Introducing Specialist Integrated Mental Health Care in Lebanon: The Psychosis Recovery Outreach Program

Psychosis can manifest itself in various psychiatric disorders. Schizophrenia is the archetypal psychotic disorder, with the most debilitating and chronic course of illness. An individual’s complete or partial lack of insight about his or her psychiatric condition is characteristic of the illness and a primary hurdle to treatment. The clinical presentation is often complicated by substance use, difficult socioeconomic conditions, and strained family dynamics. Globally, the prevalence rate of schizophrenia is 1%, and the incidence rate is 15.2 per 100,000. The age of onset for males is earlier (ratio of males to females: 1.4:1), which disrupts the psychological state and social integration at a critical stage of human development (1,2). In the context of Lebanon, with a population (indigenous and displaced) exceeding five million, these rates would translate to an estimated prevalence of 50,000 individuals with a psychotic illness (3). This presents a burden of care that cannot be neglected.

Over the past decades, priority has been given to improving outcomes for patients with psychotic disorders through early detection and intervention. The duration of untreated psychosis, counted as the time from the occurrence of the first psychotic symptoms until the initiation of psychotropic medication, is now considered a “toxic” phase that is significantly associated with a more severe course of illness and a poor overall outcome (4).

Initiated in Australia (5), specialist care programs that provide services based on an integrated outreach strategy have been established in many countries, including continental Europe, the United Kingdom (6), and, more recently, the United States (7). These programs, despite many variables, generally comprise early assessment teams, outpatient and inpatient departments, and day treatment programs. Furthermore, they include psychiatrists, psychotherapists, psychiatric nurses, occupational therapists, case managers, and health care assistants (5–7). Early Australian studies showed that patients receiving specialist care compared with standard care were less likely to be hospitalized and had shorter hospital stays, reduced negative symptoms, and a better quality of life (5). Other studies in the United Kingdom confirmed the positive effect on relapse and readmission rates and the likelihood of maintaining contact with mental health services (6). In addition, recent studies in the United States demonstrated improved social and occupational functioning, as well as increased odds of being enrolled in school or of working (7).

In Lebanon, the treatment of psychotic disorders follows a classical model of outpatient clinic follow-ups and acute inpatient admissions, with a proportion of treatment-resistant cases being accommodated in long-term care facilities, akin to traditional psychiatric hospitals. The bulk of the mental health care is provided by private facilities, voluntary-sector services, and public hospitals. Several deficits persist despite efforts to improve the general conditions. Primary care staffs are poorly trained in mental health, and there are scant interactions between the primary care and mental health sectors. Furthermore, only 1.26 psychiatrists are estimated to be available per 100,000 population in Lebanon (8), thus covering only a small percentage of the need. In contrast, there are 12.4 psychiatrists per 100,000 in the United States. In Lebanon, the shortage of other mental health professionals is even greater (9). In addition, an authority to monitor mental health facilities and a legal framework to preserve the rights of individuals with mental health problems are lacking. A mental health strategy for the country was drafted recently with a goal to improve coordination of current resources and provide a vision for the future (8).

Psychotic disorders constitute a significant proportion of the burden of disease. Twenty-nine percent of patients treated in mental health outpatient facilities, 21% in community-based psychiatric inpatient units, and 37% in psychiatric hospitals are diagnosed as having schizophrenia or schizotypal or delusional disorders (8). These disorders are the most prevalent in psychiatric hospitals, which highlights the importance of establishing new mental health services for psychosis in the country, with the aim of reducing delay in treatment, decreasing admission and relapse rates, educating families about psychosis, and setting a long-term plan to maintain mental health. It is in that context that the Psychosis Recovery Outreach Program (PROP) at the American University of Beirut Medical Center was initiated in February 2016. PROP draws on clinical experience and reliance on international evidence related to the treatment of schizophrenia and related disorders.

PROP

Lebanon, similar to countries across the Middle East and North Africa, is underresourced in terms of mental health care provision. The existence of a handful of private psychiatric centers in Lebanon, staffed with highly qualified psychiatrists, provided the opportunity for developing dedicated services building on the evidence base acquired globally over the past decades. The American University of Beirut Medical Center is a recognized secondary care center for excellence and has a high flow of patients. In addition to performing their academic and administrative duties, the small workforce of five senior psychiatrists with dual faculty appointments covers a 10-bed inpatient unit and daily outpatient clinics. A strategic goal of department leadership in the short to medium term is the development of specialist services.

With the absence of universal health coverage and the reluctance of insurance companies to cover psychiatric care, ensuring affordability to patients was a priority. A team of three psychiatric nurses was drawn from the inpatient service and allocated to rotate monthly in our program. This team leads a weekly drop-in clinic. It is offered free of charge to all patients enrolled in the program and who generally pay for other services. This ensures a degree of financial sustainability for the sponsoring institution. As the need grew and the limitations of this model became clear in regard to the most acutely ill patients, who tend to require more proactive care, nursing home visits were initiated in May 2017.

