One year prevalence of psychotic disorders among first treatment contact patients at Butabika National Psychiatric Referral Hospital in Uganda

Introduction Hospital based studies for psychotic disorders are scarce in low and middle income countries. This may impact on development of intervention programs. Objective We aimed to determine the burden of psychotic disorders among first treatment contact patients at the national psychiatric referral hospital in Uganda. Methods A retrospective patient chart-file review was carried out in March 2019 for all patients presenting to the hospital for the first time in the previous year. Patients were categorised into those with and without psychotic disorders. We collected sociodemographic data on age, gender, occupation, level of education, ethnicity, religion and home district. We determined the one year prevalence of psychotic disorders among first treatment contact patients. Using logistic regression models, we also determined the association between psychotic disorders and various exposure variables among first treatment contact patients. Results In 2018, 63% (95% CI: 60.2 – 65.1) of all first time contact patients had a psychosis related diagnosis. Among the patients with psychotic disorders, the median age was 29 years (IQR 24 – 36). Most of the patients were male (62.8%) and unemployed (63.1%). After adjusting for patients’ residence, psychotic disorders were found to be more prevalent among the female gender [OR 1.58 (CI1.46-1.72)] and those of Pentecostal faith [OR 1.25 (CI 1.10-1.42)]. Conclusion Among first treatment contact patients in Uganda, there is a large burden of psychotic disorders. The burden was more prevalent among females as well as people of Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies are warranted to determine if this phenomenon is replicated at illness onset.

categorised into those with and without psychotic disorders. We collected sociodemographic 25 data on age, gender, occupation, level of education, ethnicity, religion and home district. We 26 determined the one year prevalence of psychotic disorders among first treatment contact 27 patients. Using logistic regression models, we also determined the association between 28 psychotic disorders and various exposure variables among first treatment contact patients.

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Conclusion: Among first treatment contact patients in Uganda, there is a large burden of 36 psychotic disorders. The burden was more prevalent among females as well as people of 37 Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies 38 are warranted to determine if this phenomenon is replicated at illness onset. INTRODUCTION

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Psychotic disorders that include schizophrenia spectrum disorders as well as bipolar affective 41 disorders are the leading contributors to disease burden globally (1-3). Schizophrenia was 42 assigned the highest disability coefficient in global burden of disease (GBD) study (4,5). 43 Psychotic disorders run a chronic course in the life of an individual. They usually present in 44 early adolescence with a first episode of psychosis; and then continue with some form of 45 disability thorough out the life of the individual (6). Patients with psychotic disorders are more 46 likely to have worse social functioning, poor quality of life and die earlier than their peers (7-47 12). Correct management at initial presentation of psychotic disorders has been associated 48 with lower relapse rates, greater functional recovery and improved quality of life (13,14).

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Worldwide the prevalence for psychotic disorders has remained relatively stable between 1-50 3% even in low and middle income countries (LMIC) like Uganda (3). Hospital based 51 prevalence rates for psychotic disorders especially among first time attended in LMIC are 52 however scarce. The current literature in the Ugandan setting has mainly dwelt on people with 53 HIV/AIDS among first time mental treatment contacts (15).

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There is limited literature on the burden of psychotic disorders at initial mental treatment 55 contact in LMICs (16). It is unclear if the burden of psychotic disorders is greater than that for 56 other disorders like anxiety, mood or substance use disorders. Such information is crucial in 57 human resource allocation and the development of specialised services in tertiary care. The 58 sociodemographic profile of patients presenting to tertiary care in the Ugandan setting is not 59 well described. For example, literature has shown higher incident rates for psychotic disorders 60 among males than females (17)(18)(19)(20)(21). Whether this is replicated at presentation for care in our 61 setting is unknown. Also, the clinical profiles of the various psychotic disorders are unknown.

