World Health organization guidelines for management of acute stress, PTSD, and bereavement: key challenges on the road ahead

Effectiveness of psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in low- and middle-income countries: A systematic review and meta-analysis

Refugees and asylum seekers are more prone to posttraumatic stress disorder (PTSD) than the general population. This systematic review aims to determine which psychosocial interventions effectively treat PTSD among refugees and asylum seekers in low- and middle-income countries (LMIC). Relevant papers were retrieved from the bibliographic databases. PTSD symptoms post-intervention was the primary outcome. Ten studies were selected with 1981 participants. In meta-analyses of Randomised control trials (RCTs), psychosocial interventions for PTSD (SMD -0.60, 95% CI -0.96 to -0.23; I2 = 91%; 95% CI 75-100; nine studies, 1789 participants) were shown to be clinically effective. Also, in case of depression (SMD -0.59, 95% CI -0.95 to -0.22; I2 = 84%; 95% CI 50-90; seven studies, 1248 participants). Eye Movement Desensitization and Reprocessing (EMDR) had the greatest effect size among psychosocial therapies for this demographic. However, the number of studies is small, and their methodological rigour is limited, thus future study should concentrate on performing more rigorous trials.

Improving bereavement outcomes in Zimbabwe: results of a feasibility cluster trial of the 9-cell bereavement tool

CONTEXT

Despite high mortality rates from both communicable and non-communicable diseases, bereavement is under-researched in African countries. The 9-cell bereavement tool was designed to assist individuals to reflect on their feelings about bereavement and identify resources in families and communities to manage bereavement. This study aimed to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

METHODS

A feasibility cluster randomized trial with embedded qualitative interviews was conducted in two comparable neighbourhoods in Chitungwiza, Zimbabwe. Community leaders identified potential community lay bereavement supporters (interventionists). Each community lay bereavement supporter recruited two to three recently bereaved community members (trial participants). Following baseline data collection, the communities were randomly allocated to intervention or wait-list control. Self-administered questionnaires were completed at T0 (month 0), T1 (3 months) and T2 (6 months). Grief, mental health and social support were assessed. Focus group discussions with selected interventionists described training impact and intervention processes. Quantitative and qualitative analyses were performed.

RESULTS

Implementation of the nine-cell bereavement tool and recruitment to experimental evaluation were successful. Implementation of the tool and the recruitment of study participants were conducted within the intended timeframe of 3 weeks. In line with the suggested sample size, the study was able to recruit and retain at least 75% of the trial participants for the total duration of the study.

CONCLUSION

The feasibility cluster trial was successfully implemented and assessed. Through the published protocol, the literature review and the results of this study, it has been noted that there is an urgent need to carry out a full trial in this subject matter, not only as a contribution to the currently sparse literature in this regard, but for the enormous potential public health benefit in supporting and saving lives in many more under-resourced and under-supported countries.

TRIAL REGISTRATION

Protocol registration: http://www.isrctn.com/ISRCTN16484746 . Protocol publication: https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-019-0450-5.

Association of Psychosocial Stress With Risk of Acute Stroke

IMPORTANCE

Psychosocial stress is considered a modifiable risk factor for stroke. Given the prevalence of chronic and acute exposure to stress, it represents a potentially attractive target for population-health interventions.

OBJECTIVES

To determine the association of psychosocial stress with the risk of acute stroke and explore factors that might modify the association of stress with risk of acute stroke in a large international population.

DESIGN, SETTING, AND PARTICIPANTS

INTERSTROKE is an international retrospective case-control study of risk factors for first acute stroke in 32 countries in Asia, North and South America, Europe, Australia, the Middle East, and Africa. A total of 13 462 patients with stroke and 13 488 matched controls were recruited between January 11, 2007, and August 8, 2015. The present analyses were performed from June 1 to 30, 2021, and included 13 350 cases and 13 462 controls with available data on psychosocial stress.

EXPOSURES

Psychosocial stress and occurrence of stressful life events within the preceding year were measured using a standardized questionnaire of self-reported stress at home and work.

MAIN OUTCOMES AND MEASURES

The association of stress with acute stroke and its subtypes was examined using multivariable conditional logistic regression and factors that might modify the association, particularly self-reported locus of control.

RESULTS

Among 26 812 participants included in the analysis, the mean (SD) age of cases was 62.2 (13.6) years; that of controls, 61.3 (13.3) years; 7960 cases (59.6%) and 8017 controls (59.6%) were men. Several periods of stress and permanent stress were reported for 2745 cases (20.5%) and 1933 controls (14.4%), with marked regional variation in prevalence, with the lowest in China (201 of 3981 [5.0%] among controls and 364 of 3980 [9.1%] among cases) and highest in South East Asia (233 of 855 [26.1%] among controls and 241 of 782 [30.8%] among cases). Increased stress at home (odds ratio [OR], 1.95 [95% CI, 1.77-2.15]) and at work (OR, 2.70 [95% CI, 2.25-3.23]) and recent stressful life events (OR, 1.31 [95% CI, 1.19-1.43]) were associated with an increased risk of acute stroke on multivariable analyses (vs no self-reported stress). Higher locus of control at home was associated with a reduced odds of all stroke (OR, 0.73 [95% CI, 0.68-0.79]), and higher locus of control both at work and at home were associated with a lower odds of acute stroke and significantly diminished the association with stress at work (OR, 2.20 [95% CI, 1.88-2.58]; P = .008 for interaction) and home (OR, 1.69 [95% CI, 1.44-1.98]; P < .001 for interaction) for acute stroke.

CONCLUSIONS AND RELEVANCE

Psychosocial stress is a common risk factor for acute stroke. The findings of this case-control study suggest that higher locus of control is associated with lower risk of stroke and may be an important effect modifier of the risk associated with psychosocial stress.

Risk and protective factors affecting the symptom trajectory of posttraumatic stress disorder post-rape

INTRODUCTION

The prevalence of posttraumatic stress disorder (PTSD) in rape survivors is considerably higher than the prevalence in non-sexual trauma survivors. Few studies have investigated risk and protective factors in survivors early-after-rape in a prospective longitudinal design.

