Caregivers' experiences with major depression concealed by physical illness in patients recruited from central Ugandan Primary Health Care Centers

"Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa

Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom "thinking too much" is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people's well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom "thinking too much" within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing "thinking too much" across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on "thinking too much" focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. "Thinking too much" reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with "too many thoughts." This research demonstrates that "thinking too much" is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.

Not Enough Money and Too Many Thoughts: Exploring Perceptions of Mental Health in Two Ugandan Districts Through the Mental Health Literacy Framework

Mental health disorders account for a heavy disease burden in Uganda. In order to provide culturally appropriate mental health prevention and treatment approaches, it is necessary to understand how mental health is conceptualized in the population. Three focus group discussions (FGDs) and 31 in-depth interviews (IDIs) were conducted with men and women aged 14 to 62 years residing in rural, urban, and semi-urban low-income communities in central and western Uganda to explore perceptions and knowledge of mental health. Interpretive thematic analysis was undertaken; results were organized through the lens of the mental health literacy framework. Environmental and societal stressors were identified as primary underlying causes of poor mental health. While participants recognized symptoms of poor mental health, gaps in mental health literacy also emerged. Mental health resources are needed in this setting and additional qualitative work assessing knowledge and attitudes toward mental health care seeking behavior can inform the development of acceptable integrated services.

Child mental illness and the help-seeking process: a qualitative study among parents in a Ugandan community

BACKGROUND

Child mental illness contributes significantly to the burden of disease worldwide, and many are left untreated due to factors on both the provider and user side. Recognising this, the Ugandan Ministry of Health recently released the Child and Adolescent Mental Health (CAMH) Policy Guidelines. However, for implementation to be successful the suggested policy changes must resonate with the service users. To better understand the sociocultural factors influencing parental mental help-seeking, we sought insights from parents in the Mbale district of eastern Uganda.

METHOD

In this qualitative study, eight focus group discussions were conducted with mothers and fathers in urban and rural communities. Parents of children younger than 10 years were purposively selected to discuss a vignette story about a child with symptoms of depression or ADHD as well as general themes relating to child mental illness. The data were analysed using qualitative content analysis.

RESULTS

Descriptions of severe symptoms and epileptic seizures were emphasised when recognising problem behaviour as mental illness, as opposed to mere 'stubbornness' or challenging behaviour. A mixture of supernatural, biomedical, and environmental understandings as underlying causes was reflected in the help-seeking process, and different treatment providers and relevant institutions, such as schools, were contacted simultaneously. A notion of weakened community social support structures hampered access to care.

CONCLUSION

Awareness of symptoms closer to normal behaviour must be increased in order to improve the recognition of common mental illnesses in children. Stakeholders should capitalise on the common recognition of the importance of the school when planning the upscaling of and improved access to services. Multifactorial beliefs within the spiritual and biomedical realms about the causes of mental illness lead to multisectoral help-seeking, albeit without collaboration between the various disciplines. The CAMH Policy Guidelines do not address traditional service providers or provide a strategy for better integration of services, which might mean continued fragmentation and ineffective service provision of child mental health care.

Recruitment and Baseline Characteristics of Participants in the Social, Emotional, and Economic Empowerment Through Knowledge of Group Support Psychotherapy Study (SEEK-GSP): Cluster Randomized Controlled Trial

BACKGROUND

Psychosocial characteristics, including self-esteem, perceived social support, coping skills, stigma, discrimination, and poverty, are strongly correlated with depression symptoms. However, data on the extent of these correlations among persons living with HIV and the associations between psychosocial characteristics and HIV treatment outcomes are limited in sub-Saharan Africa.

OBJECTIVE

This paper aims to describe the recruitment process and baseline characteristics associated with depression in a sample of HIV-positive people in a cluster randomized trial of group support psychotherapy (GSP) for depression delivered by trained lay health workers (LHWs).

METHODS

Thirty eligible primary care health centers across three districts in Uganda were randomly allocated to have their LHWs trained to deliver GSP (intervention arm) or group HIV education and treatment as usual (control arm) to persons living with HIV comorbid with depression. Baseline demographic, socioeconomic, and psychosocial characteristics were collected via interviewer-administered questionnaires. Among eligible participants, differences between those enrolled versus those who refused enrollment were assessed using chi square for categorical variables and t tests for continuous variables. Spearman rank order correlation analyses were conducted to determine associations between baseline depression symptoms and adherence to antiretroviral therapy (ART), viral load suppression, and other psychosocial variables.