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This is especially important as management differs between the different psychosis spectrum 63 disorders (22). The majority of patients with psychotic disorders prefer alternative and 64 complimentary therapies over western medicine (23)(24)(25)(26)(27)(28)(29). It is unclear if this preference 65 translates to lower rates and/or different clinical profiles for psychotic disorders among patients 66 presenting to mental health services for the first time. Such differences are important in 67 directing policy and developing interventions to improve care for patients with psychotic 68 disorders.

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Describing the burden and risk factors for psychotic disorders at initial treatment contact is a 70 crucial step in developing interventions to improve the outcomes for patients with psychotic 71 disorders. In Uganda there is a precedent for this approach where extensive literature on the 72 burden of HIV/AIDS in the psychiatric setting was instrumental in development of interventions 73 for patients with severe mental illness suffering with AIDS (30-34). The current study therefore 74 aims to determine the burden of psychotic disorders among initial treatment contact patients 75 at the national psychiatric hospital in Uganda.

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The study took place at Butabika National Psychiatric Referral and Teaching Hospital, a 600 78 bed capacity mental hospital located approximately twelve kilometres from Kampala (35). The 79 hospital is located in the heart of the Greater Kampala Metropolitan Area (GKMA) where 10% 80 of Uganda's population reside and responsible for a third of the country's gross domestic 81 product (GDP) (36). Butabika National Psychiatric Referral and Teaching Hospital determines 82 the policy agenda for mental health in the country together with the Ministry Of Health and is 83 responsible for various levels of mental health training (37). It also plays a supervisory role 84 over all mental health provision services in the country that include 12 regional referral 85 hospitals and 96 district hospitals. Functioning below the district hospitals are three different 86 levels of health centres (HC) namely HC4, HC3 and HC2. Mental health provision starts at 87 HC3 level with subsequent referrals to higher centres. Currently, the hospital has specialised 88 services for substance use disorders at the Alcohol and drug unit, a forensic ward, a 89 specialised child and adolescent mental health unit as well as specialised occupational 90 therapy and psychotherapy units. In terms of human resource allocation, the national 91 psychiatric and teaching hospital is run by 72 clinicians (psychiatrists' clinical psychologists 92 and psychiatric clinical officers); 157 nurses, 4 social workers and 59 mental attendants. Given 93 that it is a national referral hospital it also provides non psychiatric care like HIV/AIDS care, 94 minor surgeries and dental services. Like in many similar facilities in LMICs there are a number 95 of challenges in provision of services primarily due to limited budgetary allocation (37, 38).

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We used a retrospective case analysis of chart records to determine the burden, profile and 97 associated factors for psychotic disorders among first treatment contact patients. Approval for 98 the study was obtained from the Uganda National Council for Science and Technology 99 (UNCST) and the School of Medicine Research and Ethics Committee (SOMREC) of 100 Makerere University. We also received institutional approval from the hospital to carry out the 101 study. As this was a retrospective chart review of file records, we did not receive patient 102 consent. All patients presenting to the hospital for the first time who had a psychiatric diagnosis 103 on file between January 1 st and December 31 st , 2018 made our study population. We excluded 104 patients presenting for the first time for non-psychiatric services like dental services, routine 105 HIV care or minor surgeries like circumcision.

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On a routine clinic day, the hospital records team opens a file for all patients presenting to the 107 hospital for the first time. The patient sociodemographic variables including age, gender, 108 ethnicity, religion, occupation and home district are recorded in the file before the patient is 109 sent to see a clinician. The clinician then makes a diagnosis, and a decision of whether to treat 110 the patient as an out-patient or send them to admission in one of the units described above.

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Once the patient has received care, the health care workers return the patient file to the 112 records office for safe storage. Some patients receive care as in-patients, and others are 113 treated as out-patients and return to their homes the same day.

