Establishing a clinical high‐risk program in Tunisia, North Africa: A pilot study in early detection and identification

Abstract

Background Early identification and prevention research has provided huge advances in our understanding of early screening and identification of young people at clinical high‐risk (CHR). Most of these procedures were developed in high‐income countries, yet middle‐income countries in North Africa such as Tunisia can benefit from these empirically‐based assessment approaches. Methods Using established procedures, nine Tunisian psychiatric raters were trained on structured assessments: the CAARMS, BPRS, and SCID to high standards of interrater reliability. These raters developed a clinical high‐risk program (CHiRP) in Tunisia and recruited 10 patients who were exhibiting possible signs of CHR. These patients were evaluated to determine if they met criteria for a CHR group, such as Attenuated Psychosis. Results Trained raters met the following interrater reliability criteria for the CAARMS and BPRS (ICC = .80 or greater) and the SCID (Kappa = .75 or greater). Of 10 pilot patients, six were classified as CHR and belonging to the Attenuated Psychosis Group. One of the six patients converted to psychosis 3 months after study entry for a conversion rate of 17% which is comparable with currently published rates globally. Discussion The first CHR program has been established in Tunisia, a middle‐income country using methods developed in high income countries. Efforts aimed at assembling a group of prevention‐oriented psychiatrists, obtaining administrative support, and training raters to high levels of interrater reliability were successful. The feasibility was demonstrated for screening, assessing, treating, and following‐up of 10 CHR patients suggesting that conversion rates are comparable to those of Western and European countries.

Public health primary prevention implemented by clinical high-risk services for psychosis

“…1 ). It included 13 standalone CHR-P services from Australia [ 17 – 20 ], Brazil [ 21 ], Germany [ 22 ], Netherlands [ 23 ], Poland [ 24 , 25 ], South Korea [ 26 ], Singapore [ 27 , 28 ], UK [ 29 – 36 ], and US [ 37 , 38 ], and 40 integrated CHR-P services from Australia [ 39 – 42 ], Canada [ 43 , 44 ], Chile [ 45 ], China (Hong Kong) [ 46 – 48 ], France [ 49 ], Greece [ 50 , 51 ], Italy [ 52 – 61 ], Japan [ 62 ], Norway [ 63 , 64 ], South Korea [ 65 ], Spain [ 66 , 67 ], Switzerland [ 68 – 71 ], Tunisia [ 72 ], UK [ 36 , 73 , 74 ]; three networks of CHR-P services: the Early Detection Intervention and Prevention of Psychosis Program (EDIPPP) [ 75 , 76 ], the Pan-London Network for Psychosis Prevention (PNP) [ 36 ], and Swiss Early Psychosis Project (SWEPP) [ 70 ]; five studies on national or regional surveys: 18 Early Intervention Services (EIS) from Canada [ 77 ], 45 [ 78 ] and 46 [ 79 ] EIS from Italy (two different surveys), 11 EIS from Portugal [ 80 ], and 50 EIS from the United Kingdom [ 81 ]; and one global survey of 47 CHR-P services [ 11 ] (eFig. 1 ).…”

“…[ 19 , 20 , 22 , 27 , 29 , 30 , 32 , 36 – 38 , 40 , 43 , 44 , 53 , 56 , 57 , 63 , 66 , 77 – 79 ] Mental health literacy, attitude towards mental disorders • Training and mental health awareness for professionals working with young people. [ 19 , 20 , 22 , 24 , 27 , 29 , 32 , 35 – 38 , 40 , 44 , 45 , 49 , 50 , 52 , 54 , 56 , 57 , 62 – 64 , 68 – 70 , 72 , 73 , 75 , 77 – 79 ] Mental health literacy, attitude towards mental disorders Selective strategies and corresponding good mental health domains • Problem-solving training. [ 18 , 57 , 58 , 78 , 79 ] Self-management skills • Individual or group psychoeducation.…”

“…[ 18 , 57 , 58 , 78 , 79 ] Self-management skills • Individual or group psychoeducation. [ 18 , 28 , 31 , 36 , 49 , 50 , 58 , 65 , 71 , 72 , 74 , 78 – 81 ] Mental health literacy, self-management skills • Life/practical skills training. [ 74 , 77 ] Self-management skills • Family psychoeducation, counselling or support.…”

“…[ 11 , 27 , 28 , 30 , 36 , 43 , 45 , 49 , 50 , 54 , 55 , 58 , 59 , 77 ] Social skills • Educational support. [ 11 , 27 , 28 , 35 , 36 , 49 , 52 , 57 , 58 , 74 , 76 , 77 ] Academic/occupational performance • Cognitive Remediation Training [ 72 ] Cognitive skills • Physical health assessment and monitoring. [ 36 , 39 , 41 , 42 , 45 , 73 , 80 ] Physical health, QoL • Exercise/physical activity intervention, psychomotor therapy.…”

“…Another universal approach implemented mental health awareness and training activities targeting professionals working in close contact with young people, commonly including GPs, mental health professionals, counsellors, private practitioners, teachers and educators, social workers, and front-line youth workers [ 19 , 20 , 22 , 24 , 27 , 29 , 32 , 35 – 38 , 40 , 44 , 45 , 49 , 50 , 52 , 54 , 56 , 57 , 62 – 64 , 68 – 70 , 72 , 73 , 75 , 77 – 79 ]. These activities addressed issues such as stigma reduction, risk factors for mental disorders, best preventive practices, case recognition, and were delivered through workshops [ 22 , 24 , 44 , 68 ], education sessions and informal meetings [ 24 , 32 , 37 , 38 , 40 , 56 , 73 , 75 , 77 ], articles in professional journals and other printed media [ 19 , 22 , 37 , 40 , 62 , 68 ], phone or email consultation [ 36 , 62 , 75 ], and websites specifically tailored to professionals [ 37 ].…”