Trends in clinical practice and its effect on relapse among patients with severe mental disorders in Ethiopia: a retrospective chart review

Background Studies have suggested that developing good trends in clinical practices in adherence to the recommended processes and guidelines for basic care have been associated with good health outcomes. However, no previous studies have explored trends in psychiatric practices and their impact on relapse among patients with severe mental disorders. Methods: We conducted a retrospective chart review of 401 patients with severe psychiatric disorders selected by systematic random sampling technique. Trends in clinical practice were assessed by a tool adapted from published evidence based on advice from well-known experts in psychiatric practice. A univariable and multivariable logistic regression model was used to investigate the association between psychiatric practices and relapse. Results This study provided evidence of a signicant decit in adherence to the recommended practices of basic care. The vast majority of professionals were not following the appropriate psychiatry history-taking format at rst contact (73.6%), not documented the reasons for drug discontinuation (88.5%), did not follow the correct guideline of shifting across psychrotrophic medications (86.8%), and did not put their name or signature on the chart (61.8%). In multivariable analysis, not following psychiatric history taking format at rst contact 1.63 (1.04, 2.56)], the diagnosis of bipolar disorders [4.85 (2.01, 8.36)], drug discontinuation after a short duration of treatment [1.21 (1.02, 2.42)], poor documentation of patient data during follow up [3.10 (2.35, 4.43)], absence of name and signature of treating physician on the chart [7.58 (2.64, 21.79)], and failing to treat medication side effect [2.55 (1.02, 6.39)] were found to signicant predictors of relapse among the participants. Conclusions The ndings provided evidence of notably higher rates of decits in adherence to the existing guideline of basic psychiatric care, which resulted in a higher risk of relapse among patients with severe psychiatric disorders.


Introduction
Epidemiological data suggest that there exists a clear gap between what is recommended or effective care and what happens in real clinical practice (1,2). Studies have suggested that developing good trends in clinical practices in adherence to the recommended processes and guidelines for basic care have been associated with good health outcomes (3). For example, a study conducted in Australia by Hubbard and colleagues found that adherence to the recommended treatment guidelines has been associated with good rehabilitation outcomes and recovery from stroke (4). This study found that following the recommended guidelines of management was associated with early discharge, satisfactory response to medical and psychological therapy, and better overall recovery from the medical conditions (5). In another study by Hepner et.al. adherence to the recommended treatment guidelines was associated with good depression outcomes in primary health care (6). A 2005 study also showed that provider's adherence to testament guidelines was associated with larger reductions in depressive and Page 3/14 other psychiatric disorder symptoms( including bipolar disorders symptoms) over time (7). Other studies have also reported that adherence to practical guidelines of care was consistently linked with good mental health outcomes (2,8).
However, the existing scienti c data suggest that a signi cant proportion of health professionals involved in the care and treatment of people with mental health problems did not adhere to the suggested guideline of care. For instance, in a study conducted in the united states in 2012, a signi cant number of professionals involved in the management of common mental disorders did not adhere to the recommended guidelines of care, which resulted in poor treatment outcomes. outcomes (9). A recent study also found that more than half of provides did not follow the recommended guidelines of care for depressive problems, which is lowest for severe depressive problems when compared to mild or moderate symptoms (10).
Generally, there are a few studies that assessed provider's adherence to the recommended guidelines of care for patients with mental health problems and the associated effects on patient outcomes, which are all con ned to developed countries. To the best of our knowledge, this is the rst study to evaluate adherence to the recommended guidelines of care in patients with severe mental disorders ─ schizophrenia, bipolar, and major depressive disorders and the association with relapse. We hypothesized that a larger number of professionals might be non-adherent to the recommended guidelines of care which could be associated with higher risks of relapse in a patient.

Methodology
Study design, study area, and period A retrospective chart review was conducted from April 01-May-30/2020 at Amanuel Mental Specialized Hospital.

Target population
A chart of all patients with severe mental illness who are on follow-up at Amanuel Mental Specialized Hospital.

Study population
All charts of patients who had been on follow-up at Amanuel Mental specialized hospital in 2015-2019.

Inclusion Criteria
All charts of patients who had been on follow-up at Amanuel Mental specialized hospital in 2015-2019.

Exclusion criteria
If the old chart of the patient is lost in between the follow-up.

Sample size and sampling procedure
The sample size for this study was determined by using single population proportion formula with the following assumptions: Since there was no study conducted in developing countries regarding the raised issue, we used a 50% proportion of the population. Measures used for data collection The instrument used for data collection was developed by a team of experienced experts in mental health services and research in accordance with the guidelines of care in mental health services. The instrument was then tested on 5% of the charts and modi ed accordingly. The instrument which was used to assess socio-demographic factors is also developed by the research team.
Data collection procedure A semi-structured and structured questionnaire was used to evaluate the chart. Four Degree level mental health professionals were hired as data collectors and they were supervised by one psychiatrist. The English version of the questionnaire was used for data collection.

Data Quality Control
A pretest was done on 5% of the sample to check whether there is a common understanding among the data collectors on the developed questionnaire. All lled data was checked immediately at the end of the chart review. During we experienced any missed data or inappropriate data, the patient's chart was reviewed again to correct the inappropriate data or to be sure that the information is missed on the chart.

