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Assessing Cognition in People with a Diagnosis of Schizophrenia in Resource-Limited Settings

by Dr Yohannes Gebreegziabhere, Lecturer at Debre Berhan University, Ethiopia

Studies have shown that a variety of cognitive remediation therapies can improve cognitive impairments in people with a diagnosis of schizophrenia. But how do we measure cognition in this population in a country like Ethiopia, where resources are limited and there are no validated assessment tools?

Photo of rural Ethiopian landscape

This was the main focus of my PhD research conducted at Addis Ababa University, Ethiopia. My aspiration was to develop a feasible and acceptable measure of cognition that could be used in Ethiopia by mental health professionals providing care for people who have a diagnosis of schizophrenia.

Measuring cognition is a necessary first step for treatment. By doing this, it is possible to track the illness course over time, assess the effectiveness of interventions, and identify rehabilitation programs that are suitable for each person.

However, developing a valid and acceptable measure of cognition in resource-limited settings presents many challenges because of a lack of clinicians, limited time to administer measures, and limited awareness of cognitive difficulties in people with a diagnosis of schizophrenia. Cultural adaptations from those traditionally developed in the higher income countries are also challenging. Translations won’t work, and language differences may make it complex to adapt verbal tests. For example, when translating memory tests using word lists, the words used must reflect items routinely available in peoples’ lives. After considering in detail the literature on cognitive measures and identifying potential assessment tools that would be more suitable for translation, I consulted extensively with local clinicians, service users, research experts and family members. These extensive consultations allowed me first to select and then adapt and refine several measures to evaluate cognition. These efforts culminated in the development and validation of the Ethiopian Cognitive Assessment Battery in Schizophrenia (ECAS), a battery of tests that assesses six aspects of cognition (verbal memory, working memory, verbal fluency, attention, processing speed, and executive function) and is available for clinicians and researchers in Ethiopia.

Of course, I wanted to disseminate my research, and with support from my supervisors, I completed and published six papers. I’ve added the paper references below in case anyone reading this blog would want to dig a bit deeper into my research.

My research was supported by the AMARI network, a Wellcome Trust initiative that aims to train mental health researchers in Africa. I feel very fortunate to have been part of this.

It was an incredible journey, and I hope completing the development and validation of ECAS along with my research output will improve the recognition and consideration of cognitive difficulties in people who experience schizophrenia in Ethiopia. However, more work is still needed in Africa and in low-income settings to improve the prospects of people with a schizophrenia diagnosis, so if you have interest, skills, or expertise to share, do get involved. There is much to give and much more to gain.


Detailed information can be found in the following articles.

1. Haile YG, Habatmu K, Derese A, Gouse H, Lawrie SM, Cella M, Alem A: Assessing cognition in people with severe mental disorders in low-and middle-income countries: a systematic review of assessment measures. Social psychiatry and psychiatric epidemiology 2022, 57(3):435-460.

2. Gebreegziabhere Y, Habatmu K, Cella M, Alem A: Development and evaluation of a cognitive battery for people with schizophrenia in Ethiopia. Schizophrenia Bulletin 2023:sbad178.

3. Gebreegziabhere Y, Habatmu K, Cella M, Alem A: Introducing an interview-based cognitive assessment tool for people with schizophrenia in Ethiopia. Psychiatry Research 2023, 328:115474.

4. Gebreegziabhere Y, Habatmu K, Cella M, Alem A: The Ethiopian Cognitive Assessment battery in Schizophrenia (ECAS): a validation study. Schizophrenia 2024, 10(1):42.

5. Gebreegziabhere Y, Habatmu K, Cella M, Alem A: Validaiton of the Amharic verison of Cognitive Assessment Interview (CAI-A) in People with Schizophrenia in Ethiopia. Under review 2024.

6. Gebreegziabhere Y, Habatmu K, Mihretu A, Cella M, Alem A: Cognitive impairment in people with schizophrenia: an umbrella review. European archives of psychiatry and clinical neuroscience 2022, 272(7):1139-1155.


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