Schizophrenia is an enduring mental condition that affects about 26 million people each year globally (1). The onset of schizophrenia can be from childhood through to adulthood. Schizophrenia intensely affects the lives of the patients and their families due to the high cost of its management (2). Mostly, schizophrenia is treated by the use of antipsychotics. These antipsychotics have their associated side effects which when not catered for, can compound the mental disease. However, nutrition has been found to significantly improve schizophrenic conditions with no side effects (3). Schizophrenia as a mental disorder is characterised by a breakdown of thought processes and by poor emotional responsiveness (4). Several maternal micronutrients have been related to an increased risk of schizophrenia, such as elevated homocysteine and iron, essential fatty acids, retinoids, and vitamin D deficiency (2). The protection and treatment of people with mental disorders are recognised by the United Nations as a fundamental human right (5). All affected individuals should be helped to live a life free from prejudice, discrimination, and hostility. They have the right to be protected from abuse and from behaviour, attitudes, and assumptions that lead to exclusion; and access health care and benefit from the best available treatment (6). As well as the potential human cost, the burden of schizophrenia and other mental health disorders is very high on healthcare resources and on society as they contribute to increased hospitalisation and emergency care, physical comorbidities and premature death, school absence, access to criminal justice system for violent act, unemployment, sickness absence, and lost productivity at work (5). The treatment of schizophrenia is therefore critical. Although antipsychotic medication has persisted as the optimal treatment and is effective in managing the positive symptoms, it is limited in terms of treating negative symptoms (7). In addition to the drawback of drug treatment, this type of therapy is based solely on symptomatology and dosage is often determined by a process of trial and error (8). In those who respond to antipsychotic medication, side effects can be distressing and often intolerable; these include involuntary movements such as tremor and rigidity, drug-induced Parkinson’s, Tardive dyskinesia, hyper-salivation, increased heart rate, metabolic syndrome and weight gain. Often the side effects themselves require further pharmacological treatment and/or result in treatment discontinuation, leading to subsequent relapse. Furthermore, approximately one-third of individuals with schizophrenia do not respond to antipsychotic medication, either alone or in conjunction with psychodynamic counselling and other pharmacotherapy (9). However, there is now increasing evidence that a number of physiological mechanisms such as oxidative stress, one-carbon metabolism, and atypical immune-mediated responses exist in individuals with schizophrenia, not solely dopaminergic pathophysiology as per the dopamine hypothesis. Furthermore, these differing pathophysiological manifestations may be ameliorated by nutritional treatment strategies (10). Diet and nutrition have a complex relationship with mental health and there is evidence that specific micronutrients may have an effect on mood — particularly depression — and also on the risk of developing and progress of dementia. It is important for community nurses who may come across people with mental health problems to think holistically about diet and how this is affected by mental illness, for example people may start to eat less when depressed, or when their memory is deteriorating, or if they have delusional beliefs which may affect what they choose to eat (11). Often, the foremost group of people who are contacted for the management of all mental diseases, which include schizophrenia, are psychiatric doctors and nurses. It is believed that mental health nurses possess the requisite knowledge to offer treatment for schizophrenia. However, with the increasing evidence of the critical role that nutrition plays in the treatment and management of schizophrenic patients, coming by research evidence concerning the knowledge that psychiatric nurses possess on the efficacy of nutrition in the management of the disease is rare within the Ghanaian context. It is against this phenomenon that this current study was targeted at the understanding that nurses have on the use of nutrition in the management of the disease.
The study was guided by the following research questions:
What is the knowledge of the nurses about the various management methods of schizophrenia?
What role does nutrition play in the management of schizophrenia?
What should be the dietary composition of persons suffering from schizophrenia?
Research Design
Descriptive cross-sectional survey research design was used. The study was solely quantitative as numerical data were gathered and analysed to give a description of the situation at hand. The use of the cross-sectional design for this study was informed by the researcher’s intentions to collect data from a quite larger sample within a relatively shorter period.
The study was conducted in the Psychiatric Hospital, Pantang. Psychiatric Hospital, Pantang is one of three psychiatric hospitals in Ghana, and it is the largest. The hospital is situated near a village called Pantang, about 1.6 kilometres off the Accra-Aburi road and 25 kilometres from Accra Central. It has 500 beds and patients are from all over Ghana and nearby countries. It is separated into 10 wards with 50 beds each. Pantang hospital is comprised of 28 departments including a mortuary, eye clinic, HIV counselling and testing, and family planning. There are 327 staff members which are made up of psychiatrists, occupational therapist, medical doctors, psychologist, and medical assistants. Cases mostly seen at the hospital are schizophrenia (42.9%).
Source: Google Maps (2019)
Population
The population of this study comprised Registered Mental Health Nurses in the Psychiatric Hospital, Pantang. The hospital has about 275 Registered Mental Health Nurses (RMNs). Therefore, these 275 mental health nurses constituted the population for the study.