METHODS

In a sample of 639 rape-exposed women who were assessed within 20 days of rape and over 6 months, baseline data were used to predict PTSD symptom severity scores up to 6 months post-rape.

RESULTS

The incidence of PTSD at 3 months was 48.5% and the cumulative incidence at 6 months post-rape was 54.8%. Baseline experience of rape stigma (guilt, shame, self-blame, social devaluation and discredit) and depression were significant predictors of PTSD symptom scores over time, in mixed linear regression models. Higher levels of depression and rape stigma were associated with higher PTSD scores. Assault-related factors were not associated with PTSD scores.

LIMITATIONS

We could not measure PTSD symptom trajectories in all rape survivors, some of who may be at greater risk for PTSD e.g. non-disclosing rape survivors, those who declined participation and those who were extremely distressed at the time of recruitment.

CONCLUSION

Addressing internalised and externalised stigma and resultant mental health effects on women who present to rape clinics may reduce the long-term adverse effects of rape on mental health outcomes, such as PTSD. Rape survivors who present with high levels of depression soon after a rape should be carefully monitored and appropriately treated in order to reduce PTSD severity.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

Prevalence of stressful life events and associations with symptoms of depression, anxiety, and post-traumatic stress disorder among people entering care for HIV in Cameroon

BACKGROUND

Exposure to stressors increases the risk of mental health disorders. People living with HIV (PLWH) are particularly affected by poor mental health which can contribute to adverse HIV treatment outcomes.

METHODS

We estimated the prevalence of recent stressful life events (modified Life Events Survey) among a cohort of PLWH entering HIV care at three public health care facilities in Cameroon and quantified the association of seven types of stressful life events with symptoms of depression (Patient Health Questionnaire-9 scores>9), anxiety (General Anxiety Disorder-7 scores>9), and PTSD (PTSD Checklist for DSM-5 scores>30) using separate log-binomial regression models.

RESULTS

Of 426 PLWH enrolling in care, a majority were women (59%), in relationships (58%), and aged 21 to 39 years (58%). Recent death of a family member (39%) and severe illness of a family member (34%) were the most commonly reported stressful life events. In multivariable analyses, more stressful life event types, a negative relationship change, death or illness of a friend/family member, experience of violence, work-related difficulties, and feeling unsafe in one's neighborhood were independently associated with at least one of the mental health outcomes assessed. The greatest magnitude of association was observed between work-related difficulties and PTSD (adjusted prevalence ratio: 3.1; 95% confidence interval: 2.0-4.8).

LIMITATIONS

Given the design of our study, findings are subject to recall and social desirability bias.

CONCLUSIONS

Stressful life events were common among this population of PLWH entering care in Cameroon. Evidence-based interventions that improve coping, stress management, and mental health are needed.

The 'good life', personal appearance, and mental health of Congolese refugees in Rwanda and Uganda

RATIONALE

Research into mental health and wellbeing recognises the role of positive mental health to enable people to lead healthy and emotionally fulfilling lives. Mental health difficulties continue to be associated with high levels of disability worldwide, and refugees fleeing conflict are known to suffer from poor mental health for years after their forced migration.

METHOD

Informed by Sen's Capability Approach and as part of a wider research project, we used semi-structured interviews to engage with 60 men and women in two refugee communities in Uganda and Rwanda to explore their aspirations and what a 'good life' meant to them.

FINDINGS

While aspects of what constituted a good life were gendered, both men and women struggled to achieve their aspirations within their communities. Following the basic needs of food and shelter, the complex needs of being dressed well and being clean were consistently associated with be able to achieve a 'good life' by women and men across age groups. Looking good and being clean were highly valued and associated with gaining the respect of others, achieving good relationships with neighbours, and avoiding conflict. Participants identified personal appearance and related social status as critical precursors to their successful engagement with other gendered dimensions of social and economic life in their communities, such as finding employment and being well regarded in their religious communities.

CONCLUSIONS

Our findings suggest that without the means to present a good appearance, people living in refugee communities may experience feelings of shame and isolation and are unable to gain self-respect and the respect of others needed to achieve the positive mental and physical health they associate with leading 'a good life'.

Psychometric properties of the Chinese version of the Courtauld Emotional Control Scale in women newly diagnosed with breast cancer

PURPOSE

Emotional control, the attempt to suppress the expression of negative effects, is an essential factor in the prevalence of psychological distress in women with breast cancer. The Courtauld Emotional Control Scale (CECS) is a commonly used self-report tool for assessing emotional suppression in both clinical and general groups. This study aimed to validate the Chinese version of the Courtauld Emotional Control Scale (CECS) in women newly diagnosed with breast cancer.

METHODS

The study involved 680 women newly diagnosed with breast cancer aged 25 to 76 (mean age = 48.19, standard deviation (SD) = 8.57) from Changsha (China). Data analysis included Cronbach's alpha coefficients, the intraclass correlation coefficient (ICC), Pearson's correlations, Independent-Samples T test, confirmatory factor analysis (CFA) and exploratory structural equation modeling (ESEM) were conducted to determine the optimal model. For the best fitting model stability was assessed with tests for invariance across age, educational level, and employment status.

RESULTS

Internal consistency (α = 0.987) and test-retest reliability (ICC = 0.715) of the CECS were presented. Results confirm the structure of the Chinese version of the CECS with 21 items divided into three dimensions, anger suppression (CECS_AG), depression suppression (CECS_MD), and anxiety suppression (CECS_AX). Convergent and known-groups validity were acceptable. Additionally, this model remained invariant across age, educational levels, and employment status.

CONCLUSIONS

The Chinese version of the CECS has good psychometric properties in terms of reliability and validity, remaining invariant across age, educational levels, and employment status in women newly diagnosed with breast cancer.

Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions

Although trauma exposure is a global phenomenon, trauma reactions vary considerably across cultures. Western psychiatric diagnoses, such as posttraumatic stress disorder (PTSD), may be limited in capturing the breadth of trauma reactions in cross-cultural contexts. Instead, cross-cultural instruments should examine locally relevant reactions, such as idioms of distress and explanatory models of illness, and account for ongoing stress and adversity. This article explains the need for complementing traditional trauma assessment approaches, how to create culturally sensitive instruments, the style and stance of practicing cultural humility when administering instruments, how to account for ongoing trauma and adversity, and ways to incorporate findings into treatment. These steps can improve culturally sensitive and comprehensive trauma assessment to capture universal and culturally relevant trauma reactions.

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries

BACKGROUND

Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

METHODS

Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

RESULTS

We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

CONCLUSION

Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017058287 .

Early Hypnotic Intervention After Traumatic Events in Children

Post-traumatic stress disorder is a debilitating condition that can develop after exposure to any potentially traumatic event (natural disaster, physical assault, and car accident). This study focused on four pediatric patients presenting with an early stress response after a motor vehicle accident who were offered early therapeutic and a preventive management by hypnotherapy shortly after exposure to the traumatic event. All patients improved after one or several sessions of hypnosis. The results indicate that hypnotherapy can immediately help patients during the early period following a traumatic event.

Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review

BACKGROUND

Mental health conditions are leading causes of disability worldwide. Psychosocial interventions for these conditions might have a key role in their treatment, although applicability of findings to poor-resource settings might be a challenge. We aimed to evaluate the strength and credibility of evidence generated in low-income and middle-income countries (LMICs) on the efficacy of psychosocial interventions for various mental health outcomes.

METHODS

We did an umbrella review of meta-analyses of randomised studies done in LMICs. Literature searches were done in Medline, Embase, PsychINFO, CINAHL, Cochrane Library, and Epistemonikos from Jan 1, 2010, until May 31, 2019. Systematic reviews of randomised studies investigating the efficacy of psychosocial interventions for mental health conditions in LMICs were included. Systematic reviews of promotion, prevention, and protection interventions were excluded, because the focus was on treatment interventions only. Information on first author, year of publication, outcomes, number of included studies, and reported summary meta-analytic estimates was extracted from included meta-analyses. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects, and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was assessed using quantitative umbrella review criteria, and credibility of evidence using the GRADE approach. This study is registered with PROSPERO, number CRD42019135711.

FINDINGS

123 primary studies from ten systematic reviews were included. The evidence on the efficacy of psychosocial interventions in adults with depression in humanitarian settings (standardised mean difference 0·87, 95% CI 0·67-1·07; highly suggestive association, GRADE: moderate) and in adults with common mental disorders (0·49, 0·36-0·62; highly suggestive association, GRADE: moderate) was supported by the most robust evidence. Highly suggestive strength of association was found for psychosocial interventions in adults with schizophrenia for functional outcomes, in adults with depression, and in adults with post-traumatic stress disorder in humanitarian settings. In children in humanitarian settings, and in children with disruptive behaviour, psychosocial interventions were supported by suggestive evidence of efficacy.

INTERPRETATION

A relatively large amount of evidence suggests the benefit of psychosocial interventions on various mental health outcomes in LMICs. However, strength of associations and credibility of evidence were quite variable, depending on the target mental health condition, type of population and setting, and outcome of interest. This varied evidence should be considered in the development of clinical, policy, and implementation programmes in LMICs and should prompt further studies to improve the strength and credibility of the evidence base.

FUNDING

University of Verona.

Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial

BACKGROUND

Innovative solutions are required to provide mental health support at scale in low-resource humanitarian contexts. We aimed to assess the effectiveness of a facilitator-guided, group-based, self-help intervention (Self-Help Plus) to reduce psychological distress in female refugees.

METHODS

We did a cluster randomised trial in rural refugee settlements in northern Uganda. Participants were female South Sudanese refugees with at least moderate levels of psychological distress (cutoff ≥5 on the Kessler 6). The intervention comprised access to usual care and five 2-h audio-recorded stress-management workshops (20-30 refugees) led by briefly trained lay facilitators, accompanied by an illustrated self-help book. Villages were randomly assigned to either intervention (Self-Help Plus or enhanced usual care) on a 1:1 basis. Within 14 villages, randomly selected households were approached. Screening of women in households continued until 20-30 eligible participants were identified per site. The primary outcome was individual psychological distress, assessed using the Kessler 6 symptom checklist 1 week before, 1 week after, and 3 months after intervention, in the intention-to-treat population. All outcomes were measured at the individual (rather than cluster) level. Secondary outcomes included personally identified problems, post-traumatic stress, depression symptoms, feelings of anger, social interactions with other ethnic groups, functional impairment, and subjective wellbeing. Assessors were masked to allocation. This trial was prospectively registered at ISRCTN, number 50148022.

FINDINGS

Of 694 eligible participants (331 Self-Help Plus, 363 enhanced usual care), 613 (88%) completed all assessments. Compared with controls, we found stronger improvements for Self-Help Plus on psychological distress 3 months post intervention (β -1·20, 95% CI -2·33 to -0·08; p=0·04; d -0·26). We also found larger improvements for Self-Help Plus 3 months post-intervention for five of eight secondary outcomes (effect size range -0·30 to -0·36). Refugees with different trauma exposure, length of time in settlements, and initial psychological distress benefited similarly. With regard to safety considerations, the independent data safety management board responded to six adverse events, and none were evaluated to be concerns in response to the intervention.

INTERPRETATION

Self-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees.

FUNDING

Research for Health in Humanitarian Crises (R2HC) Programme.

