A survey of psychosis risk symptoms in Kenya
Introduction
Schizophrenia and other psychotic disorders are among the most disabling psychiatric disorders, estimated to affect approximately 3% of the world's population [1]. Early detection of psychosis has been associated with less severe symptoms and fewer hospitalizations upon emergence of psychotic illness [2], which has a profound importance when considering strategies of efficient and cost-effective health care delivery [3]. Preventing the future development of a severe psychotic disorder is regarded as among the most effective ways to reduce this potentially devastating burden on the affected individual and family members [4]. In sub-Saharan Africa, where financial and health care resources for managing psychotic disorders are extremely limited, the need for effective preventive strategies before disorder onset is therefore fundamental [5].
The ultra-high-risk (UHR) criteria, a concept of early detection of help-seeking patients at short-term risk of psychosis, have become an increasing focus of current research [6]. Retrospective studies have confirmed an average prodromal period (ie, period before disorder onset) of 5 to 6 years [7], and the introduction of UHR criteria has significantly advanced the possibility of indicated prevention during this period [6]. The substantial body of UHR research has led some authors to create criteria for the identification of UHR individuals using structured interviews [8]. These schedules generally identify 3 groups of UHR: those at familial high risk, those with attenuated positive symptoms, and those with brief limited intermittent psychotic symptoms. Studies have indicated that 16% to 54% of the youth who meet the current UHR criteria develop a major psychotic disorder (eg, schizophrenia, schizoaffective disorder, and bipolar or unipolar depression with psychotic features) within 1 to 2.5 years [6], [9], [10].
The PRIME-Screen [11], [12] is a self-reported instrument based on the Structured Interview for Psychosis-Risk Symptoms [8] and designed to enable rapid identification of those at risk for psychotic disorders. It consists of 12 items covering positive symptoms and uses a self-rated scoring system of between 0 (definitely disagree) and 6 (definitely agree), with a score of 3 indicating “not sure.” Using limited samples of patients, a high sensitivity and a perfect specificity have been reported [11], although predictive validity has not been examined. General agreement on what constitutes the UHR state using the PRIME-Screen has not been established, although a score of 6 in at least 1 item is considered suggestive [11], [12]. A modified version of the PRIME-Screen, which considered the duration of symptoms, showed a specificity and a sensitivity (against the Structured Interview for Psychosis-Risk Symptoms as a criterion standard) of 0.74 and 1.00, respectively, and a concordant validity of 0.43 [12]. A brief self-administered screen has a potential advantage in evaluating the prevalence of psychosis risk symptoms in large community settings where administration of a more extensive, time-consuming semistructured interview may not be feasible. Self-administration may also reduce inherent biases that may exist in researcher-assisted interviewing, particularly in cultures where certain questions may seem unfamiliar.
There have been no previous published reports evaluating prodromal or clinically high-risk individuals in the continent of Africa [5]. The limited data available from more developed countries may not be representative of Africa, as the presentation of schizophrenia and psychosis differs across cultures [13], [14]. Epidemiologic studies in Africa suggest that there may be differences in the prevalence of psychotic illness across cultures [15], although there have been variable results across studies and surveyed populations within the continent. For example, the prevalence of schizophrenia in rural African communities has ranged between 4.3 and 60.0 per 1000 [16], [17], [18], which is lower than that typically reported in Western countries. However, such comparisons are limited by cultural differences in the worldview of concepts, which may influence the perception of psychotic illness [19] and, thus, the estimated prevalence.
Our primary aim was to evaluate the prevalence of various psychotic risk symptoms in a large community sample (n = 2758) in Nairobi, Kenya, using a culturally modified version of the PRIME. We explored the effect of gender on symptom manifestation, hypothesizing that symptoms will be more prevalent in males compared with females, consistent with previous studies showing higher rates of schizophrenia and psychotic experiences or an earlier age of onset in males [20]. Age effects on reporting psychosis risk were also evaluated, to gain insight into screening questions that may be more useful at various stages of development. Finally, we explored subject reports on the severity of specific psychosis risk symptoms to identify groups of subjects, using cluster analysis.
Section snippets
Recruitment
Participants were recruited between August 9 and 26, 2010, through house-to-house visits in Kangemi, a slum neighborhood of the city of Nairobi, Kenya, located 6 miles from the city center. Conditions in Kangemi are very poor, and many of its residents lack access to basic services, including electricity and running water; however, most youth attend public schools and are proficient in reading and writing in English. There were 8 recruiters involved in the study. Recruiters were trained third-
Demographics
In total, 2758 individuals participated in the study. Participant ages ranged from 14 to 29 years, with a mean (SD) age of 18.5 (3.4) years and a median age of 18 years. There were 1628 (60.5%) males and 1064 (39.5%) females among the participants, with 66 participants not disclosing their sex.
