bipolar disorder. Am J Psychiatry 161(2):262–270
Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B (2007) Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370:851–858. https://doi.org/10.1016/S0140-6736(07)61415-9
Kebede D, Alem A, Shibre T, Negash A, Deyassa N, Beyero T, Medhin G (2005) Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia. Schizophr Res 78:171–185. https://doi.org/10.1016/j.schres.2005.05.028
Kebede D, Alem A, Shibire T, Deyassa N, Negash A, Beyero T, Medhin G, Fekadu A (2006) Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia. J Affect Disord 90:239–249. https://doi.org/10.1016/j.jad.2005.11.009
Mogga S, Prince M, Alem A, Kebede D, Stewart R, Glozier N, Hotopf M (2006) Outcome ofmajor depression in Ethiopia: Population-based study. Br J Psychiatry 189:241–246. https://doi.org/10.1192/bjp.bp.105.013417
Mausbach BT, Harvey PD, Pulver AE, Depp CA, Wolyniec PS, Thornquist MH, Luke JR, McGrath JA, Bowie CR, Patterson TL (2010) Relationship of the brief UCSD performance-based skills assessment (UPSA-B) to multiple indicators of functioning in people with schizophrenia and bipolar disorder. Bipolar Disord 12:45–55
Judd LL, Schettler PJ, Solomon DA, Maser JD, Coryell W, Endicott J, Akiskal HS (2008) Psychosocial disability and work role function compared across the long-term course of bipolar I, bipolar II and unipolar major depressive disorders. J Affect Disord 108:49–58
Bottlender R, Strauß A, Möller H-J (2010) Social disability in schizophrenic, schizoaffective and affective disorders 15 years after first admission. Schizophr Res 116:9–15
Brissos S, Dias VV, Carita AI, Martinez-Arán A (2008) Quality of life in bipolar type I disorder and schizophrenia in remission: Clinical and neurocognitive correlates. Psychiatry Res 160:55–62
Martinez-Aran A, Vieta E, Torrent C, Sanchez-Moreno J, Goikolea JM, Salamero M, Malhi GS, Gonzalez-Pinto A, Daban C, Alvarez-Grandi S, Fountoulakis K, Kaprinis G, Tabares-Seisdedos R, Ayuso-Mateos JL (2007) Functional outcome in bipolar disorder: the role of clinical and cognitive factors. Bipolar Disord 9:103–113
MacQueen GM, Young LT, Joffe RT (2001) A review of psychosocial outcome in patients with bipolar disorder. Acta Psychiatr Scand 103:163–170
Harvey PD, Strassnig M (2012) Predicting the severity of everyday functional disability in people with schizophrenia: cognitive deficits, functional capacity, symptoms, and health status. World Psychiatry 11:73–79
Swartz MS, Miller DD, Wagner HR, Reimherr F, Swanson JW, Khan A, Stroup TS, Cañive JM, McEvoy JP, Lieberman JA, McGee M (2006) Substance use and psychosocial functioning in schizophrenia among new enrollees in the NIMH CATIE Study. Psychiatr Serv 57(8):1110–1116
Racenstein JM, Harrow M, Reed R, Martin E, Herbener E, Penn DL (2002) The relationship between positive symptoms and instrumental work functioning in schizophrenia: a 10 year follow-up study. Schizophr Res 56(1):95–103
Marchesi C, Affaticati A, Monici A, De Panfilis C, Ossola P, Ottoni R, Tonna M (2015) Decrease of functioning in remitted and non-remitted patients 16 years after a first-episode schizophrenia. J Nerv Ment Dis 203(6):406–411
Kovasznay B, Fleischer J, Tanenberg-Karant M, Jandorf U, Miller AD, Bromet E (1997) Substance use disorder and the early course of illness in schizophrenia and affective psychosis. Schizophr Bull 23(2):195–201
Cannon M, Jones P, Gilvarry C, Rifkin L, McKenzie K, Foerster A, Murray RM (1997) Premorbid social functioning in schizophrenia and bipolar disorder: Similarities and differences. Am J Psychiatry 154:1544–1550
