Effectiveness of psycho-education on depression, hopelessness, suicidality, anxiety and substance use among basic diploma students at Kenya Medical Training College

1 Kenya Medical Training College and Daystar University, Nairobi, Kenya

2 Department of Psychiatry, University of Nairobi, Kenya

3 Africa Mental Health Foundation, Nairobi, Kenya

Corresponding author: S K Muriungi (skagwi2004@yahoo.com)

Objective. To determine the effectiveness of psycho-education on symptom severity in depression, hopelessness, suicidality, anxiety and risk of substance abuse among para-medical students at Kenya Medical Training College (KMTC).

Methodology. A clinical trial drew experimental (N=1 181) and control (N=1 926) groups from different KMTC campuses. Self-administered questionnaires were used to collect data: the researcher-designed social demographic questionnaire was used at baseline only, while Beck’s Depression Inventory, Beck’s Hopelessness Scale, Beck’s Suicide Ideation Scale, Beck’s Anxiety Inventory and World Health Organization alcohol, smoking and substance involvement screening test (ASSIST) (for drug abuse) were used for baseline, mid-point and end-point assessments at 3-month intervals. The experimental group received a total of 16 hours of structured psycho-education. All study participants gave informed consent.

Results. Overall, there was no significant reduction in symptom severity between the experimental and control groups at 3 months (p>0.05) but there was a significant difference at 6 months (p<0.05).

Conclusion. Psycho-education was effective in reducing the severity of symptoms of depression, hopelessness, suicidality, anxiety and risk of substance abuse at 6 months.

S Afr J Psych 2013;19(2):41-50. DOI:10.7196/SAJP.401

Substantial evidence supports the use of psychological therapies – particularly cognitive behavioural therapy (CBT) – through various methods of psycho-education in the prevention or treatment of mild to moderate depression, anxiety, moderate substance abuse and consequently, hopelessness and suicidality.1 Researchers have devised several components of psycho-education geared towards symptom recognition and stress-coping skills, among other things, which mental health professionals have found to be effective in preventing and reducing the symptoms of these conditions.

Psycho-education has also been found to promote self-referral to healthcare providers, by enhancing symptom recognition and reducing stigma.2 , 3 An individual’s ability to understand the effects of psycho-stressors as risk factors can help reduce these conditions’ prevalence among patients or the general population, and individuals equipped with appropriate stress-coping strategies can deal with possible psycho-stressors before they become chronic.2

The most common mental disorders diagnosed in primary-care settings are depression, anxiety and substance-related disorders, which can be present alone or comorbid with another mental disorder. 4 Hopelessness and suicidality are symptoms in a number of mental disorders, such as depression, schizophrenia, anxiety or substance abuse.5-7 Common in the general population, these debilitating conditions affect general well-being, functioning, productivity and quality of life if left unmanaged, making it hard to do everyday tasks completely, competently and efficiently.8-11

These conditions also have a psychosocial component that is closely related to negative social relationships, environmental challenges or an individual’s inadequate ability to cope effectively with stress. These challenges have been found to be predominant among medical students.12-15 Because the diagnosis of depression, anxiety, hopelessness or suicidality by general practitioners is often poor, the proportion of sufferers who receive treatment is low.

Among students entering the health professions, these conditions not only affect their lives negatively but may also have repercussions for patient care in the long run.10 , 14 Rosenthal and Okie 5 noted that medical students are more prone to depression than their non-medical peers. This could be because medical students constantly encounter very sick patients or even deaths among their patients. Psycho-education in recognising the symptoms of these conditions and understanding their causes, as well as skills for coping with stress, may facilitate their prevention, and possibly control of their occurrence.

In a study involving 1st- and 2nd-year medical students in a Californian University, aimed at investigating the use of mental health services and its barriers, Givens et al. found that about a quarter of the respondents were depressed.15 Noting the increased prevalence of these conditions in these students compared with their non-medical peers, the study noted a negative attitude towards mental illness among the respondents and therefore an unwillingness to openly seek help.

Givens et al.15 also found that the students had poor coping strategies for the stresses of school life, which included inadequate sleep hours, reduced social life, fatigue and academic challenges.As medical students encounter serious illness and deaths within their practical learning sessions, their emotional balance may be compromised, leaving them vulnerable to anxiety, depression and substance abuse.

Psycho-educational interventions

Various interventions have been employed to prevent or manage mental disorders. Psycho-education is a cost-effective interventional approach that emphasises teaching stress-coping strategies such as goal setting, skills teaching, satisfactory goal achievement, assertiveness and communication skills. These help to mitigate the development of depression or anxiety.16-18

According to Colom and Lam,16 psycho-education focuses on the early identification of prodromal signs and possible predisposing and precipitating causes of these mental disorders. Patients’ understanding of their conditions will facilitate compliance and encourage them to seek appropriate management. It also encourages individuals to explore their health beliefs and illness awareness, and enables them to understand the complex relationship between symptoms, personality, interpersonal factors and environment.

Over a 9-month period, Christensen et al.17 offered CBT through computerised or telephone channels to 301 clients diagnosed with depression and anxiety, and who were receiving pharmacotherapy. They found a significantly beneficial effect over 24 months.

