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

A Pilot Study of the Coping Together Virtual Family Intervention: Exploring Changes in Family Functioning and Individual Well-Being

In this pilot study, we tested a virtual family strengthening and mental health promotion intervention, Coping Together (CT), during the COVID-19 pandemic. We explored changes at the family and individual levels, as well as mechanisms of change. Participants included 18 families (24 caregivers, 24 youth) with children aged 7 to 18 years. Community health workers delivered the 8-session CT intervention using videoconferencing software. We used qualitative semi-structured interviews with 14 of the families to explore changes and mechanisms of change using a thematic content analysis approach. We also administered pre-post surveys with the 18 families to explore the direction of changes, using only descriptive statistics in this small sample. Qualitative findings supported positive changes across family and individual level outcomes including family functioning, relationship quality, and individual psychosocial well-being. Results also confirmed several hypothesized mechanisms of change with improved communication providing the foundation for increased hope and improved problem solving and coping. Pre-post survey results were mixed, showing positive, but very small, changes in family closeness, caregiver-child communication, and levels of hope; almost no change was observed on measures of caregiver and child mental health. Families reported few problems at baseline quantitatively despite qualitative descriptions of pre-intervention difficulties. Results provide preliminary support for benefits of CT with the most consistent improvements seen across family relationships. Findings were mixed related to individual-level mental health benefits. Results have implications for revising content on mental health coping strategies and suggest the need to revise the quantitative measurement strategy for this non-clinical sample.

Group-format, peer-facilitated mental health promotion interventions for students in higher education settings: a scoping review protocol

INTRODUCTION

Young people in higher education face various stressors that can make them vulnerable to mental ill-health. Mental health promotion in this group therefore has important potential benefits. Peer-facilitated and group-format interventions may be feasible and sustainable. The scoping review outlined in this protocol aims to map the literature on group-format, peer-facilitated, in-person interventions for mental health promotion for higher education students attending courses on campuses in high and low/middle-income countries.

METHODS AND ANALYSIS

Relevant studies will be identified through conducting searches of electronic databases, including Medline, CINAHL, Scopus, ERIC and PsycINFO. Searches will be conducted using Boolean operators (AND, OR, NOT) and truncation functions appropriate for each database. We will include a grey literature search. We will include articles from student participants of any gender, and published in peer-reviewed journals between 2008 and 2023. We will include English-language studies and all study types including randomised controlled trials, pilot studies and descriptive studies of intervention development. A draft charting table has been developed, which includes the fields: author, publication date, country/countries, aims, population and sample size, demographics, methods, intervention type, comparisons, peer training, number of sessions/duration of intervention, outcomes and details of measures.

ETHICS AND DISSEMINATION

No primary data will be collected from research participants to produce this review so ethics committee approval is not required. All data will be collated from published peer-reviewed studies already in the public domain. We will publish the review in an open-access, peer-reviewed journal accessible to researchers in low/middle-income countries. This protocol is registered on Open Science Framework (https://osf.io/agbfj/).

A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND

Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions.

METHODS

We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters.

RESULTS

For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery.

CONCLUSION

Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

Feasibility, acceptability and preliminary effectiveness of a community-based group psychosocial support model for conflict survivors in Colombia: An assessment of in-person and remote intervention modalities during the COVID-19 pandemic

Background

Community-based psychosocial support (CB-PSS) interventions utilizing task sharing and varied (in-person, remote) modalities are essential strategies to meet mental health needs, including during the COVID-19 pandemic. However, knowledge gaps remain regarding feasibility and effectiveness.

Methods

This study assesses feasibility, acceptability and preliminary effectiveness of a CB-PSS intervention for conflict-affected adults in Colombia through parallel randomized controlled trials, one delivered in-person (n = 165) and the other remotely (n = 103), implemented during the COVID-19 pandemic and national protests. Interventions were facilitated by nonspecialist community members and consisted of eight problem-solving and expressive group sessions.

Findings

Attendance was moderate and fidelity was high in both modalities. Participants in both modalities reported high levels of satisfaction, with in-person participants reporting increased comfort expressing emotions and more positive experiences with research protocols. Symptoms of depression, anxiety and posttraumatic stress disorder improved among in-person participants, but there were no significant changes for remote participants in comparison to waitlist controls.

Implications

This CB-PSS intervention appears feasible and acceptable in both in-person and remote modalities and associated with reduction in some forms of distress when conducted in-person but not when conducted remotely. Methodological limitations and potential explanations and areas for future research are discussed, drawing from related studies.

Application of 'Readiness for Change' concept within implementation of evidence-based mental health interventions globally: protocol for a scoping review

Background

Concerning the growing burden of mental illnesses globally, there has been an increased investment into the implementation of evidence-based mental health interventions (EBmhIs) in routine care settings. However, the uptake and implementation of these EBmhIs has faced challenges in the real-world context. Among the many barriers and facilitators of implementation of EBmhIs identified by implementation science frameworks, evidence on the role of readiness for change (RFC) remains sparse. RFC constitutes the willingness and perceived capacity of stakeholders across an organization to implement a new practice. Theoretically, RFC has been defined at organizational, group, and individual levels, however, its conceptualization and operationalization across all these levels have differed in studies on the implementation of EBmhIs. By conducting a scoping review, we aim to examine the literature on RFC within the implementation of EBmhIs.

Methods

This scoping review will be conducted following the PRISMA-ScR guidelines. Iterative review stages will include a systematic and comprehensive search through four electronic databases (PubMed, Web of Science, Embase, and PsycINFO), selecting studies, charting data, and synthesizing the results. English-language studies meeting the inclusion criteria will be screened independently by two reviewers.

Discussion

This review will synthesize knowledge on the conceptualization of RFC across organizational, group, and individual levels within the implementation of EBmhIs. In addition, it will identify how RFC has been measured in these studies and summarize the reported evidence on its impact on the implementation of EBmhIs.

Conclusions

This review will assist mental health researchers, implementation scientists, and mental health care providers to gain a better understanding of the state of research on RFC within the implementation of EBmhIs.

Registration

The final protocol was registered with the Open Science Framework on October 21, 2022 ( https://osf.io/rs5n7).

Large language models could change the future of behavioral healthcare: a proposal for responsible development and evaluation

Large language models (LLMs) such as Open AI's GPT-4 (which power ChatGPT) and Google's Gemini, built on artificial intelligence, hold immense potential to support, augment, or even eventually automate psychotherapy. Enthusiasm about such applications is mounting in the field as well as industry. These developments promise to address insufficient mental healthcare system capacity and scale individual access to personalized treatments. However, clinical psychology is an uncommonly high stakes application domain for AI systems, as responsible and evidence-based therapy requires nuanced expertise. This paper provides a roadmap for the ambitious yet responsible application of clinical LLMs in psychotherapy. First, a technical overview of clinical LLMs is presented. Second, the stages of integration of LLMs into psychotherapy are discussed while highlighting parallels to the development of autonomous vehicle technology. Third, potential applications of LLMs in clinical care, training, and research are discussed, highlighting areas of risk given the complex nature of psychotherapy. Fourth, recommendations for the responsible development and evaluation of clinical LLMs are provided, which include centering clinical science, involving robust interdisciplinary collaboration, and attending to issues like assessment, risk detection, transparency, and bias. Lastly, a vision is outlined for how LLMs might enable a new generation of studies of evidence-based interventions at scale, and how these studies may challenge assumptions about psychotherapy.

