Authors

• Nikolina Jovanovic ¹
• Jill Francis ²
• Nadja P. Maric ³
• Aliriza Arenliu ⁴
• Stojan Barjaktarov ⁵
• Alma Dzubur Kulenovic ⁶
• Lidija Injac ⁷
• Yan Feng ⁸
• Antoni Novotni ⁵

¹ Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Bart’s and The London School of Medicine and Dentistry, Queen Mary University of London, UK

² School of Health Sciences, City University of London, UK

³ Faculty of Medicine, University of Belgrade, Belgrade, Serbia

⁴ Department of Psychology, University of Prishtina, Kosovo

⁵ University Psychiatry Clinic, Skopje, Republic of North Macedonia

⁶ Clinical Center University of Sarajevo, Sarajevo; Bosnia and Herzegovina

⁷ Psychiatric Clinic, University of Montenegro, Podgorica, Montenegro

⁸ Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London

Abstract

Objectives
Psychotic disorders have large treatment gap in low- and middle-income countries (LMICs) in South-Eastern Europe, where up to 45% of affected people do not receive care for their condition. This study will assess the implementation of a generic psychosocial intervention called DIALOG+ in mental health care services and its effectiveness at improving patients’ clinical and social outcomes.


Methods
This is a protocol for a multi-country, pragmatic, hybrid effectiveness–implementation, cluster-randomised, clinical trial. The trial aims to recruit 80 clinicians and 400 patients across 5 South-Eastern European LMICs: Bosnia and Herzegovina, Kosovo*, Montenegro, Republic of North Macedonia and Serbia. Clusters are clinicians working with patients with psychosis, and each clinician will deliver the intervention to five patients. After patient baseline assessments, clinicians will be randomly assigned to either the DIALOG+ intervention or treatment as usual, with an allocation ratio of 1:1. The intervention will be delivered six times over 12 months during routine clinical meetings. TThe primary outcome measure is the quality of life at 12 months [Manchester Short Assessment of Quality of Life (MANSA)]; the secondary outcomes include mental health symptoms [Brief Psychiatric Rating Scale (BPRS), Clinical Assessment Interview for Negative Symptoms (CAINS), Brief Symptom Inventory (BSI)], satisfaction with services [Client Satisfaction Questionnaire (CSQ-8)] and economic costs at 12 months [based on Client Service Receipt Inventory (CSRI), EQ-5D-5L and Recovering Quality of Life (ReQOL-10)]. The study will assess the intervention fidelity and the experience of clinicians and patients’ about implementing DIALOG+ in real-life mental health care settings. In the health economic assessment, the incremental cost-effectiveness ratio is calculated with effectiveness measured by quality-adjusted life year. Data will also be collected on sustainability and reach to inform guidelines for potentially scaling up and implementing the intervention widely. Conclusion: The study is expected to generate new scientific knowledge on the treatment of people with psychosis in health care systems with limited resources. The learning from LMICs could potentially help other countries to expand the access to care and alleviate the suffering of patients with psychosis and their families.
Trial registration: ISRCTN 11913964

Keywords

• psychosis
• Mental health care
• Trial
• Technology
• Communication
• Low- and middle-income countries