Data processing and Analysis
The collected data was checked for completeness, entered into Epidata version 3.1, exported to SPSS version 20 for further analysis. Descriptive statistics was used to present the data in frequency and percentage. Binary logistic regression was used to measure the association between trends of clinical practice and relapse. OR and 95% CI was used to see the strength of association and P-value was used to see the statistical signi cance of the association.

Ethical consideration
Ethical clearance was obtained from the institution review board (IRB) of Amanuel Mental Specialized Hospital. The con dentiality of the chart and the information contained in the chart were kept. For the sake of anonymity, the name of the patient wasn't written on the questionnaire.

Sociodemographic characteristics of the participants
We have reviewed a total of 401 charts for this study. The mean age of the patients at rst contact was 35.3 with a standard deviation of +10.3. Most of the extracted data was from a chart of male patients (225 (56.1%)). The majority of the patients were from the Oromo ethnic group. Most of the participants were single (57.1%) and unemployed (72.8%). (Table 1).  (Table 3).

Discussion
To the best of our knowledge, this is the rst study to evaluate adherence to the recommended guidelines of care in patients with severe mental disorders and the association with relapse. The ndings demonstrated a signi cant de cit in adherence to the recommended practices of basic psychiatric services. The vast majority of professionals were not following the appropriate psychiatry history-taking format at rst contact (73.6%), not documented the reasons for drug discontinuation (88.5%), did not follow the correct guideline of shifting across psychrotrophic medications (86.8%), and did not put their name or signature on the chart (61.8%). In multivariable analysis, not following psychiatric history taking format at rst contact, diagnosis of bipolar disorder or schizophrenia, drug discontinuation after a short duration of treatment, poor documentation of patient data during follow up, absence of name and signature of treating physician on the chart, and failing to treat medication side effect were found to signi cant predictors of relapse among the participants. The results suggest the urgent need for training and subsequent follow-up of the professionals regarding adherence to the recommended practices during their routine psychiatric care.
Our ndings suggest that the psychiatric practices including history taking and documentation process, transparency of treating physicians, shifting across medications, and management of medication side effects, and risk assessment of the patients were against the national and international guideline of care or management of people with mental health problems (11, 12). These ndings are supported by the reported results from prior studies. For example, a 2012 study conducted in the united states has reported that a signi cant number of professionals involved in the management of common mental disorders did not adhere to the recommended guidelines of care that resulted in poor treatment outcomes (9). Another study also found that roughly half of healthy provides did not follow the recommended guidelines of care and interventions for depressive problems with signi cantly lower adherence rates for severe depressive problems when compared to mild or moderate symptoms (10).
Regarding the associated factors of suicide, in this study, not following the appropriate psychiatry historytaking format at rst contact was associated with 1.63 increased odds of experiencing relapse compared to following psychiatric history-taking format [1.63 (1.04, 2.56)]. This is due to the fact that if the detailed history of the patient was not documented well; the management plan wouldn't be comprehensive which directly affects treatment outcome and progress of the problem and consequently leading to adverse outcomes such as relapse.
Those patients with a diagnosis of Bipolar disorder were 4.85 times more likely to encounter relapse compared to that of major depressive disorder We also found that failure to follow the correct guideline of shifting across psychrotrophic medication was associated with a 1.21 higher odds of relapse among the participants Finally, failing to treat medication side effects was linked with a 2.55 odd of increasing relapse in patients [2.54 (1.02, 6.39)]. The possible reason for this association is; the patients may prefer stopping the medication and follow up to stop the pain and suffering from side effects, which subsequently worsen their illness (leads to relapse).

The strength and limitations of the study
The present study has several stretches. First, being the rst study to assess adherence to the recommended guidelines of care in patients with severe mental disorders and the association with relapse. Second, we have examined the risk of relapse including important confounders related to general principles of medical practices. Third, the inclusion of adequates number of participants in the nal analysis.
Our study has also some limitations: (1) because if the nature of the study (cross-sectional) the association observed between different factors and suicide may not represent cause ─the temporality of the variables (exposures vs. outcome) has been not well established. has been used.

Conclusions
In summary, in this study we found that the vast majority of professionals were not following the appropriate psychiatry history-taking format at rst contact (73.6%), not documented the reasons for drug discontinuation (88.5%), did not follow the correct guideline of shifting across psychrotrophic medications (86.8%), and did not put their name or signature on the chart (61.8%). Not following psychiatric history taking format at rst contact, the diagnosis of bipolar disorders, drug discontinuation after a short duration of treatment, poor documentation of patient data during follow up, absence of name and signature of treating physician on the chart, and failing to treat medication side effect were found to signi cant predictors of relapse among the participants. The ndings suggest the need for appropriate training and capacity building of the health care professions to the bene ts and the rami cations of adherence to the clinical guideline of care. The necessary leaders or stakeholders must follow the professional whether or not they are practicing in accordance with the recommended guidelines and take appropriate measures as early as possible.
Declarations research work.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate Ethical approval was obtained from the Amanuel Mental Specialized Hospital. Con dentiality was maintained at all levels of the survey. Informed, written consent was obtained from each study participant to review their charts.