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

Health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo: a multimethod study

BACKGROUND

The integration of mental health into primary care-i.e., the process by which a range of essential mental health care and services are made available in existing multipurpose health care settings that did not previously provide them-can be facilitated or hindered by several health system factors that are still poorly understood. This study aimed to identify health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo (DRC) to improve the success rate of integration programs.

METHODS

We conducted a multimethod, cross-sectional exploratory study. Stakeholders (managers, health service providers, service users, etc.) from sixteen of the twenty-six provinces of the DRC participated. We collected qualitative data through 31 individual, semistructured, face-to-face key informant interviews. We then collected quantitative data through a population-based survey of 413 respondents. We analyzed the interviews via thematic analysis, assigning verbatims to predefined themes and subthemes. For the survey responses, we performed descriptive analysis followed by binomial logistic regression to explore the associations between the variables of interest.

RESULTS

Strong leadership commitment, positive attitudes toward mental health care, the availability of care protocols, mental health task sharing (p < 0.001), and sufficient numbers of primary care providers (PCPs) (p < 0.001) were identified as key health system facilitators of successful integration. However, barriers to integration are mainly related to a poor understanding of what integration is and what it is not, as well as to the poor functionality and performance of health facilities. In addition, stigma, low prioritization of mental health, lack of mental health referents, low retention rate of trained health professionals, lack of reporting tools, lack of standardized national guidelines for integration (p < 0.001), lack of funding (p < 0.001), shortage of mental health specialists to coach PCPs (p < 0.001), and lack of psychotropic medications (p < 0.001) were identified as health system barriers to integration.

CONCLUSION

Improving the functionality of primary care settings before integrating mental health care would be beneficial for greater success. In addition, addressing identified barriers, such as lack of funding and mental health-related stigma, requires multistakeholder action across all building blocks of the health system.

Physical activity and sedentary behavior levels among individuals with mental illness: A cross-sectional study from 23 countries

People with mental illness tend to present low levels of physical activity and high levels of sedentary behavior. The study aims to compare these levels in mental illness patients, exploring the role of socioeconomic development and treatment setting. This cross-sectional study used accelerometers and the Simple Physical Activity Questionnaire (SIMPAQ) to assess physical activity and sedentary behavior in mental illness individuals living in 23 countries. Two-way ANOVAs were used to evaluate the interaction between socioeconomic development and the treatment settings on physical activity and sedentary behavior. A total of 884 (men = 55.3%) participants, mean age of 39.3 (SD = 12.8), were evaluated. A significant interaction between socioeconomic development and treatment settings was found in sedentary behavior (F = 5.525; p = 0.019; η2p = 0.009; small effect size). Main effects were observed on socioeconomic development (F = 43.004; p < 0.001; η2p = 0.066; medium effect size) and treatment setting (F = 23.001; p < 0.001; η2p = 0.036; small effect size) for sedentary behavior and physical activity: socioeconomic development (F = 20.888; p < 0.001; η2p = 0.033; small effect size) and treatment setting (F = 30.358; p < 0.001; η2p = 0.047; small effect size), showing that HIC patients were more active, while MIC patients were more sedentary. Moreover, despite of inpatients had presented higher levels of physical activity than outpatients, they also spent more time sitting. Socioeconomic development plays an important role in sedentary behavior in patients with mental disorders, warning the need to develop new strategies to reduce these levels in this population.

Effectiveness of Psychotherapy for Internalising Symptoms in Children and Adolescents When Delivered in Routine Settings: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to examine the effectiveness of psychological interventions for internalising disorders in youth when delivered in routine settings. Secondary aims were to examine the effectiveness of cognitive behavioural therapy and determine moderators of treatment response. The study was pre-registered (PROSPERO 2020 CRD42020202776). Databases were systematically searched (PsycINFO, Medline, Embase, PubMed, ERIC) in December 2022 and screened according to the PRISMA 2020 statement. Inclusion: School aged participants (4-18 years) with a primary internalising disorder; psychotherapy delivered in a routine setting (e.g. outpatient clinic, school) by setting staff; compared psychotherapy to any control in a randomised controlled trial; reported pre-to-post or pre-to-follow-up comparisons on the primary disorder according to child, parent or independent evaluator report; and was published in English. Risk of bias was assessed using the ROB 2.0 Cochrane tool. Results were synthesised using random effects to pool estimates. Risk ratios were used to analyse dichotomous data and standardised mean differences (SMD) for continuous data. Forty-five studies were included (N = 4901 participants; M = 13 years; range 8-16; SD = 2.5). Nine used waitlist control, 17 treatment as usual, 4 placebo; 15 compared psychotherapy to active control. Psychotherapy was associated with small significant effects pre- to post-treatment compared to non-active controls for anxiety (SMD =  - 0.24 to 0.50) and depression (SMD =  - 0.19 to 0.34) with effects differing by informant. Psychotherapy led to small significant pre-to-post-benefits in youth internalising disorders in routine settings. Results are limited by reporter type and follow-up.

