The Lancet Commission on global mental health and sustainable development

Food insecurity and work impairment in people with severe mental disorders in a rural district of Ethiopia: a cross-sectional survey

PURPOSE

In this study, we aimed to identify factors associated with severe food insecurity and work impairment in people with severe mental disorders (SMD) in a rural African setting, with a view to identifying potential areas for intervention.

METHODS

A community-based, cross-sectional survey was conducted in Sodo district, south central Ethiopia. Key informant-identified people with possible SMD were referred for assessment by trained primary care workers and received confirmatory psychiatric diagnoses from psychiatric nurses using a standardized clinical interview. Food insecurity was measured using a locally validated measure, the Household Food Insecurity Access Scale (HFIAS). Work impairment was assessed using the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool. Potential moderator variables were specified a priori.

RESULTS

A total of 282 people with SMD participated in the study. The proportion of participants reporting severe food insecurity was 32.5% (n = 94), with 53.6% (n = 147) of participants reporting severe work impairment. In the multivariable model, severe food insecurity was associated with poor social support, experience of negative discrimination, higher disability and lower household annual income, but not with symptom severity or work impairment. Work impairment was associated significantly with symptom severity and disability.

CONCLUSION

Work impairment and food insecurity were associated with distinct explanatory factors: predominantly social factors associated with food insecurity and clinical factors associated with work productivity. Longitudinal and intervention studies are needed to evaluate the extent to which clinical interventions need to be augmented by social interventions to alleviate food insecurity in people with SMD.

Resolving the paradox of increased mental health expenditure and stable prevalence

A doubling of Australian expenditure on mental health services over two decades, inflation-adjusted, has reduced prevalence of neither psychological distress nor mental disorders. Low rates of help-seeking, and inadequate and inequitable delivery of effective care may explain this partially, but not fully. Focusing on depressive disorders, drawing initially on ideas from the work of philosopher and socio-cultural critic Ivan Illich, we use evidence-based medicine statistics and simulation modelling approaches to develop testable hypotheses as to how iatrogenic influences on the course of depression may help explain this seeming paradox. Combined psychological treatment and antidepressant medication may be available, and beneficial, for depressed people in socioeconomically advantaged areas. But more Australians with depression live in disadvantaged areas where antidepressant medication provision without formal psychotherapy is more typical; there also are urban/non-urban disparities. Depressed people often engage in self-help strategies consistent with psychological treatments, probably often with some benefit to these people. We propose then, if people are encouraged to rely heavily on antidepressant medication only, and if they consequently reduce spontaneous self-help activity, that the benefits of the antidepressant medication may be more than offset by reductions in beneficial effects as a consequence of reduced self-help activity. While in advantaged areas, more comprehensive service delivery may result in observed prevalence lower than it would be without services, in less well-serviced areas, observed prevalence may be higher than it would otherwise be. Overall, then, we see no change. If the hypotheses receive support from the proposed research, then implications for service prioritisation and delivery could include a case for wider application of recovery-oriented practice. Critically, it would strengthen the case for action to correct inequities in the delivery of psychological treatments for depression in Australia so that combined psychological therapy and antidepressant medication, accessible and administered within an empowering framework, should be a nationally implemented standard.

Perspectives on ICD-11 to understand and improve mental health diagnosis using expertise by experience (INCLUDE Study): an international qualitative study

Developed in collaboration with WHO Department of Mental Health and Substance Abuse, this study (conducted in India, the UK, and the USA) integrated feedback from mental health service users into the development of the chapter on mental, behavioural, and neurodevelopmental disorders for ICD-11. The ICD-11 will be used for health reporting from January, 2022. As a reporting standard and diagnostic classification system, ICD-11 will be highly influential by informing policy, clinical practice, and research that affect mental health service users. We report here the first study to systematically seek and collate service user perspectives on a major classification and diagnostic guideline. Focus groups were used to collect feedback on five diagnoses: depressive episode, generalised anxiety disorder, schizophrenia, bipolar type 1 disorder, and personality disorder. Participants were given the official draft diagnostic guidelines and a parallel lay translation. Data were then thematically analysed, forming the basis of co-produced recommendations for WHO, which included features that could be added or revised to better reflect lived experience and changes to language that was confusing or objectionable to service users. The findings indicated that an accessible lay language version of the ICD-11 could be beneficial for service users and their supporters.

Alcohol use disorders

Alcohol use disorders consist of disorders characterised by compulsive heavy alcohol use and loss of control over alcohol intake. Alcohol use disorders are some of the most prevalent mental disorders globally, especially in high-income and upper-middle-income countries; and are associated with high mortality and burden of disease, mainly due to medical consequences, such as liver cirrhosis or injury. Despite their high prevalence, alcohol use disorders are undertreated partly because of the high stigma associated with them, but also because of insufficient systematic screening in primary health care, although effective and cost-effective psychosocial and pharmacological interventions do exist. Primary health care should be responsible for most treatment, with routine screening for alcohol use, and the provision of a staggered treatment response, from brief advice to pharmacological treatment. Clinical interventions for these disorders should be embedded in a supportive environment, which can be bolstered by the creation of alcohol control policies aimed at reducing the overall level of consumption.