Policies, legal frameworks, and best-practice guidelines were adopted and adapted to our local context. Particular attention was given to the United Kingdom experience with dedicated early intervention services (6). This model had been appraised and revised over the years (10). Universal ethical principles in accordance with institutional policies were applied where gaps were found in the Lebanese national code of practice. Given the absence of government funding for such initiatives and in contrast to the United Kingdom model of universal health coverage, PROP obtained an educational grant for financial support. Novel interventions were offered free of charge to incentivize and familiarize both users and clinicians. A sustainable self-funding model is being tested in parallel.

A key component of the program was the provision of regular individual supervision for various team members and group supervision through a weekly multidisciplinary meeting where all patients are discussed, thus allowing for a shared ownership of the caseload and for cross-learning between disciplines. Emphasis was placed on professionals’ acquiring understanding, if not mastery, of the various roles and on gathering input from their colleagues from other professions. This accounted for the integrated nature of patient care. For example, psychologists were made aware of the pharmacological treatment of psychotic disorders, and nurses familiarized themselves with therapeutic techniques specific to these conditions.

Capacity building is a pillar of service development. Although exposure of psychiatrists to new models of care is generally achieved through electives and short courses abroad during various stages of training, these opportunities are less available to other mental health professionals. To address this shortfall, we arranged for nurses to shadow community mental health teams in the United Kingdom. In parallel, two psychologists were tasked with attending a special course in Canada on group cognitive-behavioral therapy for psychosis (CBTp), this course was led by a recognized expert in the field. This ensured that when group therapy—an established cost-effective component in treating psychotic disorders—was introduced in Lebanon, it would be based on a standardized module. This was particularly important given that therapy is a novelty in Lebanese society, where overlapping social networks and a strong stigma against mental illness have been perceived as major hurdles to implementation. Yet, initial feedback from two rounds of groups (social skills training and CBT) was positive and provided the team with information for reflection and refinement. An even more surprising success came from the parents and caregivers group, which for the first time in Lebanon brought families together in a culturally sensitive, supportive, and educational forum.

Progress is being made in increasing the number of referrals to the program through public awareness campaigns and information dissemination among professionals. Thus far, over 50 patients have benefited from our services. These include patients with challenging treatment-refractory illness who would have otherwise been hospitalized, incurring costs and potentially traumatic experiences. A certain reluctance was initially noted, particularly among relatives concerned over a dilution of the long-established tradition of an exclusive doctor-patient relationship. Doubts were also cast over the ability of nurses and other staff to carry out more elaborate duties associated with the medical profession. These duties included mental state assessment, psychoeducation, physical monitoring, and medication advice. As the program developed, confidence grew in the benefits of case management and the flexibility it offers for patients and clinicians. With a high prevalence of substance use among the younger population, closer collaborations with addiction programs are being discussed, with the aim for comprehensive management of co-occurring mental and substance use disorders.

The program also offers the opportunity to create a research database for a clinical population that has been relatively neglected in Lebanon. So far, no outcome figures have been generated, and work is ongoing to explore meaningful clinical and service outcomes. Publications on the burden of schizophrenia at a national level are few and far between. Having the advantage of the proximity of academic resources and expertise ensures that a body of evidence can be developed with a local and regional focus. These include the testing of psychological interventions in the specific cultural context of Lebanon.

Finally, advocacy is also an avenue that needs developing. While a handful of nongovernmental organizations have sprung up over the years advocating for mental health issues, schizophrenia and related disorders have not featured significantly on their agendas. This is probably due to a genuine perception that the public is likely to connect with more common causes such as depression, suicide, or childhood adversity. Discrete funding of employment opportunities for stable patients in cooperation with the private sector would be a realistic short-term goal for the program.

Discussion

PROP is an initiative that has been well received by patients, caregivers, and professionals alike. Now in its second year, it is consolidating its operation through standardization, supervision, and clinical audit and expanding its range of services to cover home nursing interventions. The caseload is expected to grow given the chronic nature of the disorders covered. Nonetheless, community care will have a meaningful impact on mental health care in Lebanon only if it is replicated nationally, with particular focus on peripheral areas outside the Beirut metropolitan area. Over the past few years, a number of residency programs have increased their output of locally trained psychiatrists. The size of this workforce remains in the single digits and is unlikely to bridge the gap between supply and demand. Even fewer early-career psychiatrists are returning from abroad to practice in Lebanon. In addition, the projected numbers assume that psychiatrists are working as part of a multidisciplinary structure, which is not currently the case. The provision of well-trained nurses capable of assuming community responsibilities remains a challenge compounded by high attrition rates among already burdened nursing staff on inpatient units. The regulation of psychologists is under way but will not necessarily translate into greater numbers working with this challenging patient population, when more lucrative opportunities exist in the private sector for offering therapy through primary care. Similar problems are encountered with social workers, occupational therapists, and support staff, who constitute the backbone of integrated community interventions. The hope in the medium term is for increasing access to better diagnosis and essential treatment to the largest segment of the population suffering from severe mental disorders across socioeconomic and regional divides. With promised mental health legislation in the pipeline, investments in specialist community programs are the best guarantee of more humane, effective, and least restrictive care in Lebanon.