Abstract
This paper provides an overview of more than 22 years of research conducted in the central Javanese province of Yogyakarta, Indonesia, by teams of researchers associated with Gadjah Mada University and Harvard University, led by the authors of this essay. This work is placed in the context of the very limited literature on early psychosis and mental health services in Indonesia. It provides an overview of mental health services in Indonesia and of this team’s research trajectory, then addresses four key domains: the cultural phenomenology of early experiences of psychotic illness; patterns of onset, with a particular focus on extremely rapid onset psychoses; patterns of care-seeking for first episode illness; and mental health services and patterns of utilization. It then discusses the importance of rapid onset psychosis for research on early psychosis, and the question of whether collinearity of rapidity of onset and rapidity of care-seeking raises questions about the long-standing finding that a short duration of untreated psychosis leads to better outcomes. It concludes by discussing difficulties of prioritizing early intervention models in settings with very low mental health resources.
Notes
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1 Works on the development of the ‘Aceh model’ of mental health services, which has been influential for the past decade of services development in Indonesia, include Chandra, Pandav, and Bhugra (Citation2006); Good, Good and Grayman (Citation2010); Good, Grayman, and Good (Citation2016); Idaiani (Citation2015); Maramis (Citation2006); Marthoenis, Yessi, Aichberger, and Schouler-Ocak (Citation2016); and Prasetiyawan, Maramis, and Keliat (Citation2006).
2 This work was carried out by Professors Good and Subandi, with 16 months of focused research between 1996 and 1999, and was supported by Fulbright Senior Fellowships to Professors Byron and Mary-Jo Good and by an NSF grant to Byron Good.
3 Clinical rating scales used in our research include the IRAOS (Interview for the Retrospective Assessment of the Onset of Schizophrenia), PANSS (Positive and Negative Symptoms Scale), BPRS (Brief Psychiatric Rating Scale), GAF (Global Assessment of Function scale), DAS (Disability Adjustment Scale), and other related instruments, translated into Indonesian and adapted for local use (Good, Citation2008).
6 See Good et al. (Citation2019) and Good, Marchira, et al. (Citation2010) for longer descriptions of this case. It was part of what we describe above as our pilot ‘longitudinal study’.
7 This case was developed by Dr Sandeep Nanwani, as part of his Harvard MMSc research, and reported in his thesis (Nanwani, Citation2018) and in Good et al. (Citation2019).
8 This case was developed as part of the IPSOS Yogyakarta study, and is described in more detail in Good et al. (Citation2019).
9 The whole domain of rapid onset psychoses remains poorly conceptualized, and supported by relatively limited research. Historically, acute onset psychoses have been reported as common in parts of Africa and South Asia (e.g. Guinness, Citation1992; Jilek & Jilek-Aall, Citation1970; Okasha, El Dawla, Khalil, & Saad, Citation1993; Rodger & Steel, Citation2016; Singh, Citation2011; Susser, Varma, Malhotra, Canover, Amador, & 1995). Histories of the concept of rapid onset psychoses show the diversity of terms used, with a particular focus on ‘psychogenic psychoses’, ‘reactive psychoses’, and ‘acute and transient’ psychoses (Castagnini & Berrios, Citation2011; Marneros, Citation2005; Marneros & Pillmann, Citation2004; Pillmann & Marneros, Citation2003; Wimmer, Citation2003). Many definitions make the ‘transience’ of the disorder part of the criteria, rather than asking what is the course of rapid onset psychoses, as pointed out by Susser and colleagues (Susser & Wanderling, Citation1994; Susser, Finnerty, & Sohler, Citation1996; Susser et al., Citation1995). Stevens (Citation1987) asked early on whether the prevalence of such disorders might account for findings of better outcomes in some settings.
10 While we have presented these data in international meetings, we saw this as an initial survey and analyzed the results in an unpublished report only (Good & Subandi, 2002). The study used the first author’s internal Harvard funds only.
11 PPDGJ III (Pedoman Penggolongan Gangguan Jiwa) is the Indonesian diagnostic manual. It is based on ICD-10.
12 Although it is widely accepted that non-medical and religious healers are consulted for psychotic illness around Indonesia, it is almost certain that how often healers are consulted and how this is related to contact with the medical system varies by time, place, and local culture. Kurihara, Kato, Reverger, and Tirta (Citation2006) reported that, of 57 consecutive patients making first contact with the Bangli Mental Hospital in Bali, 87% had had previous contact with diverse Balinese healers.
13 We believe this may represent under-reporting, since families, particularly educated families, are often embarrassed to talk about using alternative healers with psychiatrists.