RESULTS

The study screened 1473 people and 1140 were found to be eligible and enrolled over 14 weeks. Participants recruited comprised 95% of the target sample size of 1200. The sample's mean age was 38.5 (SD 10.9) years and both genders were well represented (males: 46.32%, 528/1140). Most participants met the diagnostic criteria for major depressive disorder (96.92%, 1105/1140), had significant posttraumatic stress symptoms (72.46%, 826/1140), reported moderate suicide risk (52.54%, 599/1140), had primary or no formal education (86.22%, 983/1140), and reported no income-generating activity (72.63%, 828/1140) and no food insecurity (81.67%, 931/1140). Among eligible participants, 48 of 1140 (4.21%) refused to participate in the interventions; these participants were more likely to be males (χ²₁=4.0, P=.045) and have significantly lower depression symptoms scores (t₂=2.36, P=.01) than those who participated in the interventions. There was a significant positive correlation between viral load and number of traumatic experiences (ρ=.12, P=.05). Adherence to ART was positively correlated with perceived social support (ρ=.15, P<.001), but negatively correlated with depression symptoms (ρ=-.11, P=.05) and stigma (ρ=-.14, P<.001).

CONCLUSIONS

Men and women with HIV and depression experience multiple social and economic vulnerabilities and disadvantages. Culturally tailored psychological interventions aimed at these individuals should address these socioeconomic disadvantages in addition to addressing their mental health care needs.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201608001738234; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1738 (Archived by WebCite at http://www.webcitation.org/74NtMphom).

A service user co-facilitated intervention to reduce mental illness stigma among primary healthcare workers: Utilizing perspectives of family members and caregivers

INTRODUCTION

Service users' involvement as cofacilitators of mental health trainings is a nascent endeavor in low- and middle-income countries, and the role of families on service user participation in trainings has received limited attention. This study examined how caregivers perceive and facilitate service user's involvement in an antistigma program that was added to mental health Gap Action Program (mhGAP) trainings for primary care workers in Nepal.

METHOD

Service users were trained as cofacilitators for antistigma and mhGAP trainings delivered to primary care workers through the REducing Stigma among HealthcAre ProvidErs (RESHAPE) program. Key informant interviews (n = 17) were conducted with caregivers and service users in RESHAPE.

RESULTS

Five themes emerged: (a) Caregivers' perceived benefits of service user involvement included reduced caregiver burden, learning new skills, and opportunities to develop support groups. (b) Caregivers' fear of worsening stigma impeded RESHAPE participation. (c) Lack of trust between caregivers and service users jeopardized participation, but it could be mitigated through family engagement with health workers. (d) Orientation provided to caregivers regarding RESHAPE needed greater attention, and when information was provided, it contributed to stigma reduction in families. (e) Time management impacted caregivers' ability to facilitate service user participation.

DISCUSSION

Engagement with families allows for greater identification of motivational factors and barriers impacting optimal program performance. Caregiver involvement in all program elements should be considered best practice for service user-facilitated antistigma initiatives, and service users reluctant to include caregivers should be provided with health staff support to address barriers to including family. (PsycINFO Database Record

How is depression experienced around the world? A systematic review of qualitative literature

To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fisher's exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.

Perinatal depression in Nigeria: perspectives of women, family caregivers and health care providers

Background

Perinatal maternal depression is common and undertreated in many sub-Saharan African countries, including Nigeria. While culture shapes the social determinants and expression of depressive symptoms, there is a dearth of research investigating these processes in African contexts.

Methods

To address this gap, we conducted in-depth interviews with 14 women with perinatal depression, 14 of their family caregivers and 11 health providers, using the McGill Illness Narrative Interview as part of a larger trial of a stepped-care intervention. Interpretation of themes was guided by cultural constructivist and critical anthropological perspectives that situate perinatal depression in its complexity as a disorder that is embedded in webs of social relations and embodied practices.

