Early psychosis in Indonesia: reflections on illness and treatment

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.

Keywords:

• First episode psychosis
• Indonesia
• early intervention
• cultural phenomenology
• care-seeking
• acute onset psychosis

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 (2006); Good, Good and Grayman (2010); Good, Grayman, and Good (2016); Idaiani (2015); Maramis (2006); Marthoenis, Yessi, Aichberger, and Schouler-Ocak (2016); and Prasetiyawan, Maramis, and Keliat (2006).

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, 2008).

4 For overviews of the field, see Fusar-Poli et al. (2013); Li, Shapiro, and Seidman (2019); and Woodberry, Shapiro, Bryant, and Seidman (2016).

5 These were developed as part of our initial and on-going ethnographic research, our Jogyakarta Longitudinal Study project, and our IPSOS research. Case studies have been published in Good and Subandi (2004); Good et al. (2007); Good, Marchira, et al. (2010); Good et al. (2019) and Subandi (2011, 2015).

6 See Good et al. (2019) and Good, Marchira, et al. (2010) 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, 2018) and in Good et al. (2019).

8 This case was developed as part of the IPSOS Yogyakarta study, and is described in more detail in Good et al. (2019).

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, 1992; Jilek & Jilek-Aall, 1970; Okasha, El Dawla, Khalil, & Saad, 1993; Rodger & Steel, 2016; Singh, 2011; 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, 2011; Marneros, 2005; Marneros & Pillmann, 2004; Pillmann & Marneros, 2003; Wimmer, 2003). 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, 1994; Susser, Finnerty, & Sohler, 1996; Susser et al., 1995). Stevens (1987) 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 (2006) 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.