A Digital Platform Designed for Youth Mental Health Services to Deliver Personalized and Measurement-Based Care

Mental disorders that commonly emerge during adolescence and young adulthood are associated with substantial immediate burden and risks, as well as potentially imparting lifetime morbidity and premature mortality. While the development of health services that are youth focused and prioritize early intervention has been a critical step forward, an ongoing challenge is the heterogeneous nature of symptom profiles and illness trajectories. Consequently, it is often difficult to provide quality mental health care, at scale, that addresses the broad range of health, social, and functional needs of young people. Here, we describe a new digital platform designed to deliver personalized and measurement-based care. It provides health services and clinicians with the tools to directly address the multidimensional needs of young people. The term "personalized" describes the notion that the assessment of, and the sequence of interventions for, mental disorders are tailored to the young person-and their changing needs over time, while "measurement-based" describes the use of systematic and continuing assessment of a young person's outcomes over the entire course of clinical care. Together, these concepts support a framework for care that transcends a narrow focus on symptom reduction or risk reduction. Instead, it prioritizes a broader focus on enhancing social, health, and physical outcomes for young people and a commitment to tracking these outcomes throughout this key developmental period. Now, with twenty-first century technologies, it is possible to provide health services with the tools needed to deliver quality mental health care.

Design and Development of the "POD Adventures" Smartphone Game: A Blended Problem-Solving Intervention for Adolescent Mental Health in India

Introduction: Digital technology platforms offer unparalleled opportunities to reach vulnerable adolescents at scale and overcome many barriers that exist around conventional service provision. This paper describes the design and development of POD Adventures, a blended problem-solving game-based intervention for adolescents with or at risk of anxiety, depression and conduct difficulties in India. This intervention was developed as part of the PRemIum for ADolEscents (PRIDE) research programme, which aims to establish a suite of transdiagnostic psychological interventions organized around a stepped care system in Indian secondary schools. Methods and Materials: Intervention development followed a person-centered approach consisting of four iterative activities: (i) review of recent context-specific evidence on mental health needs and preferences for the target population of school-going Indian adolescents, including a multiple stakeholder analysis of school counseling priorities and pilot studies of a brief problem-solving intervention; (ii) new focus group discussions with N = 46 student participants and N = 8 service providers; (iii) co-design workshops with N = 22 student participants and N = 8 service providers; and (iv) user-testing with N = 50 student participants. Participants were aged 12-17 years and recruited from local schools in New Delhi and Goa, including a subgroup with self-identified mental health needs (N = 6). Results: Formative data from existing primary sources, new focus groups and co-design workshops supported a blended format for delivering a brief problem-solving intervention, with counselors supporting use of a game-based app on "offline" smartphones. User-testing with prototypes identified a need for simplification of language, use of concrete examples of concepts and practice elements to enhance engagement. There were also indications that participants most valued relatability and interactivity within real-world stories with judicious support from an in-app guide. The final prototype comprised a set of interactive and gamified vignettes and a structured set of problem-solving questions to consolidate and generalize learning while encouraging real-world application. Discussion: Findings shaped the design of POD Adventures and its delivery as an open-access blended intervention for secondary school students with a felt need for psychological support, consistent with an early intervention paradigm. A randomized controlled trial is planned to evaluate processes and impacts of POD Adventures when delivered for help-seeking students in low-resource school settings.

Prevalence and correlates of depression and anxiety symptoms among out-of-school adolescent girls and young women in Tanzania: A cross-sectional study

BACKGROUND

In sub-Saharan Africa, adolescent girls and young women (AGYW) who are out of school are at higher risk of depressive and anxiety disorders compared to their school attending peers. However, little is known about the prevalence and risk factors for these conditions among out-of-school AGYW. This study examines the prevalence of depression and anxiety and associated factors in a community sample of out-of-school AGYW in Tanzania.

METHODS

A cross-sectional analysis of baseline data from an on-going cluster randomized controlled trial in North-West Tanzania was conducted. A total of 3013 out-of-school AGYW aged 15 to 23 years from 30 clusters were included. Anxiety and depression were assessed using the Patient Health Questionnaire (PHQ-4), a tool comprising of PHQ-2 and Generalized Anxiety Disorders (GAD-2) screeners. Data were collected using Audio Computer-Assisted Self-Interview (ACASI). A random-effects logistic regression was fitted for binary outcomes and an ordinal logistic regression model with robust variance was used to adjust for clustering at the village level. Logistic regression and ordinal logistic regression were used to explore the associations between mental disorders symptoms and other factors.

RESULTS

The prevalence of depressive (PHQ-2 ≥ 3) and anxiety (GAD-2 ≥ 3) symptoms among out-of-school AGYW were 36% (95% CI 33.8%-37.3%) and 31% (95% CI 29.0%-32.3%) respectively. Further, using the PHQ-4 tool, 33% (95% CI 30.8%-34.2%) had mild, 20% (95% CI 18.3%-21.1%) moderate and 6% (95% CI 5.5%-7.2%) had severe symptoms of anxiety and depression. After adjusting for other covariates, two factors most strongly associated with having anxiety symptoms were violence experience from sexual partners (AOR = 1.63, 95% CI: 1.36-1.96) and HIV positive status (AOR = 1.54, 95% CI: 1.03-2.31). Likewise, living alone, with younger siblings or others (AOR = 2.51, 95% CI: 1.47-4.29) and violence experience from sexual partners (AOR = 1.90, 95% CI: 1.59-2.27) were strongly associated with depression symptoms. Having savings (AOR = 0.81, 95% CI: 0.70-0.95) and emotional support (AOR = 0.82, 95% CI: 0.67-0.99) were protective against depression and anxiety, respectively.