Results

Study respondents used idioms of distress that identified perinatal conditions that consist of somatic, affective, cognitive and behavior symptoms found in depressive disorders. Respondents viewed mental health problems in the perinatal period as tied to sociomoral concerns over gender roles and women’s position within the household. Conflict between women’s effort to be assertive to address interpersonal problems, while needing to be seen as non-aggressive contributed to their distress. Causal explanations for depression included husband’s lack of care, family problems, “spiritual attack”, having a female child when a male child was desired, and not resting sufficiently after childbirth. Guilt about breaching social norms for women’s conduct contributed to self blame, and feelings of shame.

Conclusions

Clinical assessment and interventions as well as public health prevention strategies for perinatal depression in global mental health need to consider local social contexts and meanings of depression, which can be explored with narrative-based methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s13033-017-0134-6) contains supplementary material, which is available to authorized users.

"Thinking too much": A systematic review of a common idiom of distress

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.

Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-centre randomised controlled trial

BACKGROUND

Group support psychotherapy (GSP) is a culturally sensitive intervention that aims to treat depression by enhancing social support, teaching coping skills, and income-generating skills. We compared GSP with group HIV education (GHE) for treatment of depression in people with HIV in Uganda.

METHODS

In this open-label randomised controlled trial, we included men and women with HIV, aged 19 years or older, who met the Mini International Neuropsychiatric Interview criteria for major depression from an urban HIV care centre in Kitgum district, northern Uganda. Participants were randomly assigned to receive eight weekly sessions of either GSP or GHE. Randomisation was achieved by urn (men and women separately picked a paper containing the intervention allocation from a basket; ratio 1:1), and the intervention sessions were given to gender-specific groups. Participants were followed up immediately after the intervention and 6 months after the end of treatment. The primary outcomes were change in depressive symptom scores (measured with the Self-Reporting Questionnaire) and in function scores (measured with a locally developed method), analysed by intention to treat using cluster-adjusted t tests and permutation tests. This trial is registered with The Pan African Clinical Trials Registry, number PACTR201402000742370.

FINDINGS

Between Jan 6, and Jan 20, 2014, we assessed 150 individuals, of whom 109 were randomly assigned to receive eight weekly sessions of either GSP (n=57) or GHE (n=52). Change in mean depression scores immediately after intervention did not differ between groups (mean difference -0·19, 95% CI -1·77 to 1·39, p=0·78). Mean function scores did not differ between groups either (0·24, -0·41 to 0·88; p=0·41). At 6 months after end of treatment, participants in the GSP group had lower mean depression scores than did those in the GHE group (-2·50, -3·98 to 1·02, p value=0·005), and higher function scores (0·74, -0·17 to 1·65, p=0·09) than did participants in the GHE group. No adverse events were reported.

INTERPRETATION

The benefits of existing HIV educational interventions in HIV care services could be improved by the addition of GSP content. Potential benefits of the integration of GSP into existing HIV interventions, such as adherence counselling or group HIV educational programmes, should be addressed in future studies.

FUNDING

Grand Challenges Canada.

Cross-cultural adaptation and validation of the self-reporting questionnaire among HIV+ individuals in a rural ART program in southern Uganda

BACKGROUND

HIV treatment programs are in need of brief, valid instruments to identify common mental disorders such as depression.

AIM

To translate and culturally adapt the Self-Reporting Questionnaire (SRQ-20) for use in Uganda and to investigate its psychometric properties in this setting.

METHODS

Following an initial translation of the SRQ-20 from English to Luganda, key informant interviews and focus-group discussions were used to produce a culturally adapted version of the instrument. The adapted SRQ-20 was administered to 200 HIV-positive individuals in a rural antiretroviral therapy program in southern Uganda. All study participants were also evaluated by a psychiatric clinical officer with the Mini International Neuropsychiatric Interview (MINI). Receiver-operating-characteristic analysis was used to examine the sensitivity and specificity of the SRQ-20 compared to the clinical diagnosis generated by the MINI.

RESULTS

The prevalence estimates of any depressive disorder and current depression were 24% (n = 48) and 12% (n = 24), respectively. The SRQ-20 scores discriminated well between subjects with and without current depression based on the MINI, with an area under the curve of 0.92, as well as between subjects with and without any current or past depressive disorder, with an area under the curve of 0.75. A score of 6 or more had 84% sensitivity and 93% specificity for current depression, and 75% sensitivity and 90% specificity for any depressive disorder.