Reflections on "Building Back Better" Child and Adolescent Mental Health Care in a Low-Resource Postemergency Setting: The Case of Sierra Leone

Over the past three decades, Sierra Leone has experienced two major humanitarian crises: an armed conflict (1991-2002) and an Ebola virus disease outbreak (2014-2015). In addition to these country-wide crises, the capital Freetown experienced a mudslide affecting thousands of people in 2017. In response to these emergencies, donors and aid organizations showed an increased interest in supporting and implementing mental health and psychosocial support interventions. Despite these efforts, the mental health infrastructure of the country remains frail. Specifically, systemic improvements in the implementation of evidence-based mental health care for children and adolescents appear to be lacking. In this article, the Interactive Systems Framework for Dissemination and Implementation is used as a tool to analyze issues related to the development of a sustainable, contextually relevant child and adolescent mental health-care delivery system. The author draws on her long-term experience as a child mental health specialist in Sierra Leone. Observations and hypotheses are tested and supplemented by formal and informal reports and national and international literature. The three systems described by the Interactive Systems Framework are explored in the context of Sierra Leone: (1) Synthesis and Translation, (2) Support, and (3) Delivery. Interaction between the three Systems is discussed as critical to the successful dissemination and implementation of interventions. Ample attention is given to contextual factors that are believed to be paramount to the development of child and adolescent mental health care in Sierra Leone. The article concludes with a reflection on the usefulness of the Interactive Systems Framework in the dissemination and implementation of child and adolescent mental health-care interventions in low-resource, postemergency settings. It is suggested that, in addition to funding and policies, the child and adolescent mental health system in Sierra Leone could benefit from the development of contextually relevant interventions, improvement of capacity-building efforts, and acknowledgment of the role of community-based practitioners in the delivery of services. Local mental health experts, especially those trained in child and adolescent mental health, should be empowered to work together with culturally competent expatriate professionals to improve child and adolescent mental health care in Sierra Leone.

Considering culture, context and community in mhGAP implementation and training: challenges and recommendations from the field

BACKGROUND

Major efforts are underway to improve access to mental health care in low- and middle-income countries (LMIC) including systematic training of non-specialized health professionals and other care providers to identify and help individuals with mental disorders. In many LMIC, this effort is guided by the mental health Gap Action Programme (mhGAP) established by the World Health Organization, and commonly centres around one tool in this program: the mhGAP-Intervention Guide.

OBJECTIVE

To identify cultural and contextual challenges in mhGAP training and implementation and potential strategies for mitigation.

METHOD

An informal consultative approach was used to analyze the authors' combined field experience in the practice of mhGAP implementation and training. We employed iterative thematic analysis to consolidate and refine lessons, challenges and recommendations through multiple drafts. Findings were organized into categories according to specific challenges, lessons learned and recommendations for future practice. We aimed to identify cross-cutting and recurrent issues.

RESULTS

Based on intensive fieldwork experience with a focus on capacity building, we identify six major sets of challenges: (i) cultural differences in explanations of and attitudes toward mental disorder; (ii) the structure of the local health-care system; (iii) the level of supervision and support available post-training; (iv) the level of previous education, knowledge and skills of trainees; (v) the process of recruitment of trainees; and (vi) the larger socio-political context. Approaches to addressing these problems include: (1) cultural and contextual adaptation of training activities, (2) meaningful stakeholder and community engagement, and (3) processes that provide support to trainees, such as ongoing supervision and Communities of Practice.

CONCLUSION

Contextual and cultural factors present major barriers to mhGAP implementation and sustainability of improved services. To enable trainees to effectively apply their local cultural knowledge, mhGAP training needs to: (1) address assumptions, biases and stigma associated with mental health symptoms and problems; (2) provide an explicit framework to guide the integration of cultural knowledge into assessment, treatment negotiation, and delivery; and (3) address the specific kinds of problems, modes of clinical presentations and social predicaments seen in the local population. Continued research is needed to assess the effectiveness these strategies.

Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.

METHODS

We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.

RESULTS

We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.

CONCLUSIONS

Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Improving bereavement outcomes in Zimbabwe: protocol for a feasibility cluster trial of the 9-cell bereavement tool

Background

The high burden of bereavement in sub-Saharan Africa is largely attributable to HIV, cancer, and other non-communicable diseases. However, interventions to improve grief and bereavement are rare. Given high rates of mortality in the context of weak health systems, community lay members are well placed to provide peer bereavement support. The 9-cell bereavement tool was developed in Zimbabwe to improve community members’ capacity to support the bereaved. This study aims to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

Methods/design

This feasibility cluster randomized trial with embedded qualitative interviews will be conducted in two comparable neighborhoods in Zimbabwe. Community leaders from each neighborhood will identify 25 potential community lay bereavement supporters, each of whom will recruit 2–3 bereaved community members into the trial. The intervention will be randomly allocated to one community, and the second community will form a wait-list control (n ≥ 75 in each community cluster). Recruitment is estimated to take place over 3 weeks. Measures at T0 (baseline, i.e., week 0), T1 (midline, i.e., week 14 or 3 months post-baseline) and T2 (endline, i.e., week 27 or 3 months post-midline) will address mental health, social support, and levels of grief per individual. Qualitative data will describe lay supporters’ views of intervention training and delivery, and participants’ experience of bereavement support.

Discussion

This is the first documented trial evaluating a bereavement intervention in sub-Saharan Africa. Recruitment, retention, and measurement data will determine the feasibility of a full trial.

Trial registration

ISRCTN, ISRCTN16484746. Registered 6 February 2018

Resilience as a predictive factor towards a healthy adjustment to grief after the loss of a child to cancer

INTRODUCTION

Grief among bereaved parents is known to cause psychological distress and physical illness, but knowledge concerning factors that can contribute to health promotion after bereavement is scarce. Childhood cancer remains the most common non-accidental cause of death among children in Norway. The aim of the present study was to explore if resilience factors among cancer-bereaved parents could predict whether they will be able to come to terms with their grief 2-8 years following the loss.

METHODS

A Norwegian cross-sectional national survey was conducted among 161 cancer-bereaved parents using a study-specific questionnaire. Logistic regression was used to explore whether resilience factors predicted parents' grief outcome 2-8 years after their loss.

RESULTS

On the Resilience Scale for Adults (RSA), three of the resilience factors contributed significantly in predicting whether the parents in the present study would come to terms with their grief 2-8 years after the loss their child: "Perception of self "(OR 2.08, p = .048), "Social resources" (OR 2.83, p = .008) and "Family cohesion" (OR .41, p = .025). The results showed a negative relationship between time since loss (2-6 years) and whether the parents answered that they had come to terms with their grief (p = < .05). The loss of a parent (OR .30, p = .030) combined with the loss of their child had a negative and significant effect on whether they indicated that they had processed their grief.