Prevalence of psychosis risk symptoms
Of those surveyed, 1255 (45.5%) indicated certainty (ie, “definitely agree” on the mPRIME) on having had any psychosis risk symptom in their lifetime. Among the total population, the percentages stating
Discussion
Our studies showed a relatively high (45.5%) adolescent and young adult lifetime prevalence of symptoms suggesting psychosis risk in a region within Nairobi, Kenya. The most commonly reported symptom (34.7%) involved feelings of having special gifts beyond one's natural ability. Other symptoms reported, of decreasing prevalence, were interrupted or controlled thinking, difficulty identifying reality, thoughts of mind reading, thoughts of predicting the future, feeling that odd things are going
Acknowledgment
The authors would like to thank George W. Couch III, for his generous support for this research project. The authors do not have any conflicts of interest and declare no financial interest from this study.
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Cited by (22)
Neurocognition in Kenyan youth at clinical high risk for psychosis
2021, Schizophrenia Research: CognitionCitation Excerpt :Psychosis conversion rates in Kenyan CHR youth in one study were also found to be lower than that reported in other countries (Mamah et al., 2016). Investigations of the CHR state and psychotic-like experiences is relatively new in Africa, with studies mostly conducted in Kenya (Mamah et al., 2016; Mamah et al., 2020; Mamah et al., 2012; Mamah et al., 2013a; Mamah et al., 2013b; Ndetei et al., 2012; Owoso et al., 2018; Owoso et al., 2014; Ndetei et al., 2019), with a few exceptions (Owoso et al., 2018; Adewuya et al., 2020; Braham et al., 2014; Okewole et al., 2015). Only one study, by our group, has investigated neurocognition in African CHR subjects, in a population of secondary school students in Kenya (Mamah et al., 2016).
Psychotic-like experiences among 9,564 Kenyan adolescents and young adults
2021, Psychiatry ResearchCharacterizing psychosis risk traits in Africa: A longitudinal study of Kenyan adolescents
2016, Schizophrenia ResearchCitation Excerpt :To our knowledge, our group was the first to investigate the CHR state in Africa and we have maintained an active research program characterizing psychosis-risk traits in Kenyan youths. Our previous investigations using various psychosis-risk screening instruments showed relatively high rates of psychotic experiences in Kenyan children (Mamah et al., 2013a), adolescents (Mamah et al., 2013a) and young adults (Mamah et al., 2012; Ndetei et al., 2012) in school and community settings. These findings may have overestimated psychotic experience prevalence rates, as these were higher than those observed in some studies done in developed countries (e.g. (Gale et al., 2011; Kelleher et al., 2012; Mojtabai, 2006)).
Advancing Research to Action in Global Child Mental Health
2015, Child and Adolescent Psychiatric Clinics of North AmericaCitation Excerpt :Data from HICs suggest, however, that psychotic symptoms, per se, are not uncommon, occurring in 4% to 8% of the general population, and the prevalence may be higher among children and adolescents.72 A community study of youth aged 14 to 29 years from Kenya reported that 45% of the sample endorsed at least 1 psychotic risk symptom.73 These experiences do not necessarily predict the onset of a psychotic disorder; rather, they are apt to be indicators of risk for a variety of mental disorders (including depression, bipolar disorder, and sometimes schizophrenia).
The WERCAP Screen and the WERC Stress Screen: Psychometrics of self-rated instruments for assessing bipolar and psychotic disorder risk and perceived stress burden
2014, Comprehensive PsychiatryCitation Excerpt :Brief self-report questionnaires have been developed for establishing the UHR state or for assessing psychotic experiences, and could increase the willingness to disclose sensitive information compared with face-to-face interviews [38]. These include the Community Assessment of Psychic Experiences (CAPE) [39], the PRIME Screen [40] and its modified versions [41,42], the Prodromal Questionnaire-Brief Version (PQ-B) [43], the PROD Screen [44], the Psychosis Screening Questionnaire (PSQ) [45], the Self-screen Prodrome (SPro) [46], the Eppendorf Schizophrenia Inventory (ESI) [47], the Peters et al. Delusions Inventory [48] and the psychosis screen from the Composite International Diagnostic Inventory (CIDI) [49–51].
Validation of a modified version of the PRIME screen for psychosis-risk symptoms in a non-clinical Kenyan youth sample
2014, Comprehensive PsychiatryCitation Excerpt :Written and signed consent was obtained from the study participants and the study was approved by the institutional review boards of Washington University School of Medicine, the Kenyan Medical Research Institute, and the Ministry of Education, Science, and Technology, Kenya. A total of 2758 individuals between the ages of 14 and 29 were recruited for our prior survey using mPRIME, as detailed in Mamah et al [25]. Ten of the twelve mPRIME questions were identical to the original PRIME screen questionnaire with the only differences being replacement of items 9 (“I think I might feel like my mind is ‘playing tricks on me’”) and 12 (“I have been concerned that I might be ‘going crazy’”) with modified items (“I feel that my ability to properly think or mentally function has seriously worsened in the last month” and “I have been concerned that I might be ‘going mad’” for items 9 and 12 respectively) (see Fig. 1 for full mPRIME screen).