Barriers and Facilitators to Implementing a Community-Based Psychosocial Support Intervention Conducted In-Person and Remotely: A Qualitative Study in Quibdó, Colombia

Community-based psychosocial support group (CB-PSS) interventions using task-shifting approaches are well suited to provide culturally appropriate services in low- and middle-income countries. However, contextual barriers and facilitators must be considered to tailor interventions effectively, particularly considering the challenges introduced by the COVID-19 pandemic. We explore the barriers, facilitators, and psychosocial changes associated with implementing a CB-PSS group intervention delivered by local lay providers to conflict-affected adults in Quibdó, Colombia, using both in-person and remote modalities. Data were analyzed from 25 individual interviews with participants and a focus group discussion involving staff members, including 7 community psychosocial agent facilitators and 2 mental health professional supervisors. The analysis used a thematic approach grounded in a descriptive phenomenology to explore the lived experiences of participants and staff members during implementation. Participant attendance in the in-person modality was compromised by factors such as competing work and family responsibilities and disruption caused by the COVID-19 pandemic. Participants in the remote modality faced challenges concerning unstable Internet connectivity, recurrent power outages caused by heavy rain, distractions, interruptions, and threats to confidentiality by family and coworkers. Despite these challenges, data revealed key contextual facilitators, including the community-based knowledge of facilitators and integration of traditional practices, such as the comadreo (informal talks and gatherings). Respondents shared that the CB-PSS groups promoted stronger community relationships and created opportunities for participants to exchange peer support, practice leadership skills, develop problem-solving skills based on peers' experiences, and enhance emotional regulation skills. Differences and similarities across in-person and remote modalities are discussed, as are key considerations for practitioners and policymakers.

Integrating mental health into primary care in Nigeria: Implementation outcomes and clinical impact of the HAPPINESS intervention

Background

The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention is a multicomponent, community-based, mobile technology-supported intervention that integrates mental health into primary health care centers in Nigeria using the World Health Organization's Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). This study evaluates its implementation and patient-level clinical impact using a quasi-experimental design (single cohort with pre- and post-measures).

Findings

The HAPPINESS intervention implementation demonstrated high feasibility with 84% adoption rate (% of participating primary health centers that completed its roll out) and 81% fidelity (% of clinicians who completed required intervention components according to the protocol). Retention rate in care at 12 months was 86%. Among patients with complete clinical records analyzed (n = 178), there was a statistically significant reduction in 9-item Patient Health Questionnaire scores from baseline (Md = 9.5) to 6 months (Md = 3.0) post-intervention (z = 80.5, p < 0.001), with a large effect size (r = 0.8) and statistically significant reduction in Brief Psychiatric Rating Scale scores from baseline (Md = 36.0) to 6 months (Md = 17.0) post-intervention (z = 128.5, p < 0.001), with a large effect size (r = 0.9).

Implications

Mobile technology-enhanced, mhGAP-IG-based efforts to scale-up mental health services in Nigeria are feasible and effective.

Assessing the need for pre-mental health competencies in undergraduate education: insights from graduate faculty surveys

Introduction

Despite the value of clinical competencies for masters- and doctoral-level practitioners as well as the tremendous variability in preparedness for graduate school and at graduation from graduate school, there are no competency standards for students pursuing mental healthcare careers prior to graduate study. This study aimed to identify potential pre-mental health competency standards for undergraduates pursuing mental healthcare careers.

Methods

Faculty at masters and doctoral programs in a range of mental healthcare fields were asked to rate their expectations of entry-level competence and the perceived entry-level competence of their first-year, bachelor-level graduate students on 42 sub-competencies derived from the APA's Competency Benchmarks in Professional Psychology.

Results

Faculty of both masters (N = 320) and doctoral (N = 220) programs reported high expectations of first-year graduate students for 11 competency categories (professional values/attitudes; relationships; management-administration; interdisciplinary systems; individual/cultural diversity; advocacy; scientific knowledge and methods; reflective practice, self-assessment, and self-care; ethical standards and policy; supervision, and research/evaluation) and 25 sub-competencies. Faculty in masters programs rated students as not meeting their expectations in 28 sub-competencies, while faculty in doctoral programs rated students as not meeting their expectations in 17 sub-competencies. Faculty recommended internships as well as improvement in writing, counseling skills, professional behavior, diversity, equity, and inclusion, cultural competence and humility, research methods, reading research, connecting research to practice, and education about the different mental healthcare professions.

Discussion

Our findings suggest that students would benefit from intentional training in multiple pre-mental health competency areas at the undergraduate level to facilitate graduate-level training in mental healthcare and to better prepare our future clinicians.

The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review

BACKGROUND

Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries.

METHODS

Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials.

RESULTS

Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor.

CONCLUSION

Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.

JE, Nair P, Mathews R, Malik K, Michelson D, Patel V. Developing knowledge-based psychotherapeutic competencies in non-specialist providers: A pre-post study with a nested randomised controlled trial of a coach-supported versus self-guided digital training course for a problem-solving psychological intervention in India

We evaluated a digital learning programme for non-specialists to develop knowledge-based competencies in a problem-solving intervention for adolescents to examine the overall impact of training on knowledge-based competencies among learners; and to compare the effects of two training conditions (self-guided digital training with or without coaching) in a nested parallel, two-arm, individually randomised controlled trial. Eligible participants were 18 or older; fluent in Hindi or English; able to access digital training; and had no prior experience of delivering structured psychotherapies. 277 participants were enrolled from 31 March 2022 to 19 June 2022 of which 230 (83%) completed the study. There was a significant increase in competency score from pre-training (Mean = 7.01, SD = 3.29) to post-training (Mean = 8.88, SD = 3.80), 6 weeks after the pre-training assessment. Knowledge competency scores showed larger increase among participants randomised to the coaching arm (AMD = 1.09, 95% CI 0.26-1.92, p = 0.01) with an effect size (d) of 0.33 (95% CI 0.08-0.58). More participants completed training in the coaching arm (n = 96, 69.6%) compared to the self-guided training arm (n = 56, 40.3%). In conclusion, a coach-supported remote digital training intervention is associated with enhanced participation by learners and increased psychotherapeutic knowledge competencies.

Testing the effectiveness and acceptability of online supportive supervision for mental health practitioners in humanitarian settings: a study protocol for the caring for carers project

BACKGROUND

Local humanitarian workers in low and middle-income countries must often contend with potentially morally injurious situations, often with limited resources. This creates barriers to providing sustainable mental health and psychosocial support (MHPSS) to displaced individuals. Clinical supervision is an often neglected part of ensuring high-quality, sustainable care. The Caring for Carers (C4C) project aims to test the effectiveness and acceptability of online group-based supportive supervision on the well-being of MHPSS practitioners, as well as service-user-reported service satisfaction and quality when working with displaced communities in Türkiye, Syria, and Bangladesh. This protocol paper describes the aim, design, and methodology of the C4C project.