CONCLUSION

Depressive and anxiety symptoms are prevalent among out-of-school AGYW in Tanzania. The findings emphasize the need to strengthen preventive interventions and scale-up mental health disorder screening, referral for diagnosis and management.

Correlates of social support on report of probable common mental disorders in Zimbabwean informal caregivers of patients with stroke: a cross-sectional survey

OBJECTIVE

Stroke is a major global public health burden. Unfortunately, stroke invariably leads to functional limitations, consequently, most stroke survivors are hugely dependent on family members/informal caregivers in carrying out essential daily activities. The increased demands of caregiving negatively impact caregivers' mental health. Nevertheless, caregivers who receive an adequate amount of social support are likely to adjust better to the caregiving role. We sought to determine the impact of social support on the mental wellbeing of 71 caregivers of patients with stroke in Zimbabwe, a low-resourced country.

RESULTS

The mean caregiver age was 41.5 (SD 13.8) years. Patients had a mean age of 65.2 (SD 15.3) years with most being functionally dependent (93.2%). 45.1% of the caregivers showed excessive psychiatric morbidity. The mean Multidimensional Scale of Perceived Social Support (MSPSS) score was 44 (SD 9.4), denoting high levels of social support. Caregivers who received an adequate amount of social support were likely to report of lower psychiatric morbidity (Rho = - 0.285, p = 0.016). Furthermore, caregiver who were; poorer, were caring for more functionally-dependent patients, and did not receive additional assistance were likely to report of poor mental health functioning. There is therefore a strong need to implement context-specific caregivers wellness programs.

The religion variable in community health promotion and illness prevention

Religion is a source of beliefs and practices, which can in turn influence health behaviors. Therefore, religious communities represent potential public health partners to improve well-being across economic and ethnic diversity. This issue of the Journal of Prevention & Intervention in the Community presents six empirical studies with a breadth of methodologies, and a range of subjects. The associations of religion with cancer fatalism, prenatal substance abuse, bereavement, suicide prevention, clergy mental health and attitudes toward the Affordable Care Act are reported here. These research findings support the key importance of community. Like community, religion is complex. This issue's studies demonstrate the need to include ethnicity in analyses as well as the necessity to measure both religious belief and practice. Consistently, religious community participation predicted more positive outcomes than one's level of belief.

Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

BACKGROUND

There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).

AIMS

To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.

METHOD

Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.

RESULTS

Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.

CONCLUSIONS

Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.

DECLARATION OF INTEREST

None.

Health system strengthening for mental health in low- and middle-income countries: introduction to the Emerald programme

This paper gives an overview of the Emerald (Emerging mental health systems in low- and middle-income countries) programme and introduces the subsequent seven papers in this BJPsych Open thematic series. The aims of the Emerald research programme were to improve mental health outcomes in six low- and middle-income countries (LMICs), namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, by building capacity and by generating evidence to enhance health system strengthening in these six countries. The longer-term aim is to improve mental healthcare, and so contribute to a reduction in the large treatment gap that exists for mental disorders. This series includes papers describing the following components of the Emerald programme: (a) capacity building; (b) mental health financing; (c) integrated care (d) mental health information systems; and (e) knowledge transfer. We also include a cross-cutting paper with recommendations from the Emerald programme as a whole. The inclusion of clear mental-health-related targets and indicators within the United Nations Sustainable Development Goals now intensifies the need for strong evidence about both how to provide effective treatments, and how to deliver these treatments within robust health systems.

A Call for Preventing Suicide by Hanging from Ceiling Fans: An Interdisciplinary Research Agenda

Hanging is a common method of suicide in several countries. Even as global suicide rates decrease, there is no evidence of suicides by hanging declining. There is limited research by type of hanging, and only a few papers present suicide by hanging from ceiling fans. Our paper proposes a research agenda that will: specify the size of the problem of hanging by ceiling fan (Stage 1: Surveillance), use standard engineering product development processes to modify ceiling fans for reducing their lethal capacity (Stage 2: Design Testing and Redevelopment), and examine the resulting beta- and release-build fans for safety and potential to reduce suicide in community samples (Stage 3: Evaluation).

Languishing in the crossroad? A scoping review of intersectional inequalities in mental health

The concept of intersectionality has gradually been introduced to health inequality research, adding depth and breadth to the way inequalities in health are approached. We conducted a scoping review with the purpose to systematically map, describe and analyze the literature about intersectional inequalities in mental health. For eligibility, the study had to analyze and report inequality defined by combinations of socioeconomic position, gender, race/ethnicity, sexual orientation or religion. The mental health outcome had to be measured as self-reported symptoms assessed through validated scales, or disorders assessed through diagnostic interviews. The search strategy was applied in two databases and the screening process yielded 20 studies. The interaction of intersectional positions showed no consistent patterns in mental health across studies, but both synergistic and antagonistic effects were observed. In most studies an absolute measure of inequality was used and few studies analyzed factors potentially explaining the intersectional inequalities. Taken together, the findings of this review highlight the value of assessing intersectional inequalities across population groups for priority setting and action on mental health inequalities.

Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders

Background

The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community.

Methods

Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations.

Results

Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital.

Conclusions

Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence.

Nutrition, Hygiene and Stimulation Education for Impoverished Mothers in Rural Uganda: Effect on Maternal Depression Symptoms and Their Associations to Child Development Outcomes

Optimal nutrition improves child development, and impaired development is associated with maternal depression symptoms, in particular in low resource settings. In this follow-up of an open cluster-randomized education trial, we examined its effects among mothers in rural Uganda on their depression symptoms and the association of these symptoms to child development. The education comprised complementary feeding, stimulation, and hygiene. We assessed 77 intervention mothers and 78 controls using Beck Depression Inventory-II (BDI-II) and Center for Epidemiologic Studies Depression Scale (CES-D) scores. Child development was assessed with Bayley Scales of Infant and Toddler Development-III (BSID-III) composite scores for cognitive, language and motor development. Compared to controls, the intervention reduced depression symptoms’ scores with mean (95% CI) differences: −8.26 (−11.49 to −1.13, p = 0.0001) and −6.54; (−8.69 to −2.99, p = 0.004) for BDI II at 20–24 and 36 months, respectively. Similar results were obtained with CES-D. There was a negative association of BDI-II scores and BSID-III cognitive and language scores at 20–24 (p = 0.01 and 0.008, respectively) and 36 months (p = 0.017 and 0.001, respectively). CES-D associations with BSID-III cognitive and language scores showed similar trends. BSID-III motor scores were associated with depression scores at 36 months for both BDI-II and CES-D (p = 0.043 and 0.028, respectively). In conclusion, the group education was associated with reduced maternal depression scores. Moreover, the depression scores were inversely associated with child cognitive and language development outcomes.

The economic burden of adult attention deficit hyperactivity disorder: A sibling comparison cost analysis

AIM

Attention Deficit Hyperactivity Disorder (ADHD) is a lifespan disorder associated with considerable economic cost. While the economic burden of ADHD has been widely estimated, there is considerable variation in reported costs between studies, which typically focus on health outcomes only, lack adequate control and fail to correct for the influence of genetic and shared environmental factors. The aim of this study is to overcome these limitations to reach a fuller understanding of the economic burden of ADHD.

METHOD

Using the Danish National Registers 5269 adults with a diagnosis of ADHD in adulthood who had not received a diagnosis in childhood were identified. Excluding cases with missing data, comorbid diagnoses, and cases without a same sex sibling free of any diagnosed psychiatric diagnoses, a final cohort was formed consisting of 460 sibling dyads. Using a cross-sectional method focusing on the year 2010, cost differences between each adult with ADHD and their sibling were calculated from data retrieved from health, education, crime, employment and social care registers.

RESULTS

Adults with ADHD had considerably lower disposable income and paid less tax than their siblings. They also received more state benefits, had higher costs for health, social care, and crime than their siblings. The total average costs difference for the year 2010 was 20,134 euros more than their sibling for each adult with ADHD.

CONCLUSION

ADHD is associated with considerable costs which are borne by both the individual and the state and underlines the need to consider the wider economic impact of ADHD beyond income and healthcare utilisation costs.

Challenges for psychosocial rehabilitation services in the Lisbon Metropolitan Area: A qualitative approach

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community-based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psychosocial services within the country's mental health reform process and characterises the profile of service users in socio-occupational units (SOUs) of the LMA. Semi-structured interviews were performed with all SOUs' managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analysis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service delivery. Community-based mental health organisations are an important actor for service provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life-course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low- and middle-income countries passing through similar reforms.

Service user involvement in global mental health: what have we learned from recent research in low and middle-income countries?

PURPOSE OF REVIEW

The Lancet Commission on global mental health and sustainable development claims the field of global mental health is undergoing a 'transformational shift' toward an ethic of 'nothing about us without us'. Yet a systematic review published in 2016 identified few examples of meaningful participation by service users in mental health systems strengthening in low and middle-income countries (LMICs). To investigate whether this is still the case, we conducted a rapid review of primary research published between June 2017 and December 2018.

RECENT FINDINGS

We identified 10 studies reporting on user involvement in LMICs, including three in mental health policy and planning, three in mental health services or capacity-building and three in treatment decision-making. An additional study was identified as having involved users in data collection, although this was unclear from the original text. Included studies were mostly qualitative and conducted as part of a situation analysis, pilot study, or other formative research. Few reported the results of efforts to improve involvement, suggesting this shift remains at an early stage.

SUMMARY

Although the number of studies published on user involvement is rapidly increasing, the potentially 'transformational' effects of this shift in global mental health are not yet being felt by most users in LMICs.

What are young Indians saying about mental health? A content analysis of blogs on the It's Ok To Talk website

OBJECTIVES

This study used thematic content analysis to examine submissions to a youth mental health website, www.itsoktotalk.in, in India.

