Feasibility and Acceptability of an Intervention to Support People With Severe Mental Illness in South Africa

The development of appropriate and effective community-based care for people living with severe mental illness (SMIs) continues to be a global challenge, especially in low-and-middle income countries (LMICs). A particularly damaging cycle emerges when people with SMIs are admitted to hospital for acute psychiatric treatment, discharged back into community settings without appropriate support, only to be readmitted again due to psychiatric relapse. This "revolving door" phenomenon is a multilevel challenge to mental health systems, including in countries such as South Africa, with little to no formal community-based support systems for people living with SMIs. Several innovative strategies have been developed to address hospital re-admission, while co-development approaches such as human-centred intervention development have shown much promise in generating improved outcomes. The proposed research project aims to explore the feasibility and limited efficacy of a co-developed health system strengthening intervention programme in a South African district in order to determine its feasibility, appropriateness and limited efficacy in reducing readmission following discharge from acute psychiatric hospitalization.

Specifically, a multi-level helath system strengthening intervention programme has been co-developed, which include 1) the improvement of referral processes across healthcare facilties; 2) the implementation of a psychosocial rehabilitation programme across tertiary, secondary and primary healthcare facilities; 3) the implementation of clinical guidelines refresher training for clinicials on primary healthcare level; 4) the implementation of a structured outreach programme by community health workers following discharge; and 5) the implementation of a Household Champion programme to empower households for better support at home. This package will be piloted in a parallel arm feasibility trial in the uMgungundlovu District Municipality in KwaZulu-Natal, South Africa. We will train registered councellors to deliver psychosocial rehabilitation on primary healthcare level in tandem with nursing staff, train community health workers to work with existing outreach teams to implement the Community Mental Health Education and Detection programme during routine household visits, and will recruit a training and quality improvement team to coordinate, support and mentor training and improvement for the referral pathway and clinician refresher training. Fourty-three people who have been admitted for acute psychiatric reasons will be recruited for each of the two arms. The intervention arm will receive the full intervention package, while the control arm will receive care as usual as well as improved referral and discharge readiness on hospital level. The primary aim is to determine whether enrollment to the full intervention package will reduce the likelihood of people discharged from acute psychiatric hospitalization after 4 months, compared to those in the control group. Secondary measures include the effects of the intervention on service users (in terms of stigma, medication adherence, and recovery) after 4 months; and qualitative measures of feasibility in terms of the acceptability, demand, implementation, practicality, adaptation, integration, and potential for expansion of the intervention. Taken together, the quantitative and qualitative data will provide an indication of the feasibility and limited efficacy of the co-developed intervention package.

Service user inclusion criteria:

• Adults (aged 18 years and above);
• Being admitted to the psychiatric ward of a hospital for observation and treatment due to an acute psychiatric event, based on ICD diagnosis on patient charts according to the following criteria:

• F20-29 including schizophrenia, delusional disorders, schizotypal disorders, acute polymorph psychotic disorders, schizoaffective disorders
• F30-39 Mood [affective] disorders with psychoses
• F30.2 Mania with psychotic symptoms
• F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms
• F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms
• F32.3 Severe depressive episode with psychotic symptoms
• F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms
• Determined by the attending psychiatrist to be discharged into community settings following appropriate recovery from the psychiatric event;
• Willing and able to participate in the intervention programme
• Resides with a caregiver (which could be a family member or member of the household).
• Resides within the geographic boundaries of uMgungundlovu

Service user exclusion criteria:

• Under 18 years of age
• Are indicated by their chart history to have the following conditions:

• Active suicidal ideation
• Substance abuse or dependence as primary diagnosed psychiatric condition
• Personality disorders
• Serious cognitive or other sensorial impairment likely to preclude informed consent and reliable assessment
• Does not reside with a caregiver
• Does not reside within the geographic boundaries of uMgungundlovu

Caregiver inclusion criteria

• Adults (aged 18 years and above)
• Willing and able to participate in the intervention programme
• Resides with a caregiver (which could be a family member or member of the household).
• Resides within the geographic boundaries of uMgungundlovu

Caregiver exclusion criteria

• Adults (aged 18 years and above)
• Willing and able to participate in the intervention programme
• Resides with a caregiver (which could be a family member or member of the household).
• Resides within the geographic boundaries of uMgungundlovu