METHOD

A quasi-experimental, mixed-method, community-based participatory research study will be conducted to test the effectiveness of online group-based supportive clinical supervision provided to 50 Syrian and 50 Bangladeshi MHPSS practitioners working with Syrian and Rohingya displaced communities. Monthly data will be collected from the practitioners and their beneficiaries during the active control (six months) and supervision period (16 months over two terms). Outcomes are psychological distress (Kessler-6), burnout (the Copenhagen Burnout Inventory), compassion fatigue, compassion satisfaction, and secondary traumatic stress (Professional Quality of Life Scale), perceived injustice, clinical self-efficacy (Counseling Activity Self-Efficacy Scale), service satisfaction, and quality (Client Satisfaction Questionnaire and an 18-item measure developed in this project). A realist evaluation framework will be used to elucidate the contextual factors, mechanisms, and outcomes of the supervision intervention.

DISCUSSION

There is a scarcity of evidence on the role of clinical supervision in improving the well-being of MHPSS practitioners and the quality of service they provide to displaced people. By combining qualitative and quantitative data collection, the C4C project will address the long-standing question of the effectiveness and acceptability of clinical supervision in humanitarian settings.

Protocol for an economic evaluation of scalable strategies to improve mental health among perinatal women: non-specialist care delivered via telemedicine vs. specialist care delivered in-person

BACKGROUND

Perinatal depression affects an estimated 1 in 5 women in North America during the perinatal period, with annualized lifetime costs estimated at $20.6 billion CAD in Canada and over $45.9 billion USD in the US. Access to psychological treatments remains limited for most perinatal women suffering from depression and anxiety. Some barriers to effective care can be addressed through task-sharing to non-specialist providers and through telemedicine platforms. The cost-effectiveness of these strategies compared to traditional specialist and in-person models remains unknown. This protocol describes an economic evaluation of non-specialist providers and telemedicine, in comparison to specialist providers and in-person sessions within the ongoing Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial.

METHODS

The economic evaluation will be undertaken alongside the SUMMIT trial. SUMMIT is a pragmatic, randomized, non-inferiority trial across five North American study sites (N = 1,226) of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a behavioural activation treatment for perinatal depressive and anxiety symptoms. The primary economic evaluation will be a cost-utility analysis. The outcome will be the incremental cost-effectiveness ratio, which will be expressed as the additional cost required to achieve an additional quality-adjusted life-year, as assessed by the EuroQol 5-Dimension 5-Level instrument. A secondary cost-effectiveness analysis will use participants' depressive symptom scores. A micro-costing analysis will be conducted to estimate the resources/costs required to implement and sustain the interventions; healthcare resource utilization will be captured via self-report. Data will be pooled and analysed using uniform price and utility weights to determine cost-utility across all trial sites. Secondary country-specific cost-utility and cost-effectiveness analyses will also be completed. Sensitivity analyses will be conducted, and cost-effectiveness acceptability-curves will be generated, in all instances.

DISCUSSION

Results of this study are expected to inform key decisions related to dissemination and scale up of evidence-based psychological interventions in Canada, the US, and possibly worldwide. There is potential impact on real-world practice by informing decision makers of the long-term savings to the larger healthcare setting in services to support perinatal women with common mental health conditions.

Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt

Over the past two decades there have been major advances in the development of interventions promoting mental health and well-being in low- and middle-income countries (LMIC), including delivery of care by non-specialist providers, incorporation of mobile technologies and development of multilevel community-based interventions. Growing inequities in mental health have led to calls to adopt similar strategies in high-income countries (HIC), learning from LMIC. To overcome shared challenges, it is crucial for projects implementing these strategies in different global settings to learn from one another. Our objective was to examine cases in which mental health and well-being interventions originating in or conceived for LMIC were implemented in the USA. The cases included delivery of psychological interventions by non-specialists, HIV-related stigma reduction programmes, substance use mitigation strategies and interventions to promote parenting skills and family functioning. We summarise commonly used strategies, barriers, benefits and lessons learnt for the transfer of these innovative practices among LMIC and HIC. Common strategies included intervention delivery by non-specialists and use of digital modalities to facilitate training and increase reach. Common barriers included lack of reimbursement mechanisms for care delivered by non-specialists and resistance from professional societies. Despite US investigators' involvement in most of the original research in LMIC, only a few cases directly involved LMIC researchers in US implementation. In order to achieve greater equity in global mental health and well-being, more efforts and targeted funding are needed to develop best practices for global health reciprocal innovation and iterative learning in HIC and LMIC.

Increasing access to specialist care with group medical visits: summary of a pilot in a post-crisis psychiatric clinic

Background

Group medical visits (GMVs) have strong evidence of acceptability and effectiveness in the management of chronic medical diseases. Adaptation of GMVs for psychiatric care has potential to increase access, decrease stigma and save costs. Despite promise, this model has not been widely adopted.

Methods

A novel GMV pilot was implemented for psychiatric care post-crisis among patients with primary mood or anxiety disorders who required medication management. Participants filled out PHQ-9 and GAD-7 scales at each visit in order to track their progress. After discharge, charts were reviewed for demographics, medication changes and symptom changes. Patient characteristics were compared between those who attended and those who didn't. Changes in total PHQ-9 and GAD-7 scores among attendees were assessed with paired t-tests.

Results

Forty-eight patients were enrolled between October 2017 and the end of December 2018, 41 of whom consented to participate. Of those, 10 did not attend, 8 attended but did not complete, and 23 completed. Baseline PHQ-9 and GAD-7 scores did not differ significantly between groups. Significant and meaningful reductions in PHQ-9 and GAD-7 scores from baseline to last visit attended occurred among those who attended at least 1 visit (decrease of 5.13 and 5.26 points, respectively).

Conclusions

This GMV pilot demonstrated feasibility of the model as well as positive outcomes for patients recruited in a post-crisis setting. This model has the potential to increase access to psychiatric care in the face of limited resources, however the failure of the pilot to sustain highlights challenges to be addressed in future pivots.