The preferences for the telemedicine and standard health care services from the perspective of the patients with schizophrenia

BACKGROUND

With the rapid development of telemedicine, has enabled new and various ways to deliver health care services for patients with schizophrenia. However, it is not clear that the newly emerged is better than the standard or not from the perspective of patients with schizophrenia. This study aims to explore their preferences between telemedicine and standard health care services and their associated factors.

METHODS

The cross-sectional study was conducted at the Ningan hospital's inpatient department in Yinchuan, and collected socio-demographic and clinical information, the preferences regarding telemedicine (WeChat, telephone, and Email), and the standard health care services (community health center and home visit). The socio-demographic and clinical characteristics associated with the five-health care service delivery ways were assessed by descriptive analysis, and the associated impact factors of preferences of patients with schizophrenia were analyzed by multiple logistic regression.

RESULTS

Among the 300 participants, most of them chose WeChat (46.3%), some of them tended to telephone (35.4%) and community health center (11.3%), and a few of them accepted home visits (4.7%), and Email (2.3%). There are so many associated factors that affected the patients with schizophrenia to choose their favorite health care services, of which age, gender, employment, residence, and duration of illness were the independent impact factors.

CONCLUSIONS

The cross-sectional study surveyed the preferences between telemedicine and standard health care services in patients with schizophrenia's opinion, disclosed independent impact factors, as well as compared the advantage and disadvantages of these. According to our findings, the best health care services should be based on the preferences of the patients with schizophrenia and adapt to realistic conditions. This provides valuable evidence to improve the health care situation, facilitate the continuity of health care services, and achieve holistic rehabilitative outcomes for the patients with schizophrenia.

Towards implementation of context-specific integrated district mental healthcare plans: A situation analysis of mental health services in five districts in Ghana

BACKGROUND

Access to quality mental health services in Ghana remains poor, yet little is known about the extent of the access gaps and provision of mental health services at the district level in Ghana. We aimed to conduct an analysis of mental health infrastructure and service provision in five districts in Ghana.

METHODS

A cross-sectional situation analysis was conducted using a standardised tool to collect secondary healthcare data, supplemented by interviews with key informants, across five purposively selected districts in Ghana. The Programme for Improving Mental Health Care (PRIME) situation analysis tool was adapted to the Ghanaian context and used for data collection.

RESULTS

The districts are predominantly rural (>60%). There were severe challenges with the provision of mental healthcare: there were no mental healthcare plans, supervision of the few mental health professionals was weak and unstructured, access to regular supplies of psychotropic medications was a major challenge, and psychological treatments were extremely limited given the lack of trained clinical psychologists. There were no available data on treatment coverage, but we estimate this to be <1% for depression, schizophrenia, and epilepsy across districts. Opportunities for mental health systems strengthening include: the commitment and willingness of leadership, the existence of the District Health Information Management System, a well-established network of community volunteers, and some collaboration with traditional and faith-based mental health service providers.

CONCLUSION

There is poor mental health infrastructure across the five selected districts of Ghana. There are opportunities for strengthening mental health systems through interventions at the district healthcare organisation, health facility, and community levels. A standardised situation analysis tool is useful for informing district-level mental healthcare planning in low-resource settings in Ghana and potentially other sub-Saharan African countries.

Global magnitude and temporal trends of idiopathic developmental intellectual disability attributable to lead exposure from 1990 to 2019: Results from Global Burden of Disease Study