SETTING

We considered submissions made to the It's OK to Talk web platform during the first year of its operation (April 2017-March 2018), focusing specifically on website users based in India.

PARTICIPANTS

We analysed 37 submissions by 33 authors aged 19-31 years (mean age 22 years) from seven Indian cities (New Delhi, Lucknow, Bengaluru, Mumbai, Pune, Hyderabad and Haryana). Eligible submissions were English-language first-person accounts of self-identified mental health problems, submitted in any media format for online publication by authors aged 18 years or older and who were based in India. Eight study participants were additionally involved in a focus group who contributed to the coding process and preparation of the final manuscript.

RESULTS

Four themes were identified: (1) living through difficulties; (2) mental health in context; (3) managing one's mental health and (4) breaking stigma and sharing hope. Overall, the participants expressed significant feelings of distress and hopelessness as a result of their mental health problems; many described the context of their difficulties as resulting from personal histories or wider societal factors; a general lack of understanding about mental health; and widespread stigma and other negative attitudes. Most participants expressed a desire to overcome mental health prejudice and discrimination.

CONCLUSIONS

Personal narratives offer a window into young people's self-identified priorities and challenges related to mental health problems and recovery. Such insights can inform antistigma initiatives and other public awareness activities around youth mental health.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care

BACKGROUND

Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe.

MAIN TEXT

The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network.

CONCLUSIONS

Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Social inclusion and exclusion of people with mental illness in Timor-Leste: a qualitative investigation with multiple stakeholders

BACKGROUND

Social inclusion is a human right for all people, including people with mental illness. It is also an important part of recovery from mental illness. In Timor-Leste, no research has investigated the social experiences of people with mental illness and their families. To fill this knowledge gap and inform ongoing mental health system strengthening, we investigated the experiences of social inclusion and exclusion of people with mental illness and their families in Timor-Leste.

METHODS

Eighty-five participants from the following stakeholder groups across multiple locations in Timor-Leste were interviewed: (1) people with mental illness and their families; (2) mental health and social service providers; (3) government decision makers; (4) civil society members; and (5) other community members. Framework analysis was used to analyse interview transcripts.

RESULTS

People with mental illness in Timor-Leste were found to face widespread, multi-faceted sociocultural, economic and political exclusion. People with mental illness were stigmatised as a consequence of beliefs that they were dangerous and lacked capacity, and experienced instances of bullying, physical and sexual violence, and confinement. Several barriers to formal employment, educational, social protection and legal systems were identified. Experiences of social inclusion for people with mental illness were also described at family and community levels. People with mental illness were included through family and community structures that promoted unity and acceptance. They also had opportunities to participate in activities surrounding family life and livelihoods that contributed to intergenerational well-being. Some, but not all, Timorese people with mental illness benefited from disability-inclusive programming and policies, including the disability pension, training programs and peer support.

CONCLUSIONS

These findings highlight the need to combat social exclusion of people with mental illness and their families by harnessing local Timorese sociocultural strengths. Such an approach could centre around people with mental illness and their families to: increase population mental health awareness; bolster rights-based and culturally-grounded mental health services; and promote inclusive and accessible services and systems across sectors.

Predictors of quality of life among community psychiatric patients in a peri-urban district of Gauteng Province, South Africa

BACKGROUND

Few studies on quality of life (QoL) among people with mental illness have been conducted in South Africa, and none in community dwelling individuals. However, a greater understanding of subjective QoL may inform community-based medical, psychotherapeutic, or social interventions. This study examined the QoL, clinical and sociodemographic characteristics of psychiatric patients attending community mental health clinics in the Gauteng Province of South Africa.

METHODS

A cross sectional interview-based study was conducted with 121 adult patients attending community psychiatric clinics. To reduce the impact of acute psychiatric symptoms on subjective QoL, only clinically stable patients were included. Sociodemographic details and clinical characteristics were recorded. Subjective QoL was assessed using the World Health Organization QOL-Bref scale (WHOQOL-Bref), and severity of psychiatric illness measured with the Brief Psychiatric Rating Scale, expanded version 4.0 (BPRS-E).

RESULTS

Just over half of the sample rated their overall QoL as good or very good. Residual psychiatric symptomatology was the strongest predictor of a poor QoL in all four domains of the WHOQOL-Bref. The most severe BPRS scores were for the symptoms of depression, anxiety and somatic concern. Perceived social support significantly predicted a better QoL in the psychological, social relationships and environmental domains.

CONCLUSION

This study highlights the negative impact of residual psychiatric symptoms on subjective QoL and the importance of social support in enhancing QoL.

Nationwide analysis of medical utilization in people with severe mental illness receiving home care case management

AIM

This nationwide study investigated the change in medical utilization of psychiatric home care case management (CM).

METHODS

This nationwide study enrolled patients receiving CM (N = 10,274) from January 1, 1999 to December 31, 2010, from Taiwan's National Health Insurance Research Database. Through a 2-year mirror-image comparison weighted by the contributed person-time for each subject, we evaluated changes in medical utilization. Furthermore, a case-crossover analysis was used to verify the independent effect of CM in changing medical utilization by adjusting the time-variant variables between the pre-2-year (within 2 years before receiving CM) and post-2-year (within years after receiving CM) periods. The same methodology was applied for the subsequent 2-year comparison to assess the maintenance effect.