Development of a Digital Program for Training Community Health Workers in the Detection and Referral of Schizophrenia in Rural India

This study aimed to develop and assess the acceptability of a digital program for training community health workers (CHWs) in the detection and referral of patients with schizophrenia in community settings in rural India. An iterative design process was employed. First, evidence-based content from existing community programs for schizophrenia care was incorporated into the curriculum, and reviewed by experts to ensure clinical utility and fidelity of the adapted content. Second, CHWs provided feedback on the appropriateness of language, content, and an initial prototype of the digital training program to ensure relevance for the local context. Focus group discussions were then used to understand the acceptability of the digital training prototype and to inform modifications to the design and layout. Qualitative data was analysed using a rapid thematic analysis approach based on predetermined topics pertaining to acceptability of the training content and digital platform. Development of the initial prototype involved content review by 13 subject matter experts with clinical expertise or experience accessing and receiving mental health services, and engagement of 23 CHWs, of which 11 provided feedback for contextualization of the training content and 12 participated in focus group discussions on the acceptability of the prototype. Additionally, 2 service-users with lived experience of schizophrenia contributed to initial testing of the digital training prototype and offered feedback in a focus group discussion. During contextualization of the training content, key feedback pertained to simplifying the language and presentation of the content by removing technical terms and including interactive content and images to enhance interest and engagement with the digital training. During prototype testing, CHWs shared their familiarity with similar symptoms but were unaware of schizophrenia as a treatable illness. They shared that training can help them identify symptoms of schizophrenia and connect patients with specialized care. They were also able to understand misconceptions and discrimination towards people with schizophrenia, and how to address these challenges by supporting others and spreading awareness in their communities. Participants also appreciated the digital training, as it could save them time and could be incorporated within their routine work. This study shows the acceptability of leveraging digital technology for building capacity of CHWs to support early detection and referral of schizophrenia in community settings in rural India. These findings can inform the subsequent evaluation of this digital training program to determine its impact on enhancing the knowledge and skills of CHWs.

Pretraining Skills as Predictors of Competence of Nonspecialists in Delivery of Mental Health Services

OBJECTIVE

Task-shared delivery of mental health care, which includes training people who are not mental health specialists to deliver components of care, has been identified as a core strategy for increasing access to mental health care globally. However, after standard training, nonspecialists attain variable and sometimes poor competence in task-shared mental health care. This study examined whether pretraining interpersonal skills (nonverbal communication, verbal communication, rapport building, and empathy-warmth) are related to posttraining competence in task-shared mental health care among nonspecialists in Nepal.

METHODS

Nonspecialists (e.g., auxiliary health workers and health assistants) (N=185) were assessed at pretraining and posttraining (4 months after training and supervision) in a task-shared mental health care program in Nepal. This study employed both a classification algorithm and a logistic regression model to examine the relationship between pretraining interpersonal skills and posttraining competence.

RESULTS

The classification model predicted posttraining competence at above-chance levels on the basis of pretraining interpersonal skills. In particular, pretraining nonverbal communication skill distinguished participants whose posttraining competence was rated as acceptable from those whose rating was not acceptable. Nonverbal communication was also a significant predictor in the regression model. No other interpersonal skills were significantly related to posttraining competence outcomes in the regression model.

CONCLUSIONS

Some pretraining interpersonal skills of nonspecialists may predict overall competence outcomes in task-shared mental health care. Future studies confirming the relationship between pretraining interpersonal skills and posttraining competence in care delivery could improve staff selection and training strategies in task-shared mental health care programs.

Scaling-up problem management plus for refugees in Switzerland - a qualitative study

BACKGROUND

Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland.

OBJECTIVE

To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process.

METHODS

22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach.

RESULTS

The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland.

CONCLUSIONS

Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

Middle-income country perspectives on global mental health

PURPOSE OF REVIEW

Despite being a relatively new discipline, global mental health (GMH) has made substantial advances, paying particular attention to optimising the provision of mental health services in low- and middle-income countries (LMICs). Much of the work done in GMH has focused on low-income countries (LIC), but middle-income countries (MIC) such as Brazil, China, India, and South Africa, have particular characteristics that may impact the nature of this work. Here we examine key GMH issues, including mental health legislation, burden of disease, task-sharing, and mental health clinical and research capacity-building, in the MIC context.

RECENT FINDINGS

In MICs there is particular concern about an increase in non-communicable diseases, including mental disorders. MICs have more resources than LICs, but the treatment gap in these settings remains significant. MICs are better equipped than LICs to mobilize task-sharing programs, and these can potentially include more high educated community health workers. In MICs there have been important advances in mental health, but more is needed regarding their implementation and the promotion of human rights. Clinical and research capacity-building initiatives in MIC contexts are easier to establish and have potential to be more ambitious in scope.

SUMMARY

GMH has developed important universal principles that apply across low-, middle-, and high-income countries. Nevertheless, particular issues in MICs may require moulding of more general GMH frameworks.

I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding

PURPOSE

Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE.

METHODS

A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically.

RESULTS

Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers.

DISCUSSION

I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.

Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India

INTRODUCTION

Human-centered design (HCD) refers to a diverse suite of interactive processes that engage end users in the development of a desired outcome. We showcase how 2 global mental health research teams applied HCD to develop mobile health tools, each directed at reducing treatment gaps in underserved populations. CASE STUDY 1: Refugees face higher risks for mental health problems, yet these communities face structural and cultural barriers that reduce access to and use of services. To address these challenges, the Research Program on Children and Adversity at the Boston College School of Social Work, in partnership with resettled refugee communities in the northeastern United States, used codesign methodology to digitally adapt delivery of the Family Strengthening Intervention for Refugees-a program designed to improve mental health and family functioning among resettled families. We describe how codesign methods support the development of more feasible, acceptable, and sustainable interventions. CASE STUDY 2: Sangath, an NGO in India focused on mental health services research, in partnership with Harvard Medical School, designed and evaluated a digital training program for community health workers to deliver an evidence-based, brief psychological treatment for depression as part of primary care in Madhya Pradesh, India. We describe how HCD was applied to program development and discuss our approach to scaling up training and capacity-building to deliver evidence-based treatment for depression in primary care.

IMPLICATIONS

HCD involves a variety of techniques that can be flexibly adapted to engage end users in the conceptualization, implementation, scale-up, and sustainment of global mental health interventions. Community solutions generated using HCD offer important benefits for key stakeholders. We encourage widespread adoption of HCD within global mental health policy, research, and practice, especially for addressing mental health disparities with underserved populations.

Understanding Lay Counselor Perspectives on Mobile Phone Supervision in Kenya: Qualitative Study

BACKGROUND

Task shifting is an effective model for increasing access to mental health treatment via lay counselors with less specialized training that deliver care under supervision. Mobile phones may present a low-technology opportunity to replace or decrease reliance on in-person supervision in task shifting, but important technical and contextual limitations must be examined and considered.

OBJECTIVE

Guided by human-centered design methods, we aimed to understand how mobile phones are currently used when supervising lay counselors, determine the acceptability and feasibility of mobile phone supervision, and generate solutions to improve mobile phone supervision.

METHODS

Participants were recruited from a large hybrid effectiveness implementation study in western Kenya wherein teachers and community health volunteers were trained to provide trauma-focused cognitive behavioral therapy. Lay counselors (n=24) and supervisors (n=3) participated in semistructured interviews in the language of the participants' choosing (ie, English or Kiswahili). Lay counselor participants were stratified by supervisor-rated frequency of mobile phone use such that interviews included high-frequency, average-frequency, and low-frequency phone users in equal parts. Supervisors rated lay counselors on frequency of phone contact (ie, calls and SMS text messages) relative to their peers. The interviews were transcribed, translated when needed, and analyzed using thematic analysis.