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We used standardized questionnaires to extract sociodemographic and diagnosis data from 115 the chart files of all patients presenting to the hospital for the first time from January to 116 December 2018. Diagnoses of schizophrenia spectrum and related psychoses, bipolar 117 affective disorder and mood disorders with psychotic disorders were classified as psychotic 118 disorders. All other diagnoses among patients presenting for the first time including but not 119 limited to temporal lobe epilepsy, anxiety disorders, substance use disorders and depressive 120 disorders were classified as non-psychotic disorders. We considered sociodemographic 121 characteristics as the exposure variables and the diagnostic categories as the outcome 122 variables. Abstracted data from the files was entered into Epidata 3.1 by a database manager 123 and exported to Stata version 13 for analysis. Data analysis was conducted in March 2019.

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Proportions of patients by different diagnostic categories were calculated to determine the one 125 year prevalence of psychotic disorders. Using bivariate analysis we compared the proportions 126 of participants with psychotic disorders to non-psychotic disorders along various exposures.

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No variables exhibited any collinearity and the dataset had no outliers. We used a modified 128 Poisson regression model to establish factors associated with psychotic disorders given that 129 it has robust standard errors and therefore gives more accurate confidence intervals. Variables 130 with a level of significance less than 0.2 were included in the multivariate analysis. However, 131 region of origin was assessed for any possible confounding effects as ethnicity has been 132 shown to have a genetic biological risk factor for psychotic disorders At multi-variate analysis 133 a level of significance of less than 0.05 was used to test for significance between different 134 exposures and FEP.

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Between January 1      burden of psychotic disorders in the Ugandan setting among patients presenting for the first 187 time at a mental facility. The burden for psychotic disorders was greater than that for mood 188 disorders as well as substance use disorders. This suggests that there may be benefit in 189 introducing specialised early intervention services for psychotic disorders at the hospital.

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Specialised services for psychotic disorders especially at the first episode of psychosis usually 191 lead to better outcomes for patients (39)(40)(41)(42). Currently the hospital has specialised services 192 for substance use disorders, and it would be important to determine the benefit of similar 193 services for psychotic disorders. Future work on necessary components for an early 194 intervention psychosis clinic as well as cost benefit analyses of such a program are 195 recommended (13,21,42,43). It is also known and often observed that psychotic disorders 196 tend to present with aggression and violence injuring staff and fellow patients (44, 45). Acute 197 psychiatric units or psychiatric intensive care units have been shown to be especially effective 198 in containing such potentially dangerous behaviour (44), hence calling for such care facilities 199 as useful additions to mental hospitals as opposed to just locked seclusion rooms as is the 200 practice at this facility (44, 45).

Time of presentation and duration of untreated illness: The low numbers of patients 202
presenting to the hospital younger than 18 years of age is worrying as it may point to delay in 203 presentation for services. The course of psychotic disorders is characterised by a psychosis 204 prodrome before onset of illness usually in the late teens or early adulthood (40,46). That 205 most of our patients present outside this age range may imply that either the onset of 206 psychosis is late in this population or that there is a long duration of untreated psychosis 207 (DUP). The latter theory is probably more likely since DUP has been reported to be longer in 208 Sub-Saharan Africa compared to high income countries (47)(48)(49). This is important for future 209 intervention programs given that DUP is a key predictor of outcomes for patients with psychotic 210 disorders (14,46,50).

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Gender and initial presentation to care with psychotic disorders: Females were more 212 likely to present to the hospital than males with a psychotic illness. The incidence of psychotic 213 disorders is higher in males than females in previous literature (17)(18)(19)(20)(21). Greater prevalence 214 among the female gender might be due to the difference in care seeking between males and 215 females rather than greater incidence in the community. This, however, would need 216 confirmation with longitudinal studies. It is also important to note that it is unlikely that a patient 217 with psychosis brought themselves to the hospital. Further studies are therefore required to 218 understand why there is preference for bringing females to the hospital than males.

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Culture and initial presentation to care with a psychotic disorder: Culture plays an 220 important role in symptom presentation, care seeking and access to health services (51, 52).