A comparative randomised trialby MacKinnon et al.18 used online CBT (consisting of 5 interactive modules on cognitive restructuring, pleasant activities and assertiveness training, problem solving and relaxation sessions), which was provided through the information website for depression in the United States. The study found significant benefits in symptom reduction among the experimental group. Their initial mean on the Center for Epidemiologic Studies depression scale (CES-D) was 21.8, which fell to 15.6 after 6 months and 14.1 after 12 months. In comparison, the control group’s was 21.6, which fell to 17.8 after 6 months and 16.4 after 12 months.

No similar studies have studied the effects of psycho-education among college students or any other category of respondents in Kenya. This study aimed to fill this knowledge gap, while contributing to the global data.

Methods

The study aimed to determine the effectiveness of psycho-education on depression, hopelessness, suicidality, anxiety and risk of substance abuse among first- and second-year basic diploma students. Three assessments of both groups were carried out at 3-month intervals to determine the effectiveness of the psycho-education given to the experimental group.

Study population

The current study was a clinical trial involving an experimental (N=1 181) and control (N=1 926) group drawn from 7 campuses of Kenya Medical Training College (KMTC). The Nairobi campus the constituted experimental group and the Nakuru, Port Reize, Mombasa, Kisumu, Muranga and Meru campuses constituted the control group. Students were pursuing any of the courses offered at basic diploma level: nursing, medical records and information sciences, community oral health, laboratory sciences, public health sciences, medical imaging sciences, neurophysiology, clinical medicine, dental technology, occupational therapy, optometry, orthopaedic technology, physiotherapy, pharmacy and medical engineering sciences.

This was a cross-sectional study. All students from the campuses who gave informed consent were recruited. Exclusion criteria included undertaking a post-basic course or not giving consent.

Data collection instruments

The research instruments were 6 self-administered questionnaires:

• A researcher-designed questionnaire for socio-demographic characteristics (SDQ): gender, age, year of study, marital status, place of residence while studying, religion and campus location.

• The Beck’s Depression Inventory (BDI),19 a 21-item self-report inventory which measures the severity of depression in a general population. This widely used instrument discriminates subtypes of depression, differentiates depression from non-depressed patients has a high coefficient alpha of 0.93 (p=0.001) for college students, and a validity and reliability of 90%. The BDI cut-off points used in this study were: 0 – 9 for minimal depression, 10 – 18 for mild depression, 19 – 29 for moderate depression and 30 – 63 for severe depression.

• The Beck’s Anxiety Inventory (BAI)22 is a 21-question instrument designed to measure the severity of anxiety in a general population. It shows proven high interval consistency and test/re-test reliability over 1 week. In the general population, respondents must score ≥36 to be considered to have anxiety. The BDI and BAI have been validated against the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) respective diagnostic criteria in the western countries, where they have been used extensively for similar and other relevant surveys.19 , 22 The cut-off points for the BAI used for this study were: 0 – 7 for minimal, 8 – 15 for mild, 16 – 25 for moderate and 26 – 63 for severe anxiety.

All 6 instruments were self-administered and took an average of 1.5 hours to complete.

Intervention

All participants gave informed consent and confidentiality was maintained throughout the study. All respondents in both groups were advised that if they recognised the symptoms/conditions being investigated, they were free to make self-referrals. All respondents were given information on resources available for help.

In the experimental group, baseline characteristics were obtained. This was followed by 4 psycho-education sessions. These 2-hour sessions comprised lectures, simulations, group discussions and role-plays. They incorporated predisposing/precipitating causes of depression, hopelessness, suicidality, anxiety and substance abuse, as well as symptom recognition and stress-coping skills/ strategies. Reassessment was carried out 3 months after the initial intervention to investigate its effects, followed immediately by another 8 hours of psycho-education in 2-hour sessions. A final reassessment was carried out 3 months after the second assessment (6 months after the baseline assessment). All participants were free to contact the principal investigator if they felt that they had a psychological problem or related to the symptoms featured in the questionnaires.

In the control group, no interventions were provided. (However, respondents were free to self-refer to a healthcare provider. Reassessment was done at 3 and 6 months. Participants were provided with a 24-hour helpline in case they developed suicidal tendencies or needed help of any kind.

Psycho-education intervention and reassessments

The initial 4 sessions of psycho-education given to the experimental group included a 2-hour session on definitions of terms, causes of the conditions and symptom recognition. Another 2 sessions involved theoretical lectures and simulations on stress-coping strategies/skills. These included scheduling/time management, communication skills, decision-making techniques, problem solving, assertiveness training, improving self esteem, sleep hygiene, breathing techniques, controlled breathing/de-arousal, anger-management techniques, relaxation exercises, progressive muscle relaxation, general exercise activities and adherence training. A clinical psychologist supervised small group discussions.

After 3 months, assessment was followed immediately by a repeat of the same process of psycho-education, in addition to addressing the challenges that the respondents had experienced after the first round.

Each psycho-education programme in all the departments in the experimental group lasted between 1.5 months and 2 months.

Data management

The collected data were double-entered by 2 separate groups of data-entry clerks, and cleaned and analysed using SPSS (version 16), utilising descriptive and inferential statistics. Results were presented in the form of tables and narratives.