RESULTS

Participants described a range of mobile phone uses, including providing clinical updates, scheduling and coordinating supervision and clinical groups, and supporting research procedures. Participants liked how mobile phones decreased burden, facilitated access to clinical and personal support, and enabled greater independence of lay counselors. Participants disliked how mobile phones limited information transmission and relationship building between supervisors and lay counselors. Mobile phone supervision was facilitated by access to working smartphones, ease and convenience of mobile phone supervision, mobile phone literacy, and positive supervisor-counselor relationships. Limited resources, technical difficulties, communication challenges, and limitations on which activities can be effectively performed via mobile phone were barriers to mobile phone supervision. Lay counselors and supervisors generated 27 distinct solutions to increase the acceptability and feasibility of mobile phone supervision. Strategies ranged in terms of the resources required and included providing phones and airtime to support supervision, identifying quiet and private places to hold mobile phone supervision, and delineating processes for requesting in-person support.

CONCLUSIONS

Lay counselors and supervisors use mobile phones in a variety of ways; however, there are distinct challenges to their use that must be addressed to optimize acceptability, feasibility, and usability. Researchers should consider limitations to implementing digital health tools and design solutions alongside end users to optimize the use of these tools.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s43058-020-00102-9.

Agents of Change for Mental Health: A Survey of Young People's Aspirations for Participation Across Five Low- and Middle-Income Countries

PURPOSE

Effective intervention, policy, and research in mental health and well-being (MHWB) require young people to be understood not only as beneficiaries, but also as active agents in codesigning and implementing initiatives. To identify pathways for young people's participation in promoting MHWB in low- and middle-income countries (LMICs), this study surveyed young people's aspirations for engagement, their spheres of influence, capacity building needs, and key barriers to participation.

METHODS

Using U-Report, United Nations Children's Emergency Fund's social messaging tool and data collection platform, we distributed a short quantitative survey to a nonrepresentative, but large sample of young people aged 15-29 across five LMICs: Nigeria, Brazil, Jamaica, South Africa, and Burundi.

RESULTS

A total of 42,689 young people responded, with representation from most or all provinces within each country. Participants' average age was 23.8 years (SD = 3.77). Young people's core aspirations were to join a mental health awareness project and to support their peers. Participants considered schools and community settings to be the most important spheres for engagement. Lack of information about mental health was the main perceived barrier to participation, and mental health classes the main training need.

DISCUSSION

In many countries, MHWB is not taught or discussed in schools and youth-led mental health interventions are rare. Findings from this study reveal clear aspirations for participatory engagement to promote MHWB among young people in LMICs. To support meaningful participation, policymakers and youth service providers must ensure that young people have access to mental health literacy training and opportunities to raise awareness in schools or community settings.

Scaling up community-delivered mental health support and care: A landscape analysis

Introduction

The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.

Methods

A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.

Results

The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.

Discussion

This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

High levels of mild to moderate depression among men who have sex with men and transgender women in Lima, Peru: implications for integrated depression and HIV care

ABSTRACTDepression disproportionally affects people at risk of acquiring or living with HIV and is associated with worse health outcomes; however, depression care is not routinely integrated with HIV prevention and treatment services. Selection of the best depression intervention(s) for integration depends both on the prevalence and severity of depression among potential users. To inform depression care integration in a community-based setting in Lima, Peru, we retrospectively analyzed routinely collected depression screening data from men who have sex with men and transgender women seeking HIV prevention and care services (N = 185). Depression was screened for using the Patient Health Questionnaire-9. Prevalence of any depression (PHQ-9 ≥ 5) was 42% and was significantly associated with the last sexual partner being "casual" (p = 0.01). Most (81%) depressive symptoms were mild to moderate (≥5 PHQ-9 ≤ 14). Integrating depression care with HIV prevention and treatment services in Peru should begin by implementing interventions targeting mild to moderate depression.

Schizophrenia Assessment, Referral and Awareness Training for Health Auxiliaries (SARATHA): Protocol for a Mixed-Methods Pilot Study in Rural India

BACKGROUND

Workforce shortages pose major obstacles to the timely detection and treatment of schizophrenia, particularly in low-income and middle-income countries. The SARATHA (Schizophrenia Assessment, Referral, and Awareness Training for Health Auxiliaries) project involves the systematic development, iterative refinement, and pilot testing of a digital program for training community health workers in the early detection and referral of schizophrenia in primary care settings in rural India.

METHODS

SARATHA is a three-phase study. Phase 1 involves consulting with experts and clinicians, and drawing from existing evidence to inform the development of a curriculum for training community health workers. Phase 2 consists of designing and digitizing the training content for delivery on a smartphone app. Design workshops and focus group discussions will be conducted to seek input from community health workers and service users living with schizophrenia to guide revisions and refinements to the program content. Lastly, Phase 3 entails piloting the training program with a target sample of 20 community health workers to assess feasibility and acceptability. Preliminary effectiveness will be explored, as measured by community health workers' changes in knowledge about schizophrenia and the program content after completing the training.

DISCUSSION

If successful, this digital training program will offer a potentially scalable approach for building capacity of frontline community health workers towards reducing delays in early detection of schizophrenia in primary care settings in rural India. This study can inform efforts to improve treatment outcomes for persons living with schizophrenia in low-resource settings.

Innovations in community-based mental health care: an overview of meta-analyses

In the last four decades, mental health services for people with Severe Mental Illness (SMI) have seen asylums replaced by a balanced model of Community Mental Healthcare (CMH). Innovative approaches and strategies in the field of CMH have been extensively researched. However, this research has been hampered by issues limiting their capacity to inform clinicians and policymakers. We conducted an overview of meta-analyses of the effectiveness of innovative CMH models focussing on clinical and psychosocial outcomes in comparisons with standard care in adults with SMI. Based on the 12 eligible studies, we appraised, synthesised and graded the resulting evidence. There was moderate quality evidence that case management, Early Intervention Services (EIS) and caregiver-directed interventions were superior to standard care in reducing hospital admission. In relation to psychosocial outcomes, EIS showed high quality evidence of a small effect on global functioning. There was moderate quality evidence for a similar effect of Intensive Case Management, and for a large effect of family intervention. For quality of life, both EIS and self-management education had a small effect, with moderate quality. The level of research about effective CMH models is therefore substantial. However, several gaps related to innovative CMH not yet covered in meta-analytic synthesis, need to be filled.

Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review

AIM

The study aimed to synthesize evidence comparing task-shifting interventions led by general practice nurses and mental health specialists in improving mental health outcomes of adults in primary care.

DESIGN

This study used a systematic review of randomized controlled trials.

DATA SOURCES

Articles from the databases CINAHL, MEDLINE, APA PsycInfo, PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and ProQuest Dissertation and Thesis published between 2000 and 2020 were included.

REVIEW METHODS

The review was arranged based on the Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Twelve articles met the eligibility criteria. Eight studies revealed that nurse-led intervention was significantly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments.

CONCLUSION

Nurses could be temporarily employed to provide mental health services in the absence of mental health specialists as long as appropriate training and supervision was provided. This finding should be interpreted with caution due to the high risk of bias in the studies reviewed and the limited generalisability of their findings.