As an important environmental pollutant, lead exposure can result in idiopathic developmental intellectual disability (IDII). However, the latest spatiotemporal patterns across the world are unclear. Therefore, in this study, the global burden of lead exposure-related IDII was assessed using the Global Burden of Disease (GBD) study (2019). The data were downloaded from the Institute for Health Metrics and Evaluation (IHME), and the estimated annual percentage change (EAPC) was calculated to assess the changing trend of the age-standardized disability-adjusted life-years (DALYs) rates (ASDR) of global IDII attributed to lead exposure. In 2019, the number of global DALYs of IDII attributed to lead exposure was 2.72 million, the corresponding ASDR was 35.70 per 100,000. The ASDR was highest in children and adolescents, and low- and middle-income countries. From 1990 to 2019, the global number of DALYs of IDII attributable to lead exposure increased by 7.89%, while the ASDR of IDII decreased by 19.19% [EAPC = -0.78, 95% confidence interval (CI): (-0.90, -0.66)]. The downward trends were seen in most GBD regions and countries, especially in high-income countries, but 11 countries presented an upward trend. Therefore, it is important to continue to improve primary mental healthcare globally, especially in low- and middle-income countries. Meanwhile, the implementation of effective strategies to reduce lead exposure should be continually strengthened.

Using participatory action research to pilot a model of service user and caregiver involvement in mental health system strengthening in Ethiopian primary healthcare: a case study

Background

Little is known about actual involvement or how to achieve service user and caregiver in mental health systems strengthening in low-and middle-income countries. This study describes the processes and explores involvement experiences of participants in a pilot study of a new model of service user involvement in mental health system strengthening in a rural district in southern Ethiopia.

Methods

We applied a case study design using participatory action research (PAR). The PAR process comprised of three stages, each with iterative activities of plan, act, observe and reflect. Two stakeholder groups, a Research Advisory Group (RAG) and Research Participant Group (RPG), were established and collaborated in the PAR process. Data collection involved process documentation of meetings and activities: attendances, workshop minutes, discussion outputs, reflective notes, participatory observation of sessions, and in-depth interviews with 12 RPG members. We analyzed the process data descriptively. Thematic analysis was used for qualitative data. Triangulation and synthesis of findings was carried out to develop the case study.

Results

The stakeholder groups identified their top research priorities, developed an intervention and action plan and made a public presentation of preliminary findings. Key mechanisms used for inclusive participation included capacity building and bringing together diverse stakeholders, anchoring the study in established strong community involvement structures, and making use of participatory strategies and activities during the PAR process. Four themes were developed about experiences of involvement in PAR: (i) expectations and motivation, (ii) experiences of the dynamics of the PAR process, (iii) perceived impacts of involvement in the PAR process, and (iv) implementation challenges and future directions.

Conclusions

This case study demonstrated the feasibility and acceptability of implementing a complex model of service-user involvement in mental health system strengthening in a resource constrained setting. More needs to be done to embed service-user involvement into routines of the primary healthcare system, alongside sustained support and strengthening multi-stakeholder collaboration at multiple levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00545-8.

Empowerment training to support service user involvement in mental health system strengthening in rural Ethiopia: a mixed-methods pilot study

BACKGROUND

Increased service user involvement is recommended to improve weak mental health systems in low-and middle-income countries (LMICs). However, involvement is rarely implemented and interventions to support involvement are sparse. In this study we evaluated the acceptability, feasibility and perceived outcomes of an empowerment and training program for service users and health professionals to facilitate service user involvement in mental health system strengthening in rural Ethiopia.

METHODS

REducing Stigma among HealthcAreProvidErs (RESHAPE) is a training curriculum for service users, their caregivers and aspirational health workers, which uses PhotoVoice methodology, to prepare them in participation of mental health systems strengthening in LMICs. We delivered the RESHAPE training augmented with empowerment content developed in Ethiopia. The interactive face-to-face training was delivered to service users and caregivers (over 10 days), and health professionals (1 day) separately. The study was an uncontrolled, convergent mixed-methods design. The quantitative data consisted of process data, satisfaction questionnaire, and a retrospective pre-test survey. Qualitative data included exit and follow-up in-depth interviews with the service users. Descriptive statistics were performed for quantitative data, and qualitative data were thematically analysed. The findings were integrated through triangulation for convergent themes following analysis.

RESULTS

Twelve service users, 12 caregivers and 18 health professionals were enrolled, and completed the training. Participants valued the content and delivery process; the standard of the training program met their expectations and participation led to positive gains in understanding about mental illness, stigma, service-user involvement and human rights. The qualitative findings identified positive impacts, including increased self-confidence, sense of empowerment, social - and perceived therapeutic benefits.

CONCLUSIONS

We found that the RESHAPE training with added content for Ethiopia, delivered using the PhotoVoice methodology, is feasible, acceptable and of value to develop and implement training programmes which can empower service users to be involved in mental health system strengthening in this setting. Further study to assess the impact on health systems strengthening is warranted.

Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

The mental disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were depressive disorders, anxiety disorders, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, eating disorders, idiopathic developmental intellectual disability, and a residual category of other mental disorders. We aimed to measure the global, regional, and national prevalence, disability-adjusted life-years (DALYS), years lived with disability (YLDs), and years of life lost (YLLs) for mental disorders from 1990 to 2019.

METHODS

In this study, we assessed prevalence and burden estimates from GBD 2019 for 12 mental disorders, males and females, 23 age groups, 204 countries and territories, between 1990 and 2019. DALYs were estimated as the sum of YLDs and YLLs to premature mortality. We systematically reviewed PsycINFO, Embase, PubMed, and the Global Health Data Exchange to obtain data on prevalence, incidence, remission, duration, severity, and excess mortality for each mental disorder. These data informed a Bayesian meta-regression analysis to estimate prevalence by disorder, age, sex, year, and location. Prevalence was multiplied by corresponding disability weights to estimate YLDs. Cause-specific deaths were compiled from mortality surveillance databases. The Cause of Death Ensemble modelling strategy was used to estimate death rate by age, sex, year, and location. The death rates were multiplied by the years of life expected to be remaining at death based on a normative life expectancy to estimate YLLs. Deaths and YLLs could be calculated only for anorexia nervosa and bulimia nervosa, since these were the only mental disorders identified as underlying causes of death in GBD 2019.

FINDINGS

Between 1990 and 2019, the global number of DALYs due to mental disorders increased from 80·8 million (95% uncertainty interval [UI] 59·5-105·9) to 125·3 million (93·0-163·2), and the proportion of global DALYs attributed to mental disorders increased from 3·1% (95% UI 2·4-3·9) to 4·9% (3·9-6·1). Age-standardised DALY rates remained largely consistent between 1990 (1581·2 DALYs [1170·9-2061·4] per 100 000 people) and 2019 (1566·2 DALYs [1160·1-2042·8] per 100 000 people). YLDs contributed to most of the mental disorder burden, with 125·3 million YLDs (95% UI 93·0-163·2; 14·6% [12·2-16·8] of global YLDs) in 2019 attributable to mental disorders. Eating disorders accounted for 17 361·5 YLLs (95% UI 15 518·5-21 459·8). Globally, the age-standardised DALY rate for mental disorders was 1426·5 (95% UI 1056·4-1869·5) per 100 000 population among males and 1703·3 (1261·5-2237·8) per 100 000 population among females. Age-standardised DALY rates were highest in Australasia, Tropical Latin America, and high-income North America.

INTERPRETATION

GBD 2019 showed that mental disorders remained among the top ten leading causes of burden worldwide, with no evidence of global reduction in the burden since 1990. The estimated YLLs for mental disorders were extremely low and do not reflect premature mortality in individuals with mental disorders. Research to establish causal pathways between mental disorders and other fatal health outcomes is recommended so that this may be addressed within the GBD study. To reduce the burden of mental disorders, coordinated delivery of effective prevention and treatment programmes by governments and the global health community is imperative.

FUNDING

Bill & Melinda Gates Foundation, Australian National Health and Medical Research Council, Queensland Department of Health, Australia.

Assessment of RHIS Quality Assurance Practices in Tarkwa Submunicipal Health Directorate, Ghana

Background. Routine health information system (RHIS) quality assurance has become an important issue, not only because of its significance in promoting high standard of patient care, but also because of its impact on government budgets for the maintenance of health services. Routine health information system comprises healthcare data collection, compilation, storage, analysis, report generation, and dissemination on routine basis at the various healthcare settings. The data from RHIS give a representation of health status, health services, and health resources. The sources of RHIS data are normally individual health records, records of services delivered, and records of health resources. Using reliable information from routine health information systems is fundamental in the healthcare delivery system. Quality assurance practices are measures that are put in places to ensure the health data that are collected meet required quality standards. Routine health information system quality assurance practices ensure that data that are generated from the system are fit for use. This study considered quality assurance practices in the RHIS processes. Methods. A cross-sectional study was conducted in eight health facilities in Tarkwa Submunicipal health service in the western region of Ghana. The study involved routine quality assurance practices among the 90-health staff and management selected from facilities in Tarkwa Submunicipal who collect or use data routinely from 24th December, 2019, to 20th January, 2020. Results. Generally, Tarkwa Submunicipal health service appears to practice quality assurance during data collection, compilation, storage, analysis, and dissemination. The results show some achievement in quality control performance in report dissemination (77.6%), data analysis (68.0%), data compilation (67.4%), report compilation (66.3%), data storage (66.3%), and collection (61.1%). Conclusions. Even though Tarkwa Submunicipal health directorate engages some control measures to ensure data quality, there is the need to strengthen the process to achieve the targeted percentage of performance (90.0%). There was significant shortfall in quality assurance practices performance especially during data collection, with respect to the expected performance.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