CONCLUSION

The total score of RSA and three of the six resilient factors contributed significantly in predicting whether cancer-bereaved parents in the present study indicated that they had come to terms with their grief to a great extent. The present study supports hypotheses that regard resilience as an important contribution in predicting healthy outcomes in people exposed to adverse life events.

Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability

A new mental health disorder, prolonged grief disorder (PGD), will be included in the 11th edition of the International Classification of Diseases (ICD-11). We provide a brief overview of the historical conceptualizations of disordered grief and the previous research efforts to assess and define this condition. We describe the new ICD-11 PGD symptom criteria and how they are conceptualized in terms of the World Health Organization's call for improved clinical utility. Finally, we review the research evidence for the clinical utility of the new ICD-11 PGD symptom structure and usability in the international arena.

Settling Ulysses: An Adapted Research Agenda for Refugee Mental Health

Refugees and asylum seekers arriving in Europe during the 2015/2016 wave of migration have been exposed to war conditions in their country of origin, survived a dangerous journey, and often struggled with negative reception in transit and host countries. The mental health consequence of such forced migration experiences is named the Ulysses syndrome. Policies regarding the right to residency can play an important role in reducing mental health symptoms. We propose that facilitating a sense of belonging should be seen as one important preventive mental healthcare intervention. A refugee mental health agenda needs to take into account the interplay between refugees’ and asylum seekers’ mental health, feeling of belonging, and access to healthcare. We urge for policies to restore individuals’ dignity, and recognize the right for homecoming to parallel the mythology of Ulysses.

Mental health care for adult refugees in high-income countries

Approximately one-third of people who have obtained refugee status live in high-income countries. Over recent years, the number of refugees has been increasing, and there are questions on how many of them need mental health care and which type of interventions are beneficial. Meta-analyses showed highly variable rates of mental disorders in adult refugees. This variability is likely to reflect both real differences between groups and contexts, and methodological inconsistencies across studies. Overall prevalence rates after resettlement are similar to those in host populations. Only post-traumatic stress disorder (PTSD) is more prevalent in refugees. In long-term resettled refugees, rates of anxiety and depressive disorders are higher and linked to poor social integration. Research on mental health care for refugees in high-income countries has been extensive, but often of limited methodological quality and with very context-specific findings. The existing evidence suggests several general principles of good practice: promoting social integration, overcoming barriers to care, facilitating engagement with treatment and, when required, providing specific psychological treatments to deal with traumatic memories. With respect to the treatment of defined disorders, only for the treatment of PTSD there has been substantial refugee-specific research. For other diagnostic categories, the same treatment guidelines apply as to other groups. More systematic research is required to explore how precisely the general principles can be specified and implemented for different groups of refugees and in different societal contexts in host countries, and which specific interventions are beneficial and cost-effective. Such interventions may utilise new communication technologies. Of particular importance are long-term studies to identify when mental health interventions are appropriate and to assess outcomes over several years. Such research would benefit from sufficient funding, wide international collaboration and continuous learning over time and across different refugee groups.

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda

BACKGROUND

In this period of unprecedented levels of displacement, scalable interventions are needed to address mental health concerns of forced migrants in low-resource settings. This paper describes the adaptation and piloting of a guided, multi-media, self-help intervention, Self-Help Plus (SH+), which was developed to reduce psychological distress in large groups of people affected by adversity.

METHODS

Using a phased approach that included community consultations, cognitive interviewing, facilitator training, pilot implementation, and a qualitative process evaluation, we adapted SH+ for use among South Sudanese refugees in a refugee settlement in northern Uganda.

RESULTS

The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Juba Arabic. Cognitive interviewing primarily resulted in adaptations to language with some minor adaptations to content. Facilitator training and supervision led to further suggested changes to delivery methods. An uncontrolled pilot study (n = 65) identified changes in the expected direction on measures of psychological distress, functional impairment, depression, wellbeing, and psychological flexibility. The process evaluation resulted in further adaptations to intervention materials and the decision to focus future effectiveness evaluations of the intervention in its current form on South Sudanese female refugees.

CONCLUSIONS

We found that this potentially scalable, guided self-help intervention could be adapted for and feasibly implemented among female South Sudanese refugees in northern Uganda. These findings lay the groundwork for a future rigorous evaluation of SH+ in this context.

Mapping the evidence on pharmacological interventions for non-affective psychosis in humanitarian non-specialised settings: a UNHCR clinical guidance

BACKGROUND

Populations exposed to humanitarian emergencies are particularly vulnerable to mental health problems, including new onset, relapse and deterioration of psychotic disorders. Inadequate care for this group may lead to human rights abuses and even premature death. The WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), and its adaptation for humanitarian settings (mhGAP-HIG), provides guidance for management of mental health conditions by non-specialised healthcare professionals. However, the pharmacological treatment of people with non-affective psychosis who do not improve with mhGAP first-line antipsychotic treatments is not addressed. In order to fill this gap, UNHCR has formulated specific guidance on the second-line pharmacological treatment of non-affective psychosis in humanitarian, non-specialised settings.

METHODS

Following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, a group of international experts performed an extensive search and retrieval of evidence on the basis of four scoping questions. Available data were critically appraised and summarised. Clinical guidance was produced by integrating this evidence base with context-related feasibility issues, preferences, values and resource-use considerations.

RESULTS

When first-line treatments recommended by mhGAP (namely haloperidol and chlorpromazine) are not effective, no other first-generation antipsychotics are likely to provide clinically meaningful improvements. Risperidone or olanzapine may represent beneficial second-line options. However, if these second-line medications do not produce clinically significant beneficial effects, there are two possibilities. First, to switch to the alternative (olanzapine to risperidone or vice versa) or, second, to consider clozapine, provided that specialist supervision and regular laboratory monitoring are available in the long term. If clinically relevant depressive, cognitive or negative symptoms occur, the use of a selective serotonin reuptake inhibitor may be considered in addition or as an alternative to standard psychological interventions.