RESULTS

Of the 10,274 patients receiving CM, 69.7% had schizophrenia. The results showed a chronological trend for the intervention of CM. The adjusted mirror-image analysis revealed a significant decrement of psychiatric and involuntary admissions after the intervention, and the utilization shifted toward psychiatric outpatient service. The case-crossover analysis with the adjustment of time-variant covariates confirmed the independent effect of CM on the changes of medical utilization. The comparable effect persisted after the next 2 years of intervention. However, CM showed no impact on lowering the admission rate for comorbid physical illnesses after the intervention.

CONCLUSIONS

The CM model can effectively reduce psychiatric hospitalization and involuntary admission frequency but has no effect on comorbid physical illnesses. Care models aimed at ameliorating physical problems in such patients are needed.

The Second Wave of Public Policy Advocacy for Eating Disorders: Charting the Course to Maximize Population Impact

Over the past decade, a first wave of US public policy advocacy for eating disorders made substantial progress, with passage of the federal 21st Century Cures Act in 2016 as its crowning achievement. However, the US response to eating disorders continues to fall short in several ways. On the cusp of a second wave of policy advocacy, efforts must be broadened to target structural determinants of illness and inequities to maximize clinical impact and diminish suffering. Mental health clinicians, patients, and their families will be essential players in public policy advocacy efforts in this regard.

Community, facility and individual level impact of integrating mental health screening and treatment into the primary healthcare system in Sehore district, Madhya Pradesh, India

Introduction

Programme for Improving Mental Health Care (PRIME) designed a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India. The objective of this paper is to describe the findings of the district-level impact evaluation of the MHCP.

Methods

Repeat community-based CS were conducted to measure change in population-level contact coverage for depression and alcohol use disorders (AUD), repeat FDS were conducted to assess change in detection and initiation of treatment for depression and AUD, and the effect of treatment on patient outcomes was assessed using disorder-specific prospective cohort studies.

Results

PRIME MHCP did not have any impact on contact coverage/treatment seeking for depression (14.8% at the baseline and 10.5% at the follow-up) and AUD (7.7% at the baseline and 7.3% at the follow-up) and had a small impact on detection and initiation of treatment for depression and AUD (9.7% for depression and 17.8% for AUD compared with 0% for both at the baseline) in the health facilities. Patients with depression who received care as part of the MHCP had higher rates of response (52.2% in the treatment group vs 26.9% in the comparison/usual care group), early remission (70.2% in the treatment group vs 44.8% in the comparison/usual care group) and recovery (56.1% in the treatment group vs 28.5% in the comparison/usual care group), but there was no impact of treatment on their functioning.

Conclusions

While dedicated human resources (eg, Case Managers) and dedicated space for mental health clinics (eg, Mann-Kaksha) strengthen the 'formal' healthcare platform, without substantial additional investments in staff, such as Community Health Workers/Accredited Social Health Activists to improve community level processes and provision of community-based continuing care to patients, we are unlikely to see major changes in coverage or clinical outcomes.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Integrating a brief mental health intervention into primary care services for patients with HIV and diabetes in South Africa: study protocol for a trial-based economic evaluation

INTRODUCTION

Depression and alcohol use disorders are international public health priorities for which there is a substantial treatment gap. Brief mental health interventions delivered by lay health workers in primary care services may reduce this gap. There is limited economic evidence assessing the cost-effectiveness of such interventions in low-income and middle-income countries. This paper describes the proposed economic evaluation of a health systems intervention testing the effectiveness, cost-effectiveness and cost-utility of two task-sharing approaches to integrating services for common mental disorders with HIV and diabetes primary care services.

METHODS AND ANALYSIS

This evaluation will be conducted as part of a three-armed cluster randomised controlled trial of clinical effectiveness. Trial clinical outcome measures will include primary outcomes for risk of depression and alcohol use, and secondary outcomes for risk of chronic disease (HIV and diabetes) treatment failure. The cost-effectiveness analysis will evaluate cost per unit change in Alcohol Use Disorder Identification Test and Centre for Epidemiological Studies scale on Depression scores as well as cost per unit change in HIV RNA viral load and haemoglobin A1c, producing results of provider and patient cost per patient year for each study arm and chronic disease. The cost utility analyses will provide results of cost per quality-adjusted life year gained. Additional analyses relevant for implementation including budget impact analyses will be conducted to inform the development of a business case for scaling up the country's investment in mental health services.

ETHICS AND DISSEMINATION

The Western Cape Department of Health (WCDoH) (WC2016_RP6_9), the South African Medical Research Council (EC 004-2/2015), the University of Cape Town (089/2015) and Oxford University (OxTREC 2-17) provided ethical approval for this study. Results dissemination will include policy briefs, social media, peer-reviewed papers, a policy dialogue workshop and press briefings.

TRIAL REGISTRATION NUMBER

PACTR201610001825405.