The sample size for this study was determined by the use of the Krejcie and Morgan table of sample size determination (12). According to the table, working with a population of about 280 requires a sample size of 162. This figure is determined at a confidence interval of 95 percent and at an error of margin of 5 percent. To anticipate any unforeseen reduction in valid data, the sample size was increased to 170. Therefore, 170 RMNs formed the sample size of this study. The sampling technique that was used in selecting the sample size for the study was the systematic sampling technique. With the use of systematic sampling, all the RMNs in the hospital had equal chances of being selected as this technique is probabilistic in nature.
R = = = 1.61 ≈ 2
N = the population size, n = sample size, and R = sampling interval.
The data collection instrument used for the study was a questionnaire. The contents of the questionnaire were developed based on the research questions of this study. The items in the questionnaire were all closed-ended in nature. The questionnaire consisted of four sections. “Section A” sought to obtain the demographic features of the respondents. “Section B” focused on the knowledge of the nurses about the various management methods of schizophrenia. “Section C” sought information on the role nutrition plays in the management of schizophrenia. Lastly, the fourth section (Section D) was concerned with the dietary composition of food for persons suffering from schizophrenia. A specialist (the supervisor of the study) was consulted in order to do a face validity of the content of the questionnaire.
An introductory was sought from the Department of Science Education, University of Cape Coast, which was presented to the administrative authority of the Psychiatric Hospital, Pantang so as to be granted permission in collecting data. After permission was granted, the purpose of the study was communicated to the RMNs who were the subjects of the study. The RMNs were then required to consent to take part in the study. The questionnaires were then distributed to the participants. The participants were required to provide answers to the items in the questionnaire within a 10-minute maximum duration. The collection of data was done within five days, 1st - 5th August, 2019, between the hours of 9:00 to 11:00 am.
The data collected were skimmed to check for incompleteness in the provision of answers to the questions. For questionnaires that were not answered completely, such were excluded in the data analysis. After sorting out complete data, questionnaires that were fit for analysis, which was 166 in number, were assigned numerical codes for the purpose of identification and ability to trace mistakes in the data entry procedure. The Statistical Package for the Social Sciences (SPSS, version 22.0) software was used to process the data and subsequently to do the analyses. Descriptive statistics were used to analyse the data, and the results were displayed in frequencies with corresponding percentages.
Ethical issues that were considered included the protection of the privacy of the respondents as well as keeping their responses confidential enough and not to disclose their identities in any way. The respondents were made to feel like they usually did in their natural environment without any form of anxiety. In addition, the selection of the respondents was done without any form of bias from the researcher. Lastly, the data were neither manipulated to favour the expectations of the researcher nor to favour the image of the respondents. Data were collected and presented in an honest and professional manner. Confidentiality was also ensured.
Background Characteristics of Respondents
The demographic features of the respondents were enquired and the results are presented in Table 1. With the age of the respondents, the majority of them were aged from 30 to 39 years (54.8% ; n = 91). Also, most of the respondents, 56.6% (n = 94) were females. A lot of the RMNs who were the respondents for this study, 56.0% (n = 93) were married. Lastly, it was revealed in the demographic features that most of the respondents, 54.2% (n = 90) had practiced as RMNs for a period of 5-9 years.
Role of Nutrition in the Management of Schizophrenia
Table 3 contains the results in relation to the second research question. Most of the respondents, 40.4% (n = 67) with a mean of 3.27 ± 1.28, were in agreement with the statement that unhealthy dietary pattern is a high risk for psychosis. Again, with a mean of 4.07 ± .80, a lot of the RMNs (56.6%; n = 94)) were in agreement that diet prescription for schizophrenic patients can help reduce weight gain. Fifty percent (n = 83) of the respondents were uncertain that gluten-free diets can have a significant symptom resolution on schizophrenic patients. Moreover, 59.0% (n = 98) of the respondents were in agreement with the statement that vitamin D is connected with the brain development of foetuses—mean response score of 3.80 ± .79. In addition, it was agreed by 53.0% (n = 88) that niacin and other vitamin B nutrients deficiency can result in psychiatric disorders. Lastly, most of the respondents were in agreement with the statement that eating less nutritious food has no correlation with schizophrenia.
The third research question sought to inquire from the nurses the nutrients that they think should be part of the diets of schizophrenic patients. Responses from the RMNs were analysed and presented in table 4. With a mean of 3.96 ± .86, many of the respondents, 54.2% (n = 90), agreed that wheat products and fish cakes must be included in the diets of schizophrenic patients. Also, with a mean of 2.70 ± 1.10, 41.6% (n = 69) disagreed that schizophrenic patients do not need to take oily fish like sardines, salmon and mackerel. Again, with a mean of 2.39 ± 1.13, most of the respondents disagreed that foods containing vitamins A, C, and E are not good for schizophrenic patients.
