Reassessing the Mental Health Treatment Gap: What Happens if We Include the Impact of Traditional Healing on Mental Illness?

Factors influencing integration of mental health screening and treatment at HIV clinic settings in Cameroon: a qualitative study of health providers' perspectives

BACKGROUND

Mental disorders are common among people with HIV (PWH) and are associated with poor HIV outcomes. Despite high unmet mental health needs among PWH, use of evidence-based mental health screening and treatment protocols remains limited at HIV treatment facilities across low-resource settings. Integrating mental health services into HIV care can reduce this gap. This study's objective was to explore factors that influence integration of mental health screening and treatment into HIV clinics in Cameroon.

METHODS

We analyzed 14 in-depth interviews with clinic staff supporting PWH at three urban HIV treatment clinics in Cameroon. Interviews focused on current processes, barriers and facilitators, and types of support needed to integrate mental health care into HIV care. Interviews were recorded and transcribed. French transcripts were translated into English. We used thematic analysis to identify factors that influence integration of mental health screening and treatment into HIV care in these settings. Ethical review boards in the United States and Cameroon approved this study.

RESULTS

Respondents discussed a lack of standardized mental health screening processes in HIV treatment facilities and generally felt ill-equipped to conduct mental health screening. Low community awareness about mental disorders, mental health-related stigma, limited physical space, and high clinic volume affected providers' ability to screen clients for mental disorders. Providers indicated that better coordination and communication were needed to support client referral to mental health care. Despite these barriers, providers were motivated to screen clients for mental disorders and believed that mental health service provision could improve quality of HIV care and treatment outcomes. All providers interviewed said they would feel more confident screening for mental disorders with additional training and resources. Providers recommended community sensitization, training or hiring additional staff, improved coordination to manage referrals, and leadership buy-in at multiple levels of the health system to support sustainable integration of mental health screening and treatment into HIV clinics in Cameroon.

CONCLUSIONS

Providers reported enthusiasm to integrate mental health services into HIV care but need more support and training to do so in an effective and sustainable manner.

A correlational and cross-sectional study on the relationship between internalized stigma and religious coping in patients with schizophrenia

Self stigmatization, which occurs as a result of internalization of public stigma in severe mental illnesses, is a factor that impairs the mental well-being of individuals and their compliance with treatment. Data on exactly which factors are associated with internalized stigma are still insufficient. Our aim in this clinical study is to investigate the relationship between internalized stigma and religious coping in patients with schizophrenia. Sociodemographic Data Form, Religious Coping Scale, internalized stigma of mental illness (ISMI) Scale were applied to 147 schizophrenic patients who were followed up by the community mental health center and met the inclusion criteria. The results were analyzed with IBM SPSS 22 package program. Descriptive statistics, Mann-Whitney U test, Pearson Chi-Square, Fisher Exact test, Spearman correlation analysis and multiple linear regression analysis were applied. There was a negative correlation between positive and negative religious coping in patients with schizophrenia (r: -0.467, P < .001); a positive correlation between negative religious coping and social withdrawal (r: 0.711, P < .001) and perceived discrimination (r: 0.706, P < .001); negative correlation between positive religious coping and social withdrawal (r: -0.343, P < .001) and perceived discrimination (r: -0.302, P < .001). There was no significant relationship between other subdimensions of ISMI and religious coping scale. There was a significant negative correlation between ISMI total score and positive religious coping (r: -0.256, P: .002), a significant positive correlation with negative religious coping (r: 0.683, P < .001). Multiple linear regression analysis was applied to reveal the explanatory effect of age, duration of illness and religious coping on internalized stigma, and according to the model obtained (R = 0.729, R2 = 0.516, F = 32.071, P < .001), 51.6% of the change in the total score of the ISMI can be explained by this model. The significant relationship between positive and negative religious coping and internalized stigma in patients included in the study suggests that it may be beneficial to consider religious coping attitudes in addition to other interventions in the fight against stigma in severe mental illnesses such as schizophrenia.