Mental health of people detained within the justice system in Africa: systematic review and meta-analysis

Worldwide, people with mental disorders are detained within the justice system at higher rates than the general population and often suffer human rights abuses. This review sought to understand the state of knowledge on the mental health of people detained in the justice system in Africa, including epidemiology, conditions of detention, and interventions. We included all primary research studies examining mental disorders or mental health policy related to detention within the justice system in Africa. 80 met inclusion criteria. 67% were prevalence studies and meta-analysis of these studies revealed pooled prevalence as follows: substance use 38% (95% CI 26-50%), mood disorders 22% (95% CI 16-28%), and psychotic disorders 33% (95% CI 28-37%). There were only three studies of interventions. Studies examined prisons (46%), forensic hospital settings (37%), youth institutions (13%), or the health system (4%). In 36% of studies, the majority of participants had not been convicted of a crime. Given the high heterogeneity in subpopulations identified in this review, future research should examine context and population-specific interventions for people with mental disorders.

The impact of urbanization on mental health service provision: a Brazil, Russia, India, China, South Africa and Africa focus

PURPOSE OF REVIEW

Asia and Africa are experiencing rapid urbanization and rural growth. This review focuses on the impact of urbanization on preventive and treatment mental health service provision with attention to the Brazil, Russia, India, China, and South Africa economic bloc and sub-Saharan Africa.

RECENT FINDINGS

A search of the PubMed, Academic Search Ultimate, and Global Health databases, and use of Google Scholar yielded relevant health, environmental, and urban planning research articles from sub-Saharan Africa and Brazil, India, China, and South Africa. Preventive services are ineffective in addressing violence exposure, substance use, poor quality housing, and spatial segregation, with differing trajectories in the various countries. Similarly, the impact of urbanization on social capital and green infrastructure is variable. Although Brazil appears to have a well-developed mental health system, it is unable to meet the care demand. Integrated country-wide and district-based analyses in China indicate planning is underway.

SUMMARY

In general, existing mental and general health services in low and middle-income countries are grossly inadequate in terms of prevention, coverage, and quality to withstand population transitions lying ahead. People with mental disability, as a vulnerable and stigmatized subpopulation, are at high risk of neglect as urbanization progresses, particularly in India and sub-Saharan Africa.

Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap

PURPOSE OF REVIEW

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing-engaging non-specialist providers-to deliver mental health care.

RECENT FINDINGS

There is strong evidence both for the effectiveness of task sharing as a means of delivering care for a range of conditions across settings and for the effectiveness of non-specialist providers and health workers in delivering elements of culturally adapted psychosocial and psychological interventions for common and severe mental disorders. Key approaches to facilitate task sharing of care include balanced care, collaborative care, sustained training and supervision, use of trans-diagnostic interventions based on a dimensional approach to wellness and illness, and the use of emerging digital technologies. Non-specialist providers and health workers are well positioned to deliver evidence-based interventions for mental disorders, and a variety of delivery approaches can support, facilitate, and sustain this innovation. These approaches should be used, and evaluated, to increase access to mental health services.

Examining the mental health outcomes of peer-led school-based interventions on young people aged between 4 and 18 years old: a systematic review protocol

BACKGROUND

Recent estimates suggest that one in ten young people worldwide experiences a diagnosable mental health disorder, with many more suffering subsyndromal levels of psychological distress. As young people spend much of their time in schools, the role of educational settings in the delivery of mental health provision is increasingly recognised. Advances in neurodevelopmental research have highlighted the important and complex role of peer influence on adolescent behaviours, suggesting peer-led support schemes have high potential utility. Schools worldwide have implemented peer-led interventions with mixed results, but the global evidence base on their effectiveness remains limited. This systematic review aims to examine the evidence base of the outcomes of school-based peer-led interventions on the mental health of young people aged 4-18.

METHODS

Eligible studies will be randomised controlled trials and observational studies that report on the mental health outcomes of a peer-led school-based intervention. Eligible participants will be aged 4-18 and will be current students of the intervention school. Individual- and group-based interventions will be included. The following 11 databases will be screened based upon their reach in healthcare and education: PsycINFO, MEDLINE, EMBASE, CINAHL, CENTRAL, BEI, Scopus, Web of Science, ERIC, SSCI and Social Care Online. There will be no restriction placed on publication period, original language or country of publication. Papers will be systematically screened for eligibility by two review authors. Data will be presented as a descriptive report. A meta-analysis will be carried out if a subset of studies allows, given the anticipated high levels of heterogeneity.

DISCUSSION

This systematic review will be the first to synthesise the global evidence on the mental health outcomes of peer-led interventions for children and adolescents in a school setting. It will analyse the available data in order to understand the role of these interventions in schools, inform future developers of peer support programmes and identify gaps in current research. This review will be of value to policy makers, health and education services, researchers and those involved in delivering peer support initiatives.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116243.