The high side-effect burden of clozapine means it is reserved for people who have not responded to other treatments (13). Based on that item, most of the respondents in this current study could rightly indicate so as described by Solanki et al. This result indicates that most of the RMNs in the Psychiatric Hospital, Pantang are knowledgeable about when clozapine should be administered. Although those who agreed to the statement that treatment resistance is recommended to be detected within the first 6-12 months (13) were many, nearly that same number of respondents who agreed were also uncertain and others disagreed totally. The result portrays that the majority of the RMNs do not know the recommended period within which to detect resistance to treatment. Such an issue is alarming and needs to be critically attended to. In agreement (14), most of the RMNs were of the view that ECT in combination with antipsychotic medications may be considered for schizophrenic patients who have failed to respond to treatment with antipsychotic agents. Also, many of the respondents in this current study could rightly respond that CBT is usually conducted in a one-to-one therapeutic relationship and that PACT treatments usually take place in the homes, neighbourhood, and workplaces of schizophrenic patients, which are consistent with what Lehman et al. and Manu et al. articulated respectively (15; 16). However, a lot of the RMNs had their responses wrong in responding to the statement that PACT therapy is still needful for patients who are able to function in the community and stick fast to treatment. People who are responding to treatment effectively and are able to fit well into the community do not need PACT therapy (15). Therefore, it could be that the respondents did not really understand the statement in the questionnaire as it was very tricky to be answered. That notwithstanding, if the RMNs were really knowledgeable about PACT therapy, they still would have been able to get the response right. In conformity to the position, on the unhealthy dietary pattern as a risk factor for schizophrenia, this study has made a confirmatory finding as most of the RMNs responded in agreement to that statement (16). This finding may not genuinely mean that most of the RMNs in the Psychiatric Hospital, Pantang are knowledgeable about how unhealthy dietary patterns can lead to psychosis. Undoubtedly, it is a common knowledge now that healthy diets promote the well-being of individuals and this might have accounted for that finding. Psychoeducation regarding diet can stabilise weight, the finding of this study regarding diet prescription and reduction in weight gain are in alignment with each other (17). Moreover, the finding of this study about the impact of gluten-free diets on symptom resolution fits in what other studies describe about the same issue (10). Moreover, low prenatal vitamin D alters brain development, the responses of the RMNs in this study also claim the same (10). More so, the finding of this study agrees with findings of other studies which point out that niacin and other vitamin B deficiency can cause psychiatric disorders (18). Lastly, many of the respondents provided wrong responses to the statement that eating less nutritious food has no correlation with schizophrenia. This finding is in contradiction to with studies which all enunciated about the correlation between nutrition and schizophrenia (16; 17;18). Clearly, the knowledge of the RMNs about gluten-containing diets is not encouraging as many of them agreed that wheat products and fish cakes must be included in the diets of schizophrenic patients. To the contrary, other studies advises that such food items must be excluded, as much as possible, in the diets of persons with schizophrenia (19). This result can be interpreted to mean that the RMNs in the Psychiatric Hospital, Pantang know less about gluten-containing food substances. Again, as rightly advocated, the RMNs in this study could conformingly indicate that oily fish like sardines, salmon and mackerel which are rich in omega 3 fatty acids are necessary food components for schizophrenic patients (19). Inclusion of vitamins A, C, and E in the diets of schizophrenic patients are the major non-enzymatic antioxidants (20). The responses of the RMNs regarding the inclusion of vitamins A, C, and E containing substances in the diets of persons with schizophrenia are in conformity to what Das admonishes (20). Finding of this study and the assertion of Food for the Brain, all allude to recognising the importance of zinc-rich foods in the resolution of mental illness (21
The study findings indicate that the RMNs in the Psychiatric Hospital, Pantang have good knowledge about the methods of managing schizophrenia. Notwithstanding the good knowledge that they possess based on the responses that they gave, the knowledge of the RMNs about the recommended duration within which to detect resistance to treatment and when to conduct PACT therapy was very low. A possible reason for this anomaly is that the nurses are not in charge of diagnosing. Schizophrenic patients are diagnosed by psychiatrists. RMNs in the Psychiatric Hospital, Pantang are knowledgeable about the role of nutrition in the management of schizophrenia. What was unexpected, however, was the responses of the RMNs that eating less nutritious foods has no correlation with schizophrenia. This raises another concern that the responses given on all the other items under the second research question might be by guessing or perhaps they had difficulty in understanding the meaning of that item. Knowledge about gluten-containing food substances is not fully developed among the RMNs. It was therefore recommended that the mental health authority and the management of the Psychiatric Hospital, Pantang should consider organising in-service training for RMNs on the detection of treatment resistance in schizophrenic patients and such training can also include the conduction of PACT treatments. Again, nutrition specialists should be employed by the various mental hospitals to help in the rightful prescription of diets for schizophrenic patients. Such specialists will be able to point out both the exclusion and essential diets for the patients. Finally, Mental health training institutions must ensure that there are enough courses on nutrition to help increase the knowledge of future RMNs on the correlation between nutrition and schizophrenia.
Approval of the study was sought from the Department of Science Education of University of Cape Coast. The study was approved by the authorities of the Pantang Hospital. Verbal informed consent was sought form the study participants
Not applicable.
The dataset is will be available on request due to ethical reasons.
The authors declare that we have no competing interest.
Nil
We acknowledge all my mentors and various writers from whom references were made. We would like to thank all other individuals who provided the needed support for me to complete this study.