Coping Strategies and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

Little is known about the coping strategies used among people with HIV (PWH), especially in sub-Saharan Africa, and the extent to which adaptive or maladaptive coping strategies are associated with symptoms of mental health disorders. We interviewed 426 PWH initiating HIV care in Cameroon and reported the prevalence of adaptive and maladaptive coping strategies, overall and by presence of symptoms of depression, anxiety, and PTSD. Log binominal regression was used to estimate the association between each type of coping strategy (adaptive or maladaptive) and symptoms of each mental health disorder, separately. Adaptive and maladaptive coping strategies were commonly reported among PWH enrolling in HIV care in Cameroon. Across all mental health disorders assessed, greater maladaptive coping was associated with higher prevalence of depression, anxiety, and PTSD. Adaptive coping was not associated with symptoms of any of the mental health disorders assessed in bivariate or multivariable models. Our study found that PWH endorsed a range of concurrent adaptive and maladaptive coping strategies. Future efforts should explore the extent to which coping strategies change throughout the HIV care continuum. Interventions to reduce maladaptive coping have the potential to improve the mental health of PWH in Cameroon.

An intercultural perspective toward supporting antipsychotic medication adherence in clinical practice

In the UK, the incidence of schizophrenia appears highest in Black Caribbean and Black African communities (four- to six-fold that of the White British population). The incidence of psychosis in other minority ethnic groups is also raised, but to a lesser magnitude. Although there are numerous environmental confounding factors, the data stresses the importance of optimising treatment in high-risk (minority) groups. Antipsychotic nonadherence is the most common reason for schizophrenia relapse, and is associated with increased rates of relapse, readmission to hospital and suicide. This article examines available literature to discover how culture can affect antipsychotic nonadherence, and considers culture-based solutions that could enhance antipsychotic adherence. Acknowledging the importance of the therapeutic alliance and sociocultural aspects in antipsychotic adherence, I argue that current cultural competence training provided to clinicians is inadequate. Organisational- and system-level approaches are required to reduce oppressive practise and promote culturally competent, person-centred care.

Barriers and facilitators to treatment seeking behaviors for depression, epilepsy, and schizophrenia in low- and middle-income countries: A systematic review

Despite the severe consequences, the treatment gap for depression, epilepsy, and schizophrenia continues to be a major concern in low and middle-income countries (LMICs). We conducted a systematic review of literature on barriers and facilitators of treatment-seeking behaviors from the perspective of individuals living with depression, epilepsy, and schizophrenia and stakeholders in LMICs. Knowledge deficits, beliefs, and stigma were barriers to treatment-seeking across disorders. The most cited facilitators were demographics, socioeconomic status, and collaboration with traditional healers. Culturally sensitive interventions in collaboration with stakeholders within the community can facilitate treatment-seeking behaviors among people living with depression, epilepsy, and schizophrenia.

Treatment Preferences for Pharmacological versus Psychological Interventions among Primary Care Providers in Nepal: Mixed Methods Analysis of a Pilot Cluster Randomized Controlled Trial

There is increasing evidence supporting the effectiveness of psychological interventions in low- and middle-income countries. However, primary care providers (PCPs) may prefer treating patients with medication. A secondary exploratory analysis of a pilot cluster randomized controlled trial was conducted to evaluate psychological vs. pharmacological treatment preferences among PCPs. Thirty-four health facilities, including 205 PCPs, participated in the study, with PCPs in 17 facilities assigned to a standard version of the mental health Gap Action Programme (mhGAP) training delivered by mental health specialists. PCPs in the other 17 facilities received mhGAP instruction delivered by specialists and people with lived experience of mental illness (PWLE), using a training strategy entitled Reducing Stigma among HealthcAre ProvidErs (RESHAPE). Pre- and post- intervention attitudes were measured through quantitative and qualitative tools. Qualitative interviews with 49 participants revealed that PCPs in both arms endorsed counseling’s benefits and collaboration within the health system to provide counseling. In the RESHAPE arm, PCPs were more likely to increase endorsement of statements such as “depression improves without medication” (F = 9.83, p < 0.001), “not all people with depression must be treated with antidepressants” (χ² = 17.62, p < 0.001), and “providing counseling to people who have alcohol abuse problems is effective” (χ² = 26.20, p < 0.001). These mixed-method secondary findings from a pilot trial suggest that in-person participation of PWLE in training PCPs may not only reduce stigma but also increase PCPs’ support of psychological interventions. This requires further investigation in a full-scale trial.