Integration of mental health into primary healthcare in low-income countries: avoiding medicalization

Implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states of Sudan

INTRODUCTION

The health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients' outcomes and ensures efficient use of the resources in such a resource limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan.

METHODS

Descriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. P value < 0.05 was considered statistically significant.

RESULTS

Most of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation.

CONCLUSION

Guidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan can be useful tools for policymakers in the optimum allocation of public health resources.

Reprioritising global mental health: psychoses in sub-Saharan Africa

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Experiences and Perceptions of Telephone-delivery of the Common Elements Treatment Approach for Mental Health Needs Among Young People in Zambia During the COVID-19 Pandemic

Background

Mental and behavioral health needs are immense in low-to-middle income countries (LMIC), particularly for adolescents and young adults (AYA). However, access to mental health services is limited in LMIC due to barriers such as distance to a health care site, low number of providers, and other structural and logistical challenges. During the COVID-19 pandemic, these barriers were significantly exacerbated and, thus, mental health services were severely disrupted. A potential solution to some of these barriers is remote delivery of such services via technology. Exploration of AYA experiences is needed to understand the benefits and challenges when shifting to remotely delivered services.

Methods

Participants included 16 AYA (15-29 years) residing in Lusaka, Zambia who met criteria for a mental or behavioral health concern and received telehealth delivery of the Common Elements Treatment Approach (CETA). AYA participated in semi-structured qualitative interviews to explore feasibility, acceptability, and barriers to telephone-delivered treatment in this context. Thematic coding analysis was conducted to identify key themes.

Findings

Three major response themes emerged: 1) Advantages of telehealth delivery of CETA, Disadvantages or barriers to telehealth delivery of CETA, 3) AYA recommendations for optimizing telehealth (ways to improve telehealth delivery in Zambia. Results indicate that logistical and sociocultural barriers i.e., providing AYA with phones to use for sessions, facilitating one face-to-face meeting with providers) need to be addressed for success of remotely delivered services.

Conclusion

AYA in this sample reported telehealth delivery reduces some access barriers to engaging in mental health care provision in Zambia. Addressing logistical and sociocultural challenges identified in this study will optimize feasibility of telehealth delivery and will support the integration of virtual mental health services in the Zambian health system.

"I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence

Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

Conceptualization, detection, and management of psychological distress and mental health conditions among people with tuberculosis in Zambia: a qualitative study with stakeholders' and TB health workers

BACKGROUND

In recent years, there has been increased recognition of the need to integrate mental health services into routine tuberculosis (TB) care. For successful integration, policymakers need to first understand the practices of TB health workers in the management of mental health conditions, including depression, anxiety, and psychological distress, and use this to decide how best mental health services could be delivered in tandem with TB services. In this qualitative study we aimed to understand how TB health workers and other stakeholders viewed mental health conditions linked to TB and how they screened and treated these in their patients.

METHODS

The study draws on qualitative data collected in 2018 as part of the Tuberculosis Reduction through Expanded Antiretroviral Treatment and Screening for active TB trial (TREATS), conducted in eight urban communities in Zambia. Data were collected through 17 focus group discussions with local health committee members (n = 96) and TB stakeholders (n = 57) present in the communities. Further in-depth interviews were held with key TB health workers (n = 9). Thematic analysis was conducted.

RESULTS

TB stakeholders and health workers had an inadequate understanding of mental health and commonly described mental health conditions among TB patients by using stigmatizing terminology and overtones, for example "madness", which often implied a characterological flaw rather an actual illness. Psychological distress was also described as "overthinking", which participants attributed to psychosocial stressors, and was not perceived as a condition that would benefit from mental health intervention. There were no standard screening and treatment options for mental health conditions in TB patients and most TB health workers had no mental health training. TB Stakeholders and health workers understood the negative implications of mental health conditions on TB treatment adherence and overall wellbeing for TB patients.

CONCLUSIONS

TB stakeholders and health workers in Zambia have a complex conceptualisation of mental health and illness, that does not support the mental health needs of TB patients. The integration of mental health training in TB services could be beneficial and shift negative attitudes about mental health. Further, TB patients should be screened for mental health conditions and offered treatment. Trial registration number NCT03739736-Registered on the 14th of November 2018- Retrospectively registered- https://clinicaltrials.gov/ct2/results?cond=&term=NCT03739736&cntry=&state=&city=&dist.

Classification, prevalence and integrated care for neurodevelopmental and child mental health disorders: A brief overview for paediatricians

‘Neurodevelopmental disorders’ comprise a group of congenital or acquired long-term conditions that are attributed to disturbance of the brain and or neuromuscular system and create functional limitations, including autism spectrum disorder, attention deficit/ hyperactivity disorder, tic disorder/ Tourette’s syndrome, developmental language disorders and intellectual disability. Cerebral palsy and epilepsy are often associated with these conditions within the broader framework of paediatric neurodisability. Co-occurrence with each other and with other mental health disorders including anxiety and mood disorders and behavioural disturbance is often the norm. Together these are referred to