Darwin's Other Dilemmas and the Theoretical Roots of Emotional Connection

Modern scientific theories of emotional behavior, almost without exception, trace their origin to Charles Darwin, and his publications On the Origin of Species (1859) and The Expression of the Emotions in Man and Animals (1872). The most famous dilemma Darwin acknowledged as a challenge to his theory of evolution through natural selection was the incomplete Sub-Cambrian fossil record. However, Darwin struggled with two other rarely referenced theoretical and scientific dilemmas that confounded his theories about emotional behavior. These included (1) the origin of social instincts (e.g., altruism, empathy, reciprocity and cooperation) and the reasons for their conservation in evolution and (2) the peripheral control of heart rate vis-à-vis emotional behavior outside of consciousness. Darwin acknowledged that social instincts are critical to the survival of some species, but had difficulty aligning them with his theory of natural selection in humans. Darwin eventually proposed that heart rate and emotions are controlled via one's intellect and cortical mechanisms, and that instinctive behavior is genetically programmed and inherited. Despite ongoing efforts, these two theoretical dilemmas are debated to this day. Simple testable hypotheses have yet to emerge for the biological mechanisms underlying instinctive behavior or the way heart rate is controlled in infants. In this paper, we review attempts to resolve these issues over the past 160 years. We posit that research and theories that supported Darwin's individualistic brain-centric and genetic model have become an "orthodox" Western view of emotional behavior, one that produced the prevailing behavioral construct of attachment as developed by John Bowlby. We trace research and theories that challenged this orthodoxy at various times, and show how these challenges were repeatedly overlooked, rejected, or misinterpreted. We review two new testable theories, emotional connection theory and calming cycle theory, which we argue resolve the two dilemmas We show emerging scientific evidence from physiology and a wide variety of other fields, as well from clinical trials among prematurely born infants, that supports the two theories. Clinical implications of the new theories and possible new ways to assess risk and intervene in emotional, behavioral and developmental disorders are discussed.

A partnership for transforming mental health globally

The large and increasing burden of mental and substance use disorders, its association with social disadvantage and decreased economic output, and the substantial treatment gaps across country-income levels, are propelling mental health into the global spotlight. The inclusion of targets related to mental health and wellbeing in the UN's Sustainable Development Goals, as well as several national and global initiatives that formed during the past 5 years, signal an increasing momentum toward providing appropriate financing for global mental health. Drawing on the organisational and financial architecture of two successful global health scale-up efforts (the fight against HIV/AIDS and the improvement of maternal and child health) and the organisational models that have emerged to finance these and other global health initiatives, we propose a multi-sectoral and multi-organisational Partnership for Global Mental Health to serve two main functions. First is the mobilisation of funds, including raising, pooling, disbursing, and allocating. Second is stewardship, including supporting countries to use funds effectively, evaluate results, and hold stakeholders accountable. Such a partnership would necessarily involve stakeholders from the mental health field, civil society, donors, development agencies, and country-level stakeholders, organised into hubs responsible for financing, scale-up, and accountability.

Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia

At the heart of this paper is an exploration of artistic co-creativity involving people with dementia and their partners. Co-creativity promotes a relational approach to creativity which nurtures inclusion and participation. This paper investigates how co-creativity can affect well-being from the perspectives of people with dementia and their carers; and explores how well-being and agency might be usefully reconsidered. The article draws on findings from a small-scale study ‘With All’ that focused on music and dance as non-verbal and therefore inclusive artforms. A range of disciplinary perspectives, from psychology, philosophy and social sciences, inform the study. The research used an intrinsic case-study methodology and within this a mixed-methods approach was adopted. This included dialogic interviews, video data analysis and the Canterbury Well-being Scale (CWS). Thematic analysis of the interviews and video data revealed three key themes: autonomy, connections, and art as an enabler. These themes captured the experiences of the participants and facilitated a more nuanced understanding of wellbeing and agency in the context of living with dementia. The analysis of the CWS indicated some improvements in well-being. Following this analysis using multiple data sources, the paper argues that well-being and agency are best understood as relational, and ongoing, rather than completed states. Further both wellbeing and agency contain their opposites (ill-being and passivity). This innovative exploration highlighted the importance of co-creative collaboration as a method that was considered valuable by participants, and that therefore should be further considered in future research with people living with dementia.

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Co-creativity is an inclusive method.

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Co-creativity is valued by people with dementia

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Agency and well-being are linked.

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Agency and well-being are relational.

Where there is no evidence: implementing family interventions from recommendations in the NICE guideline 11 on challenging behaviour in a South African health service for adults with intellectual disability

BACKGROUND

Low- and middle-income countries often lack the fiscal, infrastructural and human resources to conduct evidence-based research; similar constraints may also hinder the application of good clinical practice guidelines based on research findings from high-income countries. While the context of health organizations is increasingly recognized as an important consideration when such guidelines are implemented, there is a paucity of studies that have considered local contexts of resource-scarcity against recommended clinical guidelines.

METHODS

This paper sets out to explore the implementation of the NICE Guideline 11 on family interventions when working with persons with intellectual disability and challenging behavior by a group of psychologists employed in a government health facility in Cape Town, South Africa.

RESULTS

In the absence of evidence-based South African research, we argue that aspects of the guidelines, in particular those that informed our ethos and conceptual thinking, could be applied by clinical psychologists in a meaningful manner notwithstanding the relative scarcity of resources.

CONCLUSION

We have argued that where guidelines such as the NICE Guidelines do not apply contextually throughout, it remains important to retain the principles behind these guidelines in local contexts. Limitations of this study exist in that the data were drawn only from the clinical experience of authors. Some of the implications for future research in resource-constrained contexts such as ours are discussed. Smaller descriptive, qualitative studies are necessary to explore the contextual limitations and resource strengths that exist in low- and middle-income settings, and these studies should be more systematic than drawing only on the clinical experience of authors, as has been done in this study.