CONCLUSIONS

Adapting scientific evidence into practical guidance for non-specialised health workers in humanitarian settings was challenging due to the paucity of relevant evidence as well as the imprecision and inconsistency of results between studies. Pragmatic outcome evaluation studies from low-resource contexts are urgently needed. Nonetheless, the UNHCR clinical guidance is based on best available evidence and can help to address the compelling issue of undertreated, non-affective psychosis in humanitarian settings.

The meaning and experience of bereavement support: A qualitative interview study of bereaved family caregivers

Objective:

Experiences of bereavement can be stressful and are frequently complicated by emotional, familial, and financial issues. Some—though not all—caregivers may benefit from bereavement support. While considered standard within palliative care services in Australia, bereavement support is not widely utilized by family caregivers. There is little research focused on the forms of bereavement support desired or required by family caregivers, how such care is viewed, and/or how bereavement support is experienced. This study examined the experiences of bereaved family caregivers and their impressions of and interactions with bereavement support.

Method:

This paper reports on one aspect of a broader study designed to explore a range of experiences of patients and caregivers to and through palliative care. Focusing on experiences of bereavement, it draws on qualitative semistructured interviews with 15 family caregivers of palliative care patients within a specialist palliative care unit of an Australian metropolitan hospital. The interviews for this stage of the study were initiated 3–9 months after an initial interview with a family caregiver, during which time the palliative patient had died, and they covered family caregivers' experiences of bereavement and bereavement support. Interviews were digitally audiotaped and transcribed in full. A thematic analysis was conducted utilizing the framework approach wherein interview transcripts were reviewed, key themes identified, and explanations developed.

Results:

The research identified four prevalent themes: (1) sociocultural constructions of bereavement support as for the incapable or socially isolated; (2) perceptions of bereavement support services as narrow in scope; (3) the “personal” character of bereavement and subsequent incompatibility with formalized support, and (4) issues around the timing and style of approaches to being offered support.

Significance of results:

Systematic pre-bereavement planning and careful communication about the services offered by palliative care bereavement support centers may improve receipt of support among bereaved family caregivers in need.

An integrated intervention to reduce intimate partner violence and psychological distress with refugees in low-resource settings: study protocol for the Nguvu cluster randomized trial

BACKGROUND

Intimate partner violence (IPV) is a critical public health and human rights concern globally, including for refugee women in low-resource settings. Little is known about effective interventions for this population. IPV and psychological distress have a bi-directional relationship, indicating the potential benefit of a structured psychological component as part of efforts to reduce IPV for women currently in violent relationships.

METHODS

This protocol describes a cluster randomized controlled trial aimed at evaluating an 8-session integrated psychological and advocacy intervention (Nguvu) with female adult survivors of past-year IPV displaying moderate to severe psychological distress. Outcomes are reductions in: recurrence of IPV; symptoms of anxiety, depression and post-traumatic stress (primary); and functional impairment (secondary). Hypothesized mediators of the intervention are improvements in social support, coping skills and support seeking. We will recruit 400 participants from existing women's support groups operating within villages in Nyarugusu refugee camp, Tanzania. Women's groups will be randomized to receive the intervention (Nguvu and usual care) or usual care alone. All eligible women will complete a baseline assessment (week 0) followed by a post-treatment (week 9) and a 3-month post-treatment assessment (week 20). The efficacy of the intervention will be determined by between-group differences in the longitudinal trajectories of primary outcomes evaluated using mixed-effects models. Study procedures have been approved by Institutional Review Boards in the United States and Tanzania.

DISCUSSION

This trial will provide evidence on the efficacy of a novel integrated group intervention aimed at secondary prevention of IPV that includes a structured psychological component to address psychological distress. The psychological and advocacy components of the proposed intervention have been shown to be efficacious for their respective outcomes when delivered in isolation; however, administering these approaches through a single, integrated intervention may result in synergistic effects given the interrelated, bidirectional relationship between IPV and mental health. Furthermore, this trial will provide information regarding the feasibility of implementing a structured intervention for IPV and mental health in a protracted humanitarian setting.

TRIAL REGISTRATION

ISRCTN65771265 , June 27, 2016.

The mental health of civilians displaced by armed conflict: an ecological model of refugee distress

Early research on the mental health of civilians displaced by armed conflict focused primarily on the direct effects of exposure to war-related violence and loss. Largely overlooked in this war exposure model were the powerful effects of ongoing stressors related to the experience of displacement itself. An ecological model of refugee distress is proposed, drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors. Implications of this model for addressing the mental health and psychosocial needs of refugees and other displaced populations are considered.

Guidelines in lower-middle income countries

Guidelines include recommendations intended to optimize patient care; used appropriately, they make healthcare consistent and efficient. In most lower-middle income countries (LMICs), there is a paucity of well-designed guidelines; as a result, healthcare workers depend on guidelines developed in Higher Income Countries (HICs). However, local guidelines are more likely to be implemented because they are applicable to the specific environment; and consider factors such as availability of resources, specialized skills and local culture. If guidelines developed in HICs are to be implemented in LMICs, developers need to incorporate local experts in their development. Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to implementation in LMICs. Another option is to encourage local experts to adapt them for use in LMICs; these guidelines may recommend strategies different from those used in HICs, but will be aimed at achieving the best practicable standard of care. Infrastructural deficits in LMICs could be improved by learning from and building on the successful response to the human immunodeficiency virus/acquired immunodeficiency syndrome pandemic through interactions between HICs and LMICs. Similarly, collaborations between postgraduate medical colleges in both HICs and LMICs may help specialist doctors training in LMICs develop skills required for guideline development and implementation.

Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis

Treatment of post-traumatic stress disorder (PTSD) in refugees and asylum seekers resettled in high-income countries presents specific challenges. This systematic review examined the effectiveness of psychosocial interventions for this group. We searched the Cochrane Central Register of randomised trials, CINAHL, EMBASE, PILOTS, PsycINFO, PubMed and Web of Science up to July 2016. Studies included randomised and controlled clinical trials comparing psychosocial interventions with waiting list or treatment as usual in adult refugees and asylum seekers with PTSD resettled in high-income countries. PTSD symptoms post-intervention was the primary outcome. We computed standardized mean differences (SMD) with 95% confidence intervals (CI). This study is registered with PROSPERO: CRD42015027843. Twelve studies were included in the meta-analysis. Psychosocial interventions were effective in decreasing PTSD symptoms relative to control groups (SMD -1·03, 95% CI -1·55 to -0·51; number needed to treat 4·4; I2 86%; 95% CI 77 to 91). Narrative exposure therapy, a manualized short-term variant of cognitive behavioural therapy with a trauma focus, was the best-supported intervention (5 RCTs, 187 participants, SMD -0·78, 95% CI -1·18 to -0·38, I2 37%; 95% CI 0 to 77). Methodological quality of the included studies was limited. Overall, psychosocial interventions for asylum seekers and refugees with PTSD resettled in high-income countries were found to provide significant benefits in reducing PTSD symptoms. Yet, the number of studies is small and their methodological quality limited, so that more rigorous trials should be conducted in the future.

Mental health treatment outcome expectancies in Burundi

Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms) . In individual interviews or written surveys in French or Kirundi with patients ( N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each ("Would it work?" "Why or why not?"). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people's beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.

Internet and mobile technologies: addressing the mental health of trauma survivors in less resourced communities

Internet and mobile technologies offer potentially critical ways of delivering mental health support in low-resource settings. Much evidence indicates an enormous negative impact of mental health problems in low- and middle-income countries (LMICs), and many of these problems are caused, or worsened, by exposure to wars, conflicts, natural and human-caused disasters, and other traumatic events. Though specific mental health treatments have been found to be efficacious and cost-effective for low-resource settings, most individuals living in these areas do not have access to them. Low-intensity task-sharing interventions will help, but there is a limit to the scalability and sustainability of human resources in these settings. To address the needs of trauma survivors, it will be important to develop and implement Internet and mobile technology resources to help reduce the scarcity, inequity, and inefficiency of current mental health services in LMICs. Mobile and Internet resources are experiencing a rapid growth in LMICs and can help address time, stigma, and cost barriers and connect those who have been socially isolated by traumatic events. This review discusses current research in technological interventions in low-resource settings and outlines key issues and future challenges and opportunities. Though formidable challenges exist for large-scale deployment of mobile and Internet mental health technologies, work to date indicates that these technologies are indeed feasible to develop, evaluate, and deliver to those in need of mental health services, and that they can be effective.

Developing the Botswana Primary Care Guideline: an integrated, symptom-based primary care guideline for the adult patient in a resource-limited setting

BACKGROUND

Botswana's health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG) integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.

METHODS

The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town) collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.

RESULTS

Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.

CONCLUSION

The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better patient outcomes as similar projects elsewhere have done.

Disaster psychiatry in Asia: The potential of smartphones, mobile, and connected technologies

Disaster mental health is recognized as a crucial part of disaster preparedness and response. Despite the commonality of disasters in Asia, many countries face formidable barriers to a rapid and robust mental health care response. Mobile technologies can alleviate the immediate suffering and reduce onset of chronic conditions such as post-traumatic stress disorder and depression. This article explores the role of mobile technologies to improve mental health before, during, and after disasters in Asia.

Rethinking the service delivery system of psychological interventions in low and middle income countries

BACKGROUND

Global mental health is a growing field intricately connected to broader health, violence and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75 % of those with need in lower resource settings do not receive intervention. Most studies to date have examined the effectiveness of single-disorder mental health treatments - an approach that may be a significant challenge to scale-up and sustainability in lower resource settings.

MAIN BODY

This paper presents a brief overview of the scientific progress in global mental health, and suggests consideration of an internal stepped care delivery approach. An internal stepped care model is one idea of a delivery system, utilizing a common elements approach, where the same provider could navigate between different elements based on severity and type of problems of the client. It is distinct from traditional stepped care models in that clients remain with the same provider, rather than relying on referral systems.

CONCLUSION

An internal stepped care delivery system based on a simplified common elements approach could be more efficient, scalable, sustainable, and reduce the loss of clients to referrals in lower resource settings.

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda

BACKGROUND

In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda.

METHODS

In-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews.

RESULTS

Practices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients.

CONCLUSIONS

Guidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.

Community-based intervention for depression management at the primary care level in Ha Nam Province, Vietnam: a cluster-randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of an intervention including psychoeducation and yoga for depression management at the primary healthcare level in one district in the Hà Nam province, Vietnam.

METHOD

The Patient Health Questionnaire-9 (PHQ-9) was used for depression screening and follow-up. Screened patients were further diagnosed with the Mini-International Neuropsychiatric Diagnostic Interview, by a trained general doctor. A linear regression model, adjusted for age, gender and baseline PHQ-9 score was used to assess whether the intervention leads to decreased depression severity compared to standard care in the control communes.

RESULTS

Both groups had similar PHQ-9 scores at baseline. The intervention group had on average significantly lower PHQ-9 scores after the intervention than the control group. Almost half of the patients in the intervention group recovered from depression, whereas nobody did in the control group.

CONCLUSION

The results indicate that the intervention can be more effective than standard care in treating depression. The mean change of the PHQ-9 score after the intervention is deemed to be of clinical relevance.

Broadening perspectives on trauma and recovery: a socio-interpersonal view of PTSD

Posttraumatic stress disorder (PTSD) is one of the very few mental disorders that requires by definition an environmental context-a traumatic event or events-as a precondition for diagnosis. Both trauma sequelae and recovery always occur in the context of social-interpersonal contexts, for example, in interaction with a partner, family, the community, and the society. The present paper elaborates and extends the social-interpersonal framework model of PTSD. This was developed to complement other intrapersonally focused models of PTSD, which emphasize alterations in an individual's memory, cognitions, or neurobiology. Four primary reasons for broadening the perspective from the individual to the interpersonal-societal contexts are discussed. The three layers of the model (social affects, close relationships, and culture and society) are outlined. We further discuss additional insights and benefits of the social-interpersonal perspective for the growing field of research regarding resilience after traumatic experiences. The paper closes with an outlook on therapy approaches and interventions considering this broader social-interpersonal perspective on PTSD.