How to Transition Patients Back From Psychiatric Care to Primary Care: An Access Initiative Protocol Development

This column describes the initial steps to develop a bidirectional access initiative between outpatient psychiatric and primary care clinics within an academic medical center. The authors analyzed electronic health record data (N=2,837 patients), interviewed psychiatric and primary care providers, assembled a work group, and identified five patient tracks (treatment optimization, psychiatric continuity, specialty clinic, psychotherapy, and community referral). Over 16 months, the number of patients scheduled for new psychiatric diagnostic evaluations with medical services increased from 62.5 to 116.0 per month without significant change in the no-show rate for evaluations within the psychiatric outpatient clinic.

Early Autism Intervention Components Deliverable by Non-specialists in Low- and Middle-Income Countries: A Scoping Review

Introduction

The past decade has seen key advances in early intervention for autistic children in high-income countries, with most evidence based on specialist delivery of interventions. The care gap seen in low- and middle-income countries (LMIC) remains close to 100%. A key challenge in addressing this care gap concerns the paucity of specialists available to deliver services. Task-sharing provides an important potential solution; there is a need to identify interventions that are suitable for scaled-up delivery through task-sharing in low-resourced settings. We aimed to conduct a scoping review to identify studies which reported autism intervention delivered by non-specialists within LMIC and, using established frameworks, specify intervention components with evidence of successful non-specialist delivery.

Methods

A scoping literature search, conducted within four databases, generated 2,535 articles. Duplicates were removed, followed by screening of titles and abstracts, with 10% double-rated for reliability. 50 full text articles were then screened independently by two raters. Articles were included if studies: (a) were conducted in LMIC; (b) included samples of autistic children (age < 10); (c) evaluated psycho-social interventions delivered by non-specialists; (d) reported child outcomes; and (e) were peer-reviewed full-texts in English. Two established frameworks - @Practicewise and NDBI-Fi framework - were then used to ascertain the commonly delivered components of these interventions.

Results

Two studies met the inclusion criteria. Both studies evaluated parent-mediated interventions delivered by non-specialists in South Asia. Through the two frameworks, we identified elements and techniques that had been delivered successfully by non-specialists.

Conclusion

There is evidence from two acceptability and feasibility trials that non-specialists can be trained to deliver some intervention elements and techniques within parent-mediated interventions, with good fidelity and acceptability and evidence of effectiveness. The review points up the lack of a widespread evidence base in this area and need for further research in low resourced settings, including well-powered trials and mechanistic analyses to identify active ingredients. A focus on the pre-requisites for non-specialist delivery is critical to reduce inequity and provide universal health coverage within resource-constrained health systems.

"Not shifting, but sharing": stakeholders' perspectives on mental health task-shifting in Indonesia

Background

Task-shifting, the distribution of tasks among health workers to address health workforce shortage, has been widely used to tackle mental health treatment gaps. However, its implementation in Indonesia has still been rarely explored. This study aimed to explore stakeholders’ perspectives on the implementation of mental health task-shifting to nurses in Indonesia's primary health care.

Methods

An exploratory descriptive approach using in-depth interviews and focused group discussions (FGDs) was used. The study involved 19 stakeholders from the government's ministry directorates, professional organisations, and mental health practitioners. Thematic analysis was used to analyse the data.

Results

Three themes emerged namely, task-shifting feasibility and acceptability, shared task implementation, and nurse role enhancement issues, with 14 sub-themes.

Conclusions

Task-shifting on mental health issues in the eye of Indonesian stakeholders is viewed as a matter of sharing and collaboration. Implementation of task-shifting in Indonesia may require policies in place and political will across stakeholders. Further scrutiny on task-shifting implementation is needed by considering the local context and national environment.

Using cocreated visually informed community mental health education in low- and middle-income countries: A case study of youth substance misuse in Assam, India

Introduction

Our aim is to evaluate the visually informed community mental health education materials cocreated in our research on youth substance misuse in Assam, India, and to reflect on what we might learn for similar initiatives in low‐ and middle‐income countries.

Methods

Materials consist of: (i) images participants brought to the interview; (ii) 30 posters cocreated by participants to convey key messages from their interview; (iii) six short films on the implications of addiction, and (iv) an animation of our Pathways to Recovery model. We also created a community education package that incorporated these materials. We analyse feedback from three groups of events and a social media campaign, which drew variably across our materials and engaged a range of audiences.

Results

Outcomes indicate the cocreation process and focus on the visual was successful in promoting young people's voice, increasing awareness and has potential for stigma reduction. Our educational package was deemed useful in increasing awareness and has potential for prevention and treatment.

Conclusions

Our case study offers insights into community mental health education in low‐ and middle‐income countries, confirming the importance of cocreation, the usefulness of visual materials and the potential of social media campaigns while acknowledging the importance of local context in health messaging, particularly for stigmatized topics.

Patient or Public Contribution

Service users were involved in the cocreation of the materials evaluated in this study and contributed as presenters in one of the events reported. Members of the public took part in events in which the materials were shared and provided us with the feedback analysed in this article.

Association of Task-Shared Psychological Interventions With Depression Outcomes in Low- and Middle-Income Countries: A Systematic Review and Individual Patient Data Meta-analysis

Importance

Task sharing, the training of nonspecialist workers with no formal experience in counseling, is a promising strategy for addressing the large gap in treatment for depression in low- and middle-income countries (LMICs).

Objective

To examine the outcomes and moderators of task-shared psychological interventions associated with depression severity, response, and remission.

Data Sources

Systematic literature searches in PubMed, Embase, PsycINFO, and Cochrane Library up to January 1, 2021.

Study Selection

Randomized clinical trials (RCTs) of task-shared psychological interventions compared with control conditions for adults with depressive symptoms in LMICs were included.

Data Extraction and Synthesis

Two researchers independently reviewed the titles, abstracts, and full text of articles from an existing generic meta-analytic database that includes all RCTs on psychotherapy for depression. A systematic review and individual patient data (IPD) meta-analysis was used to estimate the outcomes of task-shared psychological interventions across patient characteristics using mixed-effects models. Procedures for abstracting data and assessing data quality and validity followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

Primary outcome was reduction in depression symptom severity measured by the 9-item Patient Health Questionnaire (PHQ-9). Response and remission rates were also estimated.

Results

Of 13 eligible trials, 11 (4145 participants) contributed IPD. Task-shared psychological interventions were associated with a greater decrease in depressive symptom severity than control conditions (Hedges g, 0.32; 95% CI, -0.26 to -0.38). Participants in the intervention groups had a higher chance of responding (odds ratio, 2.11; 95% CI, 1.60 to 2.80) and remitting (odds ratio, 1.87; 95% CI, 1.20 to 1.99). The presence of psychomotor symptoms was significantly associated with the outcomes of task-shared psychological interventions (β [SE], -1.21 [0.39]; P = .002). No other significant associations were identified. Heterogeneity among the trials with IPD was 74% (95% CI, 53%-86%).

Conclusions and Relevance

In this meta-analysis of IPD, task-shared psychological interventions were associated with a larger reduction in depressive symptom severity and a greater chance of response and remission than control conditions. These findings show potential for the use of task-sharing of psychological interventions across different groups of patients with depression. Further research would help identify which people are most likely to benefit and strengthen larger-scale implementation of this strategy to address the burden of depression in LMICs.

