Cultural differences in psychosis outcomes

A new study highlights the value of integrating patient-reported outcome measures (PROMs) in early psychosis through a cross-cultural examination. Published in Schizophrenia Researchthis study is the first longitudinal exploration of measures of self-rated health (SRH) and self-rated mental health (SRMH) in individuals experiencing first-episode psychosis.

The two-year prospective study included 233 patients receiving early intervention services in Montreal, Canada and Chennai, India. These services included safe case management, family interventions, individualized psychosocial care, and the lowest effective dose of antipsychotic medication tailored to local contexts. Patients completed both PROMs and clinician-rated outcome measures (CROMs) at the start of the program and then at 12 and 24 months.

The researchers found that cultural context significantly influences how individuals perceive their physical and mental health. Patients in Chennai reported significantly greater improvements in both SRH and SRMH over time compared to their counterparts in Montreal. Initially, the Chennai patients reported poorer health, but their substantial progress was in stark contrast to the more modest gains in Montreal.

The authors of the study, Neha Nair, Salomé Xavier, Daniel Rabouin, Greeshma Mohan, Thara Rangaswamy, Padmavati Ramachandran, Ridha Joober, Norbert Schmitz, Ashok Malla and Srividya N. Iyer, explain:

“As hypothesized, Chennai patients reported greater improvements in health and mental health. The marked differences between health and mental health in Montreal, in contrast to the overlap between the two in Chennai, are consistent with previous findings of clearer differences between mental and body in Western societies Cross-contextual (eg anxiety) and context-specific factors (eg gender) influence patients’ health perceptions Our results highlight the value of integrating simple PROMs in early psychosis .”

This study underscores the importance of cultural context in mental health care by finding that patients with early psychosis in Chennai, India, report greater improvements in health and mental health over time compared to those in Montreal, Canada. Emphasizing the value of patient-reported outcome measures (PROMs), the research challenges the dominance of clinician-reported outcomes and advocates for more patient-centered approaches. The findings support previous evidence that patients with psychosis in low- and middle-income countries often experience better outcomes, highlighting the need for culturally sensitive and specific mental health interventions.

In measure-based care, patient-reported measures are increasingly valued as they allow patients to freely communicate their experiences without clinician influence. Population surveys within and across contexts have demonstrated the reliability and validity of the SRH and SRMH, single-item self-report measures found to correlate with mental illness severity. The authors suggest that these measures, because of their brevity, are useful in early intervention protocols, providing valuable information about lived experience without being burdensome.

Previous research has highlighted the prevalence of clinician-reported outcome measures in early intervention for psychosis, conducted primarily in high-income Western contexts. Few studies have undertaken cross-cultural comparisons using the PROM, and no studies have investigated first-episode psychosis in this way. This study sought to fill that gap by examining differences in SRH and SRMH ratings between patients from Chennai and Montreal receiving similar interventions for psychosis.

At baseline, Chennai patients reported significantly poorer self-rated health than those in Montreal. Over time, Chennai patients showed significant improvements in SRH and SRMH, while Montreal patients only showed significant improvements in SRMH. These findings support previous research showing better psychosis outcomes in low- and middle-income countries. Additionally, the study found that women were more likely to report worse mental health than men, particularly in Chennai, a pattern not evident in Montreal.

The authors suggest that Montreal patients perceive their mental and physical health as distinct entities, while Chennai patients see them as interconnected. This cultural variance significantly affects how patients perceive their health.

The study notes limitations, including the substantial number of excluded Montreal participants who did not respond to at least two of the three time points, potentially influencing cross-context results. Furthermore, there is insufficient qualitative data on patient perspectives regarding the measures and constructs examined.

“Despite these limitations,” the authors write, “our study is the first longitudinal exploration of SRH and SRMH measures in first-episode psychosis.”

“Our findings that these measures vary over time, both between two contrasting cultural and geographic contexts, and in relation to each other, are valuable and novel to help implement a more multifaceted approach to care measurement-based.”

This research contributes to efforts to address discrepancies between patient and clinician reports. The authors suggest that the therapeutic alliance can be improved by implementing patient-reported measures. Self-reported measures are more accessible to a wider range of individuals, reduce the medication of symptoms, and allow patients to better express their subjective experiences. This can reduce power imbalances between patients and doctors and provide a more intersubjective experience with a shared understanding between both parties.

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Nair, N., Xavier, S., Rabouin, D., Mohan, G., Rangaswamy, T., Ramachandran, P., Joober, R., Schmitz, N., Malla, A., & Iyer, SN ( 2024). Patient-reported outcome measures in early psychosis: A cross-cultural, longitudinal examination of self-reported health and self-reported mental health measures in Chennai, India and Montreal, Canada. Schizophrenia Research, 26775–83. https://doi.org/10.1016/j.schres.2024.03.006 (Connection)