The Africa Ethics Working Group (AEWG): a model of collaboration for psychiatric genomic research in Africa

The Africa Ethics Working Group (AEWG) is a South-South-North collaboration of bioethics and mental health researchers from sub-Saharan Africa, working to tackle emerging ethical challenges in global mental health research. Initially formed to provide ethical guidance for a neuro-psychiatric genomics research project, AEWG has evolved to address cross cutting ethical issues in mental health research aimed at addressing equity in North-South collaborations. Global South refers to economically developing countries (sub-Saharan Africa in this context) and Global North to economically developed countries (primarily Europe, UK and North America). In this letter we discuss lessons that as a group we have learnt over the last three years; lessons that similar collaborations could draw on. With increasing expertise from Global South as an outcome of several capacity strengthening initiatives, it is expected that the nature of scientific collaborations will shift to a truly equitable partnership. The AEWG provides a model to rethink contributions that each partner could make in these collaborations.

EVITA 2.0, an updated framework for understanding evidence-based mental health policy agenda-setting: tested and informed by key informant interviews in a multilevel comparative case study

Background

Mental health remains a neglected issue on the global health policy agenda, particularly in low- and middle-income countries (LMIC), and the translation of research evidence into policy and practice is slow. The new EVITA framework was developed to improve mental health evidence uptake and policy agenda-setting in LMICs. In addition, behavioural science methods may be able to support knowledge translation to policy.

Methods

Using a mixed-methods study design, we applied and tested the newly developed EVITA 1.1 framework against three case studies related to South Africa at the district, national and international levels. In-depth interviews with 26 experts were conducted between August and November 2019, transcribed, coded and analysed in NVivo, using iterative categorization. The data were analysed against both the EVITA framework and the MINDSPACE framework for behavioural insights.

Results

In our case study comparison, we found that (1) research translation to the policy agenda occurs in a complex, fluid system which includes multiple “research clouds”, “policy spheres” and other networks; (2) mental health research policy agenda-setting is based on key individuals and intermediaries and their interrelationships; and (3) key challenges and strategies for successful research to policy agenda impact are known, but are frequently not strategically implemented, such as including all stakeholders to overcome the policy implementation gap. Our data also suggest that behavioural science methods can be strategically applied to support knowledge translation to policy agenda-setting.

Conclusion

We found that the EVITA framework is useful for understanding and improving mental health research policy interrelationships to support evidence uptake to the policy agenda, and that behavioural science methods are effective support mechanisms. The revised EVITA 2.0 framework therefore includes behavioural insights, for improved mental health policy agenda-setting in LMICs. More research is needed to understand whether EVITA can be applied to other LMICs and to high-income contexts.

BJPsych Open fifth anniversary editorial: history, accomplishments, trajectory and passion

BJPsych Open has come of age. This editorial celebrates the journal's fifth anniversary by reviewing the history of BJPsych Open, what we have accomplished, where we strive to go (our planned trajectory) and the passion of being an Editor-in-Chief.

Meeting the mental health needs of low- and middle-income countries: the start of a long journey

SUMMARY

Mental health is increasingly recognised as an important component of global health. In recognition of this fact, the European Union funded the Emerald programme (Emerging Mental Health Systems in Low- and Middle-Income Countries). The aims were to improve mental health in the following six low- and middle-income countries (LMICs): Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. The Emerald programme offers valuable insights into addressing the mental health needs of LMICs. It provides a framework and practical tools. However, it will be important to evaluate longer-term effects including improvements in mental health outcomes, as well as the applicability to LMICs beyond existing participant countries. Importantly, this must be coupled with efforts to improve health worker retention in LMICs.

Strengthening mental health systems in low- and middle-income countries: recommendations from the Emerald programme

BACKGROUND

There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The 'Emerging mental health systems in low- and middle-income countries (LMICs)' (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.

AIMS

To provide a set of proposed recommendations for mental health system strengthening in LMICs.

METHOD

The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012-2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.

RESULTS

The proposed recommendations align closely with the World Health Organization's key health system strengthening 'building blocks' of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.

CONCLUSIONS

These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.

DECLARATION OF INTEREST

None.