"It's a win for the clinic, it's a win for the frontline, but, most importantly, it's a win for the client": Task Shifting HIV Prevention Services from Clinicians to Community Health Workers in Ontario, Canada

Introduction

Despite strong evidence from low- and middle-income countries supporting the use of task shifting to provide quality, cost-effective HIV-related health services, this strategy has been adopted less widely in high-income countries such as Canada.

Methods

In 2020, we conducted semi-structured interviews with 19 clinicians (e.g., psychologists, nurses, physicians) and 14 community health workers (CHWs) in Ontario to examine their perspectives on the prospect of shifting HIV/STBBI testing services and PrEP in Ontario, Canada. Interviews were transcribed and then analyzed using content analysis. A community consultation with key stakeholders was also performed to assess the validity of the findings.

Results

There was substantial agreement between clinicians and CHWs with respect to shifting specific tasks related to HIV/STBBI testing and PrEP. In particular, most participants felt that rapid HIV testing could and should be provided by CHWs and that ASOs could be ideal sites for clients to obtain and use self-testing kits for STBBIs. Most respondents agreed that CHWs have the skills and expertise required to perform most non-clinical services related to PrEP (e.g., pre-counselling, follow-up, case management). The co-location of clinicians and CHWs could help support the development of task shifting initiatives.

Conclusion

Findings indicate that there is enthusiasm among both clinicians and CHWs with respect to shifting HIV prevention services. Creative solutions are required to have a meaningful impact on HIV incidence in this population.

Policy Implications

With adequate training and supervision, non-regulated CHWs should be allowed to provide certain HIV prevention services such as rapid HIV testing. A provincial, publicly funded program for PrEP is recommended.

Understanding Trustful Relationships between Community Health Workers and Vulnerable Citizens during the COVID-19 Pandemic: A Realist Evaluation

(1) Background: Community health workers (CHWs) are an essential public health workforce defined by their trustful relationships with vulnerable citizens. However, how trustful relationships are built remains unclear. This study aimed to understand how and under which circumstances CHWs are likely to build trust with their vulnerable clients during the COVID-19 pandemic. (2) Methods: We developed a program theory using a realist research design. Data were collected through focus groups and in-depth interviews with CHWs and their clients. Using a grounded theory approach, we aimed to unravel mechanisms and contextual factors that determine the trust in a CHW program offering psychosocial support to vulnerable citizens during the COVID-19 pandemic. (3) Results: The trustful relationship between CHWs and their clients is rooted in three mental models: recognition, equality, and reciprocity. Five contextual factors (adopting a client-centered attitude, coordination, temporariness, and link with primary care practice (PCP)) enable the program mechanisms to work. (4) Conclusions: CHWs are a crucial public health outreach strategy for PCP and complement and enhance trust-building by primary care professionals. In the process of building trustful relationships between CHWs and clients, different mechanisms and contextual factors play a role in the trustful relationship between primary care professionals and patients. Future research should assess whether these findings also apply to a non-covid context, to the involvement of CHWs in other facets of primary healthcare (e.g., prevention campaigns, etc.), and to a low- and middle-income country (LMIC) setting. Furthermore, implementation research should elaborate on the integration of CHWs in PCP to support CHWs in developing the mental models leading to build trust with vulnerable citizens and to establish the required conditions.

Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: scoping review and expert consultation

BACKGROUND

Lay Health Workers (LHW) are important providers of community mental health services and help mitigate access and treatment gaps in Africa. However, there is a paucity of knowledge about the role and performance of these workers, as well as about the extent to which the interventions delivered are culturally adapted to the African context.

AIMS

This scoping review aimed to explore the content and aspects concerning the cultural adaptation and sustainability of psychological interventions delivered by LHW to people with mental disorders in Africa.

METHODS

We conducted a scoping review of the peer-reviewed literature published from January 2000 to December 2018 to identify psychological interventions delivered by LHW for people with mental disorders in Africa. We systematically searched PubMed, Google scholar and Hinari to select relevant publications. The articles were evaluated for risk of bias according to study design with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools. Expert consultation was performed according to Arksey & O'Malley framework and cultural adaptation analysis was performed according to Bernal framework.

RESULTS

Out of 14,549 retrieved records, we identified ten peer-reviewed articles conducted in Zimbabwe, Uganda, South Africa and Zambia describing four distinct interventions. Six were randomized controlled trials; none addressed implementation outcomes. Group-based interpersonal therapy (n = 5), trauma-focused cognitive behaviour therapy (n = 1), problem solving therapy (n = 3) and narrative exposure therapy (n = 1) emerged as psychological interventions delivered by LHW for people with depression, anxiety, trauma and suicidal behavior. Psychological interventions delivered by LHW in Africa were all culturally adapted to meet the competence of LHW. All the interventions were associated with symptom improvement, but the quality of this evidence varied widely with study design.

CONCLUSION

Task-shifting psychological interventions delivered by LHW after appropriate cultural adaptation show promise for addressing unmet mental health care needs in Africa. More effectiveness and implementation evidence is needed, especially with regard to psychological interventions delivered by LHW for adolescence, older people and those with severe mental disorders and suicidal behaviors.

Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks

BACKGROUND

Task-sharing is a promising strategy to expand mental healthcare in low-resource settings, especially in low- and middle-income countries (LMICs). Research on how to best implement task-sharing mental health interventions, however, is hampered by an incomplete understanding of the barriers and facilitators to their implementation. This review aims to systematically identify implementation barriers and facilitators in evidence-based task-sharing mental health interventions using an implementation science lens, organizing factors across a novel, integrated implementation science framework.

METHODS

PubMed, PsychINFO, CINAHL, and Embase were used to identify English-language, peer-reviewed studies using search terms for three categories: "mental health," "task-sharing," and "LMIC." Articles were included if they: focused on mental disorders as the main outcome(s); included a task-sharing intervention using or based on an evidence-based practice; were implemented in an LMIC setting; and included assessment or data-supported analysis of barriers and facilitators. An initial conceptual model and coding framework derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework was developed and iteratively refined to create an integrated conceptual framework, the Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH), which specifies 37 constructs across eight domains: (I) client characteristics, (II) provider characteristics, (III) family and community factors, (IV) organizational characteristics, (V) societal factors, (VI) mental health system factors, (VII) intervention characteristics, and (VIII) stigma.

RESULTS

Of the 26,935 articles screened (title and abstract), 192 articles underwent full-text review, yielding 37 articles representing 28 unique intervention studies that met the inclusion criteria. The most prevalent facilitators occur in domains that are more amenable to adaptation (i.e., the intervention and provider characteristics domains), while salient barriers occur in domains that are more challenging to modulate or intervene on-these include constructs in the client characteristics as well as the broader societal and structural levels of influence (i.e., the organizational, mental health system domains). Other notable trends include constructs in the family and community domains occurring as barriers and as facilitators roughly equally, and stigma constructs acting exclusively as barriers.