CONCLUSION

The SRQ-20 appears to be a reliable and valid screening measure for depression among rural HIV-positive individuals in southern Uganda. The use of this screening instrument can potentially improve detection and management of depression in this setting.

Vulnerability to high risk sexual behaviour (HRSB) following exposure to war trauma as seen in post-conflict communities in eastern uganda: a qualitative study

BACKGROUND

Much of the literature on the relationship between conflict-related trauma and high risk sexual behaviour (HRSB) often focuses on refugees and not mass in-country displaced people due to armed conflicts. There is paucity of research about contexts underlying HRSB and HIV/AIDS in conflict and post-conflict communities in Uganda. Understanding factors that underpin vulnerability to HRSB in post-conflict communities is vital in designing HIV/AIDS prevention interventions. We explored the socio-cultural factors, social interactions, socio-cultural practices, social norms and social network structures that underlie war trauma and vulnerability to HRSB in a post-conflict population.

METHODS

We did a cross-sectional qualitative study of 3 sub-counties in Katakwi district and 1 in Amuria in Uganda between March and May 2009. We collected data using 8 FGDs, 32 key informant interviews and 16 in-depth interviews. We tape-recorded and transcribed the data. We followed thematic analysis principles to manage, analyse and interpret the data. We constantly identified and compared themes and sub-themes in the dataset as we read the transcripts. We used illuminating verbatim quotations to illustrate major findings.

RESULTS

The commonly identified HRSB behaviours include; transactional sex, sexual predation, multiple partners, early marriages and forced marriages. Breakdown of the social structure due to conflict had resulted in economic destruction and a perceived soaring of vulnerable people whose propensity to HRSB is high. Dishonour of sexual sanctity through transactional sex and practices like incest mirrored the consequence of exposure to conflict. HRSB was associated with concentration of people in camps where idleness and unemployment were the norm. Reports of girls and women who had been victims of rape and defilement by men with guns were common. Many people were known to have started to display persistent worries, hopelessness, and suicidal ideas and to abuse alcohol.

CONCLUSIONS

The study demonstrated that conflicts disrupt the socio-cultural set up of communities and destroy sources of people's livelihood. Post-conflict socio-economic reconstruction needs to encompass programmes that restructure people's morals and values through counselling. HIV/AIDS prevention programming in post-conflict communities should deal with socio-cultural disruptions that emerged during conflicts. Some of the disruptions if not dealt with, could become normalized yet they are predisposing factors to HRSB. Socio-economic vulnerability as a consequence of conflict seemed to be associated with HRSB through alterations in sexual morality. To pursue safer sexual health choices, people in post-conflict communities need life skills.

Families' and professional caregivers' views of using advanced technology to track people with dementia

in this study we examined the ethical aspects of the use of the Global Positioning Systems (GPS) to track people with dementia. The findings are based on qualitative data gathered from focus groups of family and professional caregivers. The most important theme was the need to balance patients' need for safety with the need to preserve their autonomy and privacy. The main potential benefit of the use of GPS was related to the peace of mind of the caregivers themselves. The findings also suggest that caregivers' views change according to the locus of responsibility of the caregivers for the safety of people with dementia. The caregivers give preference to patients' safety more than autonomy when they are responsible for the patients. When the patients are under the responsibility of other caregivers, they give preference to patients' autonomy more than their safety. Overall, the variety and the depth of the views of different stakeholders toward the use of electronic tracking for people with dementia presented in this article provide a meaningful contribution to the ethical debate on this topic.

Livelihood strategies and nutritional status of grandparent caregivers of AIDS orphans in Nyando District, Kenya

Although the growing role of grandparents as primary caregivers of AIDS orphans in sub-Saharan Africa has been established by previous research, few scholars have undertaken studies to explore the experiences of older persons in this new role. In this study, I used qualitative research methods to examine livelihood strategies that influenced the nutritional status of grandparent caregivers, a population largely neglected in the literature on African livelihoods. In this article I highlight the agency of older persons by identifying responses that promote their livelihood resilience. My research was guided by the sustainable livelihoods framework and involved in-depth individual interviews with 30 grandparent caregivers selected based on their nutritional status. Focus group discussions and key informant interviews were also conducted. Results indicate that the ability to mobilize new sources of labor for food production and new social networks to facilitate other forms of food entitlement are critical to nutritional status. These results are important in designing interventions targeting vulnerable grandparent caregivers.