The "treatment gap" in global mental health reconsidered: sociotherapy for collective trauma in Rwanda

BACKGROUND

The "treatment gap" (TG) for mental disorders refers to the difference that exists between the number of people who need care and those who receive care. The concept is strongly promoted by the World Health Organization and widely used in the context of low- and middle-income countries. Although accepting the many demonstrable benefits that flow from this approach, it is important to critically reflect on the limitations of the concept of the TG and its implications for building capacity for mental health services in Rwanda.

OBJECTIVE

The article highlights concerns that the evidence base for mental health interventions is not globally valid, and problematizes the preponderance of psychiatric approaches in international guidelines for mental health. Specifically, the risk of medicalization of social problems and the limited way in which "community" has been conceptualized in global mental health discourses are addressed. Rather than being used as a method for increasing economic efficiency (i.e., reducing healthcare costs), "community" should be promoted as a means of harnessing collective strengths and resources to help promote mental well-being. This may be particularly beneficial for contexts, like Rwanda, where community life has been disrupted by collective violence, and the resulting social isolation constitutes an important determinant of mental distress.

CONCLUSIONS

Moving forward there is a need to consider alternative paradigms where individual distress is understood as a symptom of social distress, which extends beyond the more individually oriented TG paradigm. Sociotherapy, an intervention used in Rwanda over the past 10 years, is presented as an example of how communities of support can be built to promote mental health and psychosocial well-being.

Facing Violence - A Global Challenge

Violence has been shown to be a global challenge resulting in long-lasting social, medical, and mental health sequelae. In this article, we focus on massive social violence, such as war and civil war. Social suffering and mental health problems related to violence as a global public health problem can be tackled only with a holistic approach that addresses the specific region, culture and group and the limited resources available in most countries. Research that can give a reliable assessment of complex long-term outcomes is still largely missing, and can be seen as a major and complex challenge for future study.

A public health approach to address the mental health burden of youth in situations of political violence and humanitarian emergencies

This paper describes how socio-ecological theory and a syndemic health systems and public health approach may help address the plight of youth in situations of political violence and humanitarian emergencies. We describe the treatment gap caused by discrepancies in epidemiological prevalence rates, individual and family needs, and available human and material resources. We propose four strategies to develop a participatory public health approach for these youth, based on principles of equity, feasibility, and a balance between prevention and treatment. The first strategy uses ecological and transgenerational resilience as a theoretical framework to facilitate a systems approach to the plight of youth and families. This theoretical base helps to engage health care professionals in a multisectoral analysis and a collaborative public health strategy. The second strategy is to translate pre-program assessment into mental health and psychosocial support (MHPSS) priorities. Defining priorities helps to develop programs and policies that align with preventive and curative interventions in multiple tiers of the public health system. The third is a realistic budgetary framework as a condition for the development of sustainable institutional capacity including a monitoring system. The fourth strategy is to direct research to address the knowledge gap about effective practices for youth mental health in humanitarian settings.

Access and use of psychotropic medicines in low-resource settings

Improving access and rational use of essential medicines at all levels of care is a global challenge. Key issues related to the provision and rational use of psychotropic medicines have recently been analysed by Padmanathan et al. who conducted a survey of the psychotropic medicines management cycle in Bihar, the third most populous state of India with approximately 104 million people, of whom 88.7% live in rural areas. It was found that availability, distance and cost were the main barriers to access and utilisation. Travelling was reported to be particularly problematic because it is expensive and may also be unfeasible for service users who are acutely ill. In this commentary, the results of this survey are discussed in view of their global policy implications for low-resource settings.

Health service utilization after terrorism: a longitudinal study of survivors of the 2011 Utøya attack in Norway

Background

For effective organization of health services after terror attacks, it is vital to gain insight into survivors’ health service utilization. Following the 2011 Utøya mass shooting in Norway, a proactive outreach programme was launched to prevent unmet help needs. All survivors received health services during the first five months, yet an important minority were not proactively followed-up. This study assessed the prevalence of health service utilization and factors associated with mental health service utilization among the survivors 5–15 months after the attack.

Methods

The study comprised data from interviews using standardised questionnaires performed 4–5 (T1) and 14–15 (T2) months after the attack. Altogether 281 of 490 (57.3%) survivors answered questions on health service utilization at T2 and were included in this study. Users and non-users of mental health services were compared using Pearson Chi Square tests (categorical variables) and independent t-tests (continuous variables). Multivariate logistic regression analyses were conducted to examine the relationship between mental health service utilization at T2 and early (model 1) and concurrent (model 2) posttraumatic stress reactions, mental distress and somatic symptoms. Both models were adjusted for age, gender and predisaster utilization of mental health services.

Results

Altogether 267 (95.0%) of 281 survivors reported contact with health services at T2, including 254 (90.4%) with ≥1 types of primary care services; and 192 (68.3%) with mental health services. In bivariate analyses, mental health service utilization was associated with female gender, injuries, PTSD, mental distress, somatic symptoms, and sleep problems. After multivariate adjustments for early symptom levels (model 1), only mental distress remained significantly associated with mental health service utilization at T2 (OR 2.8, 95% CI 1.2-6.8). In the analysis adjusting for concurrent symptom levels (model 2), only somatic symptoms were associated with mental health service utilization (OR 4.4, 95% CI 1.8-10.8).

Conclusions

The high utilization of both primary and secondary health services among young survivors 5–15 months after the attack underscores the importance of allocating resources to meet the increased demand for services over a longer time period. The results further highlight the need to address somatic symptoms in disaster survivors who receive mental health services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0811-6) contains supplementary material, which is available to authorized users.