Chandra, V., Pandav, R., & Bhugra, D. (2006). Mental health and psychosocial support after the tsunami: Observations across affected nations. International Review of Psychiatry, 18(3), 205–211. doi:10.1080/09540260600655805 Good, B. J., Marchira, C., Ul Hasanat, N., Utami, M. S. & Subandi, (2010). Is “chronicity” inevitable for psychotic illness? Studying heterogeneity in the course of schizophrenia in Yogyakarta, Indonesia. In L. Manderson & C. Smith-Morris (Eds), Chronic conditions, fluid states: chronicity and the anthropology of illness (pp. 54–74). New Brunswick, NJ: Rutgers University Press. Good, B. J., Grayman, J., & Good, M.-J. D. (2016). Is PTSD a ‘good enough’ concept for post-conflict mental health work? Reflections on work in Aceh, Indonesia. In D.E. Hinton & B.J. Good (Eds), Culture and PTSD: Trauma in global and historical perspective (pp. 387–417). Philadelphia, PA: University of Pennsylvania Press. Idaiani, S. (2015). The effectiveness of community-based mental health program by community health centers on the recovery of patients with psychosis in Aceh. ASEAN Journal of Psychiatry, 16(2), 212–221. Maramis, A. (2006). After the tsunami: Building back for better mental health care in Aceh. ASEAN Journal of Psychiatry, 7, 45–48. Marthoenis, M., Yessi, S., Aichberger, M. C., & Schouler-Ocak, M. (2016). Mental health in Aceh-Indonesia: A decade after the devastating tsunami 2004. Asian Journal of Psychiatry, 19, 59–65. doi:10.1016/j.ajp.2016.01.002 Prasetiyawan, V.E., Maramis, A., & Keliat, B. A. (2006). Mental health model of care programmes after the tsunami in Aceh, Indonesia. International Review of Psychiatry, 18, 559–562. doi:10.1080/09540260601039959 Good, B. (2008). Cultural aspects of early psychosis in Indonesia. Abstract from the 6th International Conference on Early Psychosis, Early Intervention in Psychiatry, 2(Suppl. 1), A4. Fusar-Poli, P., Borgwardt, S., Bechdolf, A., Addington, J., Riecher-Rössler, A., Schultze-Lutter, F., … Yung, A. (2013). The psychosis high-risk state: A comprehensive state-of-the-art review. JAMA Psychiatry, 70(1), 107–120. doi:10.1001/jamapsychiatry.2013.269 Li, H., Shapiro, D., & Seidman, L. eds. (2019). Handbook of Attenuated Psychosis Syndrome in Youth and Young Adults: Early Identification and Intervention across Countries. New York, NY: Springer. Woodberry, K. A., Shapiro, D. I., Bryant, C., & Seidman, L. J. (2016). Progress and future directions in research on the psychosis prodrome: A review for clinicians. Harvard Review of Psychiatry, 24(2), 87–103. doi:10.1097/HRP.0000000000000109 Good, B. J., & Subandi, M. A. (2004). Experiences of psychosis in Javanese culture: Reflections on a case of acute, recurrent psychosis in contemporary Yogyakarta, Indonesia. In J. H. Jenkins & R. J. Barrett (Eds), Schizophrenia, culture, and subjectivity: The edge of experience (pp. 167–195). Cambridge: Cambridge University Press. Good, B. J., Subandi, M. A., & Good, M.-J. D. (2007). The subject of mental illness: Psychosis, mad violence, and subjectivity in Indonesia. In J. Biehl, B.J. Good, & A. Kleinman (Eds), Subjectivity: Ethnographic investigations (pp.243–272). Berkeley, CA: University of California Press. Good, B. J., Marchira, C., Ul Hasanat, N., Utami, M. S. & Subandi, (2010). Is “chronicity” inevitable for psychotic illness? Studying heterogeneity in the course of schizophrenia in Yogyakarta, Indonesia. In L. Manderson & C. Smith-Morris (Eds), Chronic conditions, fluid states: chronicity and the anthropology of illness (pp. 54–74). New Brunswick, NJ: Rutgers University Press. Good, B. J., Marchira, C. R., Subandi, M. A., Nanwani, S., & Good, M.-J. D. (2019). Early experiences of psychotic illness from a cross-cultural perspective: An anthropological view from research in Indonesia. In H. Li, D. Shapiro, & L. Seidman, (Eds), Handbook of attenuated psychosis syndrome in youth and young adults: Early identification and intervention across countries. (pp. 145–159) NY: Springer. Subandi, M. A. (2011). Family expressed emotion in a Javanese cultural context. Culture, Medicine, and Psychiatry, 35(3), 331–346. doi:10.1007/s11013-011-9220-4 Subandi, M. A. (2015). Bangkit: The Processes of recovery from first episode psychosis in Java. Culture, Medicine and Psychiatry, 39(4), 597–613. doi:10.1007/s11013-015-9427-x Good, B. J., Marchira, C. R., Subandi, M. A., Nanwani, S., & Good, M.