Chien W-T, Lam CK, Ng BF (2015) Predictors of levels of functioning among Chinese people with severe mental illness: a 12-month prospective cohort study. J Clin Nurs 24:1860–1873. https://doi.org/10.1111/jocn.12843
Perlick DA, Rosenheck RA, Clarkin JF, Sirey JA, Salahi J, Struening EL, Link BG (2001) Stigma as a barrier to recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatr Serv 52(12):1627–1632
Rüesch P, Graf J, Meyer PC, Rössler W, Hell D (2004) Occupation, social support and quality of life in persons with schizophrenic or affective disorders. Soc Psychiatry Psychiatr Epidemiol 39:686–694. https://doi.org/10.1007/s00127-004-0812-y
Addington J, Addington D (2000) Neurocognitive and social functioning in schizophrenia: a 2.5 year follow-up study. Schizophr Res 44:47–56
Addington J, Addington D (2008) Social and cognitive functioning in psychosis. Schizophr Res 99:176–181
Hanlon C, Alem A, Medhin G, Shibre T, Ejigu DA, Negussie H, Dewey M, Wissow L, Prince M, Susser E, Lund C, Fekadu A (2016) Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial. Trials. https://doi.org/10.1186/s13063-016-1191-x
Lund C, Alem A, Schneider M, Hanlon C, Ahrens J, Bandawe C, Bass J, Bhana A, Burns J, Chibanda D, Cowan F, Davies T, Dewey M, Fekadu A, Freeman M, Honikman S, Joska J, Kagee A, Mayston R, Medhin G, Musisi S, Myer L, Ntulo T, Nyatsanza M, Ofori-Atta A, Petersen I, Phakathi S, Prince M, Shibre T, Stein DJ, Swartz L, Thornicroft G, Tomlinson M, Wissow L, Susser E (2015) Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM. Epidemiol Psychiatr Sci. https://doi.org/10.1017/S2045796015000281
Kebede D, Alem A, Shibre T, Fekadu A, Fekadu D, Kullgren G et al (2000) The Butajira-Ethiopia study on the incidence, course and outcome of schizophrenia and bipolar disorders. I. Descriptions of study settings, methods and preliminary results. Schizophr Res 41:78
World Health Organization (1997) Schedules for clinical assessment in neuropsychiatry, version 2.1. WHO, Geneva
Chang K-H, Lin Y-N, Liao H-F, Yen C-F, Escorpizo R, Yen T-H, Liou T-H (2014) Environmental effects on WHODAS 2.0 among patients with stroke with a focus on ICF category e120. Qual Life Res 23:1823–1831. https://doi.org/10.1007/s11136-014-0624-9
Silva C, Coleta I, Silva AG, Amaro A, Alvarelhão J, Queirós A, Rocha N (2013) Adaptation and validation of WHODAS 2.0 in patients with musculoskeletal pain. Rev Saúde Pública 47(4):1–6. https://doi.org/10.1590/S0034-8910.2013047004374
Üstün TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Ep**-Jordan J, Saxena S, Korffe MV, Pullf C (2010) Develo** the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ 88:815–823. https://doi.org/10.2471/BLT.09.067231
Kirchberger I, Braitmayer K, Coenen M, Oberhauser C, Meisinger C (2014) Feasibility and psychometric properties of the German 12-item WHO Disability Assessment Schedule (WHODAS 2.0) in a population-based sample of patients with myocardial infarction from the MONICA/KORA myocardial infarction registry. Popul Health Metrics 12:27. https://doi.org/10.1186/s12963-014-0027-8
Gold LH (2014) DSM-5 and the assessment of functioning: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). J Am Acad Psychiatry Law 42(2):173–181
Garin O, Ayuso-Mateos JL, Almansa J, Nieto M, Chatterji S, Vilagut G, Alonso J, Cieza A, Svetskova O, Burger H, Racca V, Francescutti C, Vieta E, Kostanjsek N, Raggi A, Leonardi M, Ferrer M (210) Validation of the “World Health Organization Disability Assessment Schedule, WHODAS-2” in patients with chronic diseases. Health Qual Life Outcomes. https://doi.org/10.1186/1477-7525-8-51
