A new study underscores the value of integrating patient-reported outcome measures (PROMs) in early psychosis through a cross-cultural examination. Published in Schizophrenia Research, this study is the first longitudinal exploration of self-rated health (SRH) and self-rated mental health (SRMH) measures in individuals experiencing first-episode psychosis.
The two-year prospective study involved 233 patients receiving early intervention services in Montreal, Canada, and Chennai, India. These services included assertive case management, family interventions, individualized psychosocial care, and the lowest effective dosage of antipsychotic medication adapted to local contexts. Patients completed both PROMs and clinician-rated outcome measures (CROMs) at the beginning of the program and then at 12 and 24 months.
Researchers found that cultural context significantly influences how individuals perceive their physical and mental health. Patients in Chennai reported substantially greater improvements in both SRH and SRMH over time compared to their counterparts in Montreal. Initially, Chennai patients reported poorer health, but their substantial progress contrasted sharply with the more modest gains in Montreal.
The study’s authors, 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, align with previous findings of clearer distinctions between mind and body in Western societies. Cross-context (e.g., anxiety) and context-specific (e.g., gender) factors 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 revealing that early psychosis patients in Chennai, India, report greater improvements in health and mental health over time compared to those in Montreal, Canada. By highlighting the value of patient-reported outcome measures (PROMs), the research challenges the predominance of clinician-reported outcomes and advocates for more patient-centered approaches. The findings support previous evidence that psychosis patients in low and middle-income countries often experience better outcomes, emphasizing the need for culturally sensitive and context-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 SRH and SRMH, single-item self-report measures found to correlate with the severity of mental illness. The authors suggest that these measures, due to their brevity, are advantageous in early intervention protocols, providing valuable lived experience information without being burdensome.
Previous research has highlighted the predominance of clinician-reported outcome measures in early intervention for psychosis, predominantly conducted in high-income, Western contexts. Few studies have undertaken cross-cultural comparisons using PROMs, and no studies have investigated first-episode psychosis in this manner. This study sought to fill that gap by examining the 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 both SRH and SRMH, while Montreal patients only showed significant improvements in SRMH. These findings support previous research indicating 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 health and physical health as distinct entities, whereas Chennai patients view them as interconnected. This cultural variance significantly influences how patients perceive their health.
The study notes limitations, including the significant number of excluded Montreal participants who did not respond to at least two out of the three time points, potentially affecting the cross-context results. Additionally, there is insufficient qualitative data on patient perspectives regarding the measures and constructs examined.
“These limitations notwithstanding,” the authors write, “our study is the first longitudinal exploration of both the SRH and SRMH measures in first-episode psychosis.”
“Our findings that these measures change over time, both between two contrasting cultural and geographical contexts and with respect to each other, are valuable and novel in helping implement a more multifaceted approach to measurement-based care.”
This research contributes to efforts addressing discrepancies between patient and clinician reports. The authors suggest that the therapeutic alliance may be improved by implementing patient-reported measures. Self-rated measures are more accessible to a broader range of individuals, reduce the medicalization of symptoms, and allow patients to better express their subjective experiences. This can reduce power imbalances between patients and clinicians and offer 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, S. N. (2024). Patient-reported outcome measures in early psychosis: A cross-cultural, longitudinal examination of the self-reported health and self-reported mental health measures in Chennai, India and Montreal, Canada. Schizophrenia Research, 267, 75–83. https://doi.org/10.1016/j.schres.2024.03.006 (Link)