-J. D. (2019). Early experiences of psychotic illness from a cross-cultural perspective: An anthropological view from research in Indonesia. In H. Li, D. Shapiro, & L. Seidman, (Eds), Handbook of attenuated psychosis syndrome in youth and young adults: Early identification and intervention across countries. (pp. 145–159) NY: Springer. Good, B. J., Marchira, C., Ul Hasanat, N., Utami, M. S. & Subandi, (2010). Is “chronicity” inevitable for psychotic illness? Studying heterogeneity in the course of schizophrenia in Yogyakarta, Indonesia. In L. Manderson & C. Smith-Morris (Eds), Chronic conditions, fluid states: chronicity and the anthropology of illness (pp. 54–74). New Brunswick, NJ: Rutgers University Press. Nanwani, S. (2018). Containing Madness: Care for the Homeless with Major Mental Illness in Yogyakarta, Indonesia (MMSc thesis for Program in Global Health Delivery), Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Good, B. J., Marchira, C. R., Subandi, M. A., Nanwani, S., & Good, M.-J. D. (2019). Early experiences of psychotic illness from a cross-cultural perspective: An anthropological view from research in Indonesia. In H. Li, D. Shapiro, & L. Seidman, (Eds), Handbook of attenuated psychosis syndrome in youth and young adults: Early identification and intervention across countries. (pp. 145–159) NY: Springer. Good, B. J., Marchira, C. R., Subandi, M. A., Nanwani, S., & Good, M.-J. D. (2019). Early experiences of psychotic illness from a cross-cultural perspective: An anthropological view from research in Indonesia. In H. Li, D. Shapiro, & L. Seidman, (Eds), Handbook of attenuated psychosis syndrome in youth and young adults: Early identification and intervention across countries. (pp. 145–159) NY: Springer. Guinness, E. A. (1992). Brief reactive psychosis and the major functional psychoses: Descriptive case studies in Africa. British Journal of Psychiatry, 160(S16), 24–41. doi:10.1192/S0007125000296773 Jilek, W. G., & Jilek-Aall, L. (1970). Transient psychoses in Africans. Psychiatria Clinica, 3(6), 337–364. Okasha, A., El Dawla, S., Khalil, A. H., & Saad, A. (1993). Presentation of acute psychosis in an Egyptian sample: A transcultural comparison. Comprehensive Psychiatry, 34(1), 4–9. doi:10.1016/0010-440X(93)90029-4 Rodger, J. & Steel, Z., (2016). Between Trauma and the Sacred. The Cultural Shaping of Remitting-Relapsing Psychosis in Post-Conflict Timor-Leste. NY: Springer. Singh, S. (2011). Acute and transient psychotic disorders. In N. Agrawal, J. Bolton, & R. Gaind (Eds), Current themes in psychiatry in theory and practice (pp. 77–98). London, UK: Palgrave Macmillan. Castagnini, A., & Berrios, G. E. (2011). The relationship of acute transient psychoses and schizophrenia. In M. Ritsner (Ed), Handbook of schizophrenia spectrum disorders, Vol.II (pp. 367–387). Dordrecht, Netherlands: Springer. Marneros, F. (2005). Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders? European Psychiatry, 20, 315–329. doi:10.1016/j.eurpsy.2005.02.001 Marneros, A., & Pillmann, F. (2004). Acute and Transient Psychoses. Cambridge, UK: Cambridge University Press. Pillman, F., & Marneros, A. (2003). Brief and acute psychoses: the development of concepts. History of Psychiatry, 14(54 Pt 2), 161–177. doi:10.1177/0957154X030142002 Wimmer, A. (2003). Psychogenic Psychoses. Adelaide, Australia: Adelaide Academic Press. Susser, E., & Wanderling, J. (1994). Epidemiology of Nonaffective Acute Remitting Psychosis vs. Schizophrenia. Archives of General Psychiatry, 51(4), 294–301. doi:10.1001/archpsyc.1994.03950040038005 Susser, E., Finnerty, M. T., & Sohler, N. (1996). Acute psychoses: A proposed diagnosis for ICD-11 and DSM-V. The Psychiatric Quarterly, 67(3), 165–176. doi:10.1007/BF02238949 Susser, E., Varma, V. K., Malhotra, S., Conover, S., & Amador, X. F. (1995). Delineation of acute and transient psychotic disorders in a developing country setting. British Journal of Psychiatry, 167(02), 216–219. doi:10.1192/bjp.167.2.216 Stevens, J. (1987). Brief psychoses: Do they contribute to the good prognosis and equal prevalence of schizophrenia in developing countries? The British Journal of Psychiatry, 151(03), 393–396. doi:10.1192/bjp.151.3.393 Kurihara, T., Kato, M., Reverger, R., & Tirta, I. G. R. (2006). Pathway to psychiatric care in Bali. Psychiatry and Clinical Neurosciences, 60(2), 204–210. doi:10.1111/j.1440-1819.2006.01487.x