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From this study, it is not possible to determine why there is greater prevalence for initial 222 presentation at the hospital for psychotic disorders over non-psychotic disorders. Previous 223 literature by  highlighted that patients are more likely to use both African 224 traditional therapies and biomedicine if the patient has a severe illness or poor global 225 functioning (23). It is therefore possible that the patients coming to the hospital are the ones 226 who were very ill and generally disruptive in the communities in which they lived. 227 Unfortunately, this chart review could not answer this question but further highlights that 228 patients may be coming late with long duration of untreated psychosis. Previous literature has 229 highlighted the preference for alternative and complementary therapies for the initial 230 management of psychotic disorders in this setting (23,24,26,27).

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Psychotic disorders were more prevalent among people of the Pentecostal faith. It is important 232 to clarify that this finding does not mean that people of this faith are more at risk for psychotic 233 disorders. Rather the findings suggest that people of Pentecostal faith with psychotic disorders 234 were more likely than other faiths to seek care from the national referral and psychiatric 235 hospital. Another plausible explanation might be due to explanatory models for mental illness 236 in our setting characterised by beliefs in supernatural causations of psychotic disorders (53).

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This may make patients resort to this faith because of its supposed ability to heal mental 238 disorders through prayer hence leading to more psychotic cases there eventually presenting 239 to the hospital (54, 55).

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Ethnicity has a strong association to genetic risk which is a key biological risk factor for 241 psychotic disorders (56, 57). Psychotic disorders were not found to be more prevalent in any 242 particular ethnic grouping or region of origin. Uganda is one of the most ethnically diverse 243 societies in the world (58) and this sample had more than 30 different tribes. It would therefore 244 require larger sample sizes to determine an association between a specific ethnicity and onset 245 of psychotic disorders. Currently a large genetic study is underway in Uganda to try and 246 determine the genetic risk for psychotic disorders (59).

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Limitations of the study: A major limitation of the study was its retrospective study design 248 which could cause information bias. The information however collected was primarily on 249 sociodemographic characteristics which are not usually prone to bias. Also, failure to confirm 250 the diagnoses with a standardized tool could lead to misclassification bias. However, Butabika 251 is a national referral hospital with expertise in mental health care service provision and the 252 diagnoses were made by qualified psychiatrists; so we were fairly confident in the diagnoses 253 made.

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There seems to be a large burden of psychotic disorders (67%) among patients presenting to 256 the national psychiatric hospital in Uganda for the first time. Many of the participants were 257 female calling for further studies to understand this phenomenon in our setting. More studies 258 are also needed to define the duration of untreated psychosis in this population given that 259 most of the first time patients were older than the normal onset for psychotic disorders. Finally, 260 there may be benefits in introducing specialised intervention services for psychotic disorders 261 at the national referral hospital in the form of specialised early intervention services as well as 262 "safe wards models" as acute psychiatric units or psychiatric intensive care units at such large 263 mental health facilities 264 ACKNOWLEDGEMENT

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We acknowledge the patients who presented to the hospital for the first time. Dr. Linnet Ongeri 266 of Kenya Medical Research Institute gave invaluable guidance on the manuscript for which 267 we are grateful.

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The work was supported by Grant Number D43TW010132 supported by Office Of The 270 Director, National Institutes Of Health (OD), National Institute Of Dental & Craniofacial 271 Research (NIDCR), National Institute Of Neurological Disorders And Stroke (NINDS), National 272 Heart, Lung, And Blood Institute (NHLBI), Fogarty International Centre (FIC), National Institute 273 On Minority Health And Health Disparities (NIMHD). Its contents are solely the responsibility 274 of the authors and do not necessarily represent the official views of the supporting offices.

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The authors declare no competing interests.

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Author contributions: EKM, NN and SM conceptualised the research idea. EKM, AN, JN 278 and JLG supervised the data extraction exercise. PB and DA advised on the analysis of the 279 results. All authors were involved in writing the manuscript and approved the final manuscript 280 for submission.

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The data underlying the results presented in the study are available from the corresponding 283 author on request.