CONCLUSIONS

Using the BeFITS-MH model we developed based on implementation science frameworks, this systematic review provides a comprehensive identification and organization of barriers and facilitators to evidence-based task-sharing mental health interventions in LMICs. These findings have important implications for ongoing and future implementation of this critically needed intervention strategy, including the promise of leveraging task-sharing intervention characteristics as sites of continued innovation, the importance of but relative lack of engagement with constructs in macro-level domains (e.g., organizational characteristics, stigma), and the need for more delineation of strategies for task-sharing mental health interventions that researchers and implementers can employ to enhance implementation in and across levels.

TRIAL REGISTRATION

PROSPERO CRD42020161357.

How can we mainstream mental health in research engaging the range of Sustainable Development Goals? A theory of change

Mental health is a leading cause of ill-health worldwide, disproportionately affects low-and-middle-income countries and, increasingly, is considered relevant across the Sustainable Development Goals (SDGs). Hence, we ask: How can we mainstream mental health in research engaging the range of SDGs? We use the UK Research and Innovation Global Challenges Research Fund (GCRF) as a case study. In a previous scoping review, we purposefully sampled non-mental health focused GCRF grants for diversity from 2015 until May-end 2020 (N = 36). In the present study, the principal investigator of each grant in this sample was invited to interview (11 accepting). Snowballing, our networks, and returning to the funding archive secured a further 15 interviews sampled for diversity (Final sample: 13 UK researchers and 13 of their overseas collaborators). A thematic analysis of this data organised key information into a trajectory from the challenges of incorporating mental health impact, to how these challenges might be overcome and, finally, to support needs. This analysis was then organised into a Theory of Change designed to promote the mainstreaming of mental health in global challenges research. We outline the implications for global challenges researchers, mental health practitioners, and global challenge research funders. One important implication is that we provide evidence to encourage funders to engage with the desire of researchers to contribute more broadly to the wellbeing of the communities with whom they work.

Using evaluative frameworks to examine the implementation outcomes of a cognitive behavioral therapy program for autistic students with anxiety within public school settings

LAY ABSTRACT

Cognitive behavioral therapy helps to treat anxiety symptoms in autistic youth, but it is difficult for families to access cognitive behavioral therapy in the community. Training school providers to deliver cognitive behavioral therapy may help autistic youth and their families to access these programs. Unfortunately, we do not know how cognitive behavioral therapy programs can be delivered by school providers and how these programs help the autistic students who access them. This study addressed this gap and was part of a larger study that looked at the effectiveness of Facing Your Fears-School-Based in 25 public schools. The study goals were to understand whether Facing Your Fears-School-Based helped students and the factors that made it easy or difficult to deliver Facing Your Fears-School-Based in schools. Thirty providers participated in interviews guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Participants shared information that fell into several major categories that included (1) delivering Facing Your Fears-School-Based to many different students; (2) the positive impact of Facing Your Fears-School-Based on students' school participation; and (3) plans to continue using Facing Your Fears-School-Based. School providers also shared that Facing Your Fears-School-Based was easy to use for non-mental health providers and reported adapting Facing Your Fears-School-Based to meet student needs. The results of this study suggest that Facing Your Fears-School-Based may help autistic students and highlight the importance of using mental health programs in schools that are flexible, able to be adapted, and that are able to be used by many different types of school providers.

Evidence to Practice for Mental Health Task-Sharing: Understanding Readiness for Change among Accredited Social Health Activists in Sehore District, Madhya Pradesh, India

Involvement of community health workers (CHWs) within task-sharing to bridge the mental health treatment gap has been proven to be efficacious in randomized controlled trials. The impact of mental health programs based on task-sharing paradigm greatly depends on the performance of CHWs which, in-turn, is influenced by their readiness for change. However, there is dearth of literature assessing the role of readiness for change as an important predicator of CHW performance. The aim of this study is to examine the applicability of the readiness for change model and investigate its cultural and contextual nuances among Accredited Social Health Activists (ASHAs), a cadre of CHWs in India, to understand their engagement in mental health task-sharing. We conducted in-depth, semi-structured interviews with a purposive sample of n = 12 key informants including ASHAs and other healthcare professionals in Sehore district, India. The interview guide consisted of open-ended questions based on the readiness for change factors including ASHAs' attitudes towards their role in mental health care, perception of capability to implement mental health task-sharing, of support from the public health system, etc. Framework analysis with a combined inductive-deductive approach was employed to code the data and generate themes. Participants endorsed three readiness for change themes relevant to task-sharing among ASHAs including change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they provided insights into the culturally and contextually salient aspects of these factors. Themes of personal empowerment, gaining respect and trust from community, professional duty, relationship with supervisors, and lack of resources availability were majorly highlighted. This is the first study to qualitatively investigate the applicability of the readiness for change model and its culture- and context-specific nuances among a cadre of non-specialist health workers in India. Our findings posit that implementation science models should strongly consider the culture and context within which they are being applied to enhance fit and relevance. Further, our results should be taken into consideration to adapt and validate measurement tools and build readiness for change in this population.

Enhancing Quality Supervision for the Delivery of Mental Health Care Through Nonspecialist Clinicians in Resource-Limited Settings

Supervision of nonspecialist clinicians by trained mental health professionals is integral to developing capacity for providing mental health care in low-resource settings. Current supervision efforts in low-resource settings, however, are often variable in quality. Scant published literature addresses how supervision practices affect treatment outcomes; only a few studies have been published on evidence-based supervision methods. Additionally, in low-resource settings many systems-level obstacles exist in providing adequate mental health supervision to nonspecialist clinicians. This article seeks to address psychiatrists' role in providing supervision and promoting quality of care in low-resource settings. We review the literature on evidence-based supervision practices, address obstacles and current practices of providing high-quality mental health supervision in low-resource settings, and weave this knowledge with our experiences learning from the clinicians at Partners in Health in Haiti. We also discuss feasible strategies and provide recommendations for strengthening the supervision process in resource-limited settings.

Child and adolescent mental health services and systems in low and middle-income countries: from mapping to strengthening

PURPOSE OF REVIEW

Most of the world's children and adolescents live in low and middle-income countries (LMICs) where mental health services are very limited. Here, we reviewed literature over the last 18 months describing the current landscape of child and adolescent mental health services and systems (CAMHSS) in LMICs, and present findings from systems strengthening research.

RECENT FINDINGS

The challenges in CAMHSS are well described with little change over the last two decades. Fortunately, research has started to move from 'mapping' towards systems 'strengthening'. Using the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) framework, we reviewed recent CAMHSS innovations. Clinical care and human resource innovations focused on primary care with validation of screening tools, training and task-sharing for capacity-building. Intersectoral collaboration emerged as a priority domain for strengthening, alongside a theme around the importance of participatory research to inform policy reforms. The potential role of digital technology to strengthen CAMHSS was identified as an emerging theme.

SUMMARY

There is an urgent need to increase the priority of CAMHSS in LMICs. This will require innovations at multiple levels aimed at all CAMHSS domains, with active participation of all relevant local stakeholders to ensure the translation of research into policy and practice.