Downing NR, Kim J-I, Williams JK, Long JD, Mills JA, Paulsen JS (2014) WHODAS 2.0 in prodromal Huntington disease: measures of functioning in neuropsychiatric disease. Eur J Hum Genet 22:958–963. https://doi.org/10.1038/ejhg.2013.275
Thomas C, Narahari SR, Bose KS, Vivekananda KNS, West DP, Kwasny M, Kundu RV (2014) Comparison of three quality of life instruments in lymphatic filariasis: DLQI, WHODAS 2.0, and LFSQQ. PLoS Negl Trop Dis 8(2):e2716. https://doi.org/10.1371/journal.pntd.0002716
Hu L, Zang Y-L, Li N (2012) The applicability of WHODAS 2.0 in adolescents in China. J Clin Nurs 21:2438–2451. https://doi.org/10.1111/j.1365-2702.2012.04126.x
Habtamu K, Alem A, Medhin G, Fekadu A, Dewey M, Prince M, Hanlon C (2017) Validation of the World Health Organization Disability Assessment Schedule in people with severe mental disorders in rural Ethiopia. Health Qual Life Outcomes 15:64
Habtamu K, Alem A, Hanlon C (2015) Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study. BMC Psychiatry. https://doi.org/10.1186/s12888-015-0418-9
Habtamu K, Alem A, Medhin G, Fekadu A, Prince M, Hanlon C (2016) Development and validation of a contextual measure of functioning for people living with severe mental disorders in rural Africa. BMC Psychiatry 16:311
Overall J, Gorham D (1962) The brief psychiatric rating scale. Psychol Rep 10:799–812
Gray R, Leese M, Bindman J, Becker T, Burti L, David A, Gournay K, Kikkert M, Koeter M, Puschner B, Schene A, Thornicroft G, Tansella M (2006) Adherence therapy for people with schizophrenia: European multicentre randomised controlled trial. Br J Psychiatry 189(6):508–514. https://doi.org/10.1192/bjp.bp.105.019489
Youngmann R, Zilber N, Workneh F, Giel R (2008) Adapting the SRQ for Ethiopian populations: a culturally-sensitive psychiatric screening instrument. Transcult Psychiatry 45(4):566–589. https://doi.org/10.1177/1363461508100783
Cottler LB, Robins LN, Helzer JE (1989) The reliability of the CIDI-SAM: a comprehensive substance abuse interview. Br J Addict 84(7):801–814
Roaldset JO, Linaker OM, Bjørkly S (2012) Predictive validity of the MINI suicidal scale for self-harm in acute psychiatry: a prospective study of the first year after discharge. Arch Suicide Res 16(4):287–302
Susser E, Finnerty M, Mojtabai R, Yale S, Conover S, Goetz R, Amador X (2000) Reliability of the life chart schedule for assessment of the long-term course of schizophrenia. Schizophr Res 42(1):67–77
Boyda JE, Adler EP, Otilingama PG, Peters T (2014) Internalized stigma of mental illness (ISMI) scale: a multinational review. Compr Psychiatry 55(1):221–231
Ritshera JB, Otilingama PG, Grajalesa M (2003) Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res 121(1):31–49
Assefa D, Shibre T, Asher L, Fekadu A (2012) Internalized stigma among patients with schizophrenia in Ethiopia: a cross-sectional facility-based study. BMC Psychiatry 12:239
Morisky DE, Ang A, Krousel-Wood M, Ward HJ (2008) Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich) 10(5):348–354
Cavelaars M, Rousseau J, Parlayan C, de Ridder S, Verburg A, Ross R, Visser GR, Rotte A, Azevedo R, Boiten J-W, Meijer GA, Belien JA, Verheul H (2015) OpenClinica. J Clin Bioinform 5(Suppl 1):S2
Mueser KT, Pratt SI, Bartels SJ, Swain K, Forester B, Cather C, Feldman J (2010) Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness. J Consult Clin Psychol 78(4):561–573. https://doi.org/10.1037/a0019629
Cohen A, Patel V, Thara R, Gureje O (2008) Questioning an axiom: better prognosis for schizophrenia in the develo** world? Schizophr Bull 34:229–244. https://doi.org/10.1093/schbul/sbm105
Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito-Smythers C, Ryan ND, Strober MA, Hunt J, Keller M (2009) Psychosocial functioning among bipolar youth. J Affect Disord 114:174–183. https://doi.org/10.1016/j.jad.2008.07.001
Harrow M, Jobe TH (2007) Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. J Nerv Ment Dis 195(5):406–414. https://doi.org/10.1097/01.nmd.0000253783.32338.6e
Tirfessa K, Lund C, Medhin G, Hailemichael Y, Fekadu A, Hanlon C (2017) Food insecurity among people with severe mental disorder in a rural Ethiopian setting: a comparative, population-based study. Epidemiol Psychiatr Sci. https://doi.org/10.1017/s2045796017000701
Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM (2009) Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 373(9657):31–41. https://doi.org/10.1016/s0140-6736(08)61764-x
Teferra S, Hanlon C, Beyero T, Jacobsson L, Shibre T (2013) Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers. BMC Psychiatry 13:168
Teferra S, Hanlon C, Alem A, Jacobsson L, Shibre T (2011) Khat chewing in persons with severe mental illness in Ethiopia: a qualitative study exploring perspectives of patients and caregivers. Transcult Psychiatry 48(4):455–472. https://doi.org/10.1177/1363461511408494
Asher L, De Silva M, Hanlon C, Weiss HA, Birhane R, Ejigu DA, Medhin G, Patel V, Fekadu A (2016) Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): study protocol for a cluster randomised controlled trial. Trials 17:299
Acknowledgements
We are grateful to all the participants for giving their time and the data. We would also like to acknowledge the TaSCS (Task Sharing the Care of People with Severe Mental Disorders) project outreach workers for hel** to recruit and inviting the participants.
Funding
This research was conducted as part of the Africa Focus on Intervention Research for Mental Health (AFFIRM). Research reported in this publication was funded by the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH) under Award Number U19MH095699. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. KH is supported by a post-doctoral fellowship from the African Mental Health Research Initiative (AMARI). AMARI is part of the DELTAS Africa Initiative [DEL-15-01]. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [DEL-15-01] and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, WellcomeTrust or the UK government.
Author information
Authors and Affiliations
Contributions
KH, CH, AA, GM, and AF conceived and designed the study. KH trained the data collectors and CH followed up the data collection. KH did the data analysis. GM and CH supervised analysis of the data. KH wrote the first draft of the manuscript. All authors agree with the results and conclusions, contributed to the writing of the manuscript, and approved the final manuscript to be submitted for possible publication.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no competing interests.
Availability of data and materials
The data are part of an ongoing cross-country clinical trial study, African Focus on Intervention Research for Mental Health (AFFIRM). Due to the cross-country and ongoing nature of the study, we are not able to make the data publicly available at present. However, the data set used for the current study will be made available and can be accessed from the corresponding author on reasonable request, once the study is completed within 2 years from now.
Rights and permissions
About this article
Cite this article
Habtamu, K., Alem, A., Medhin, G. et al. Functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 53, 803–814 (2018). https://doi.org/10.1007/s00127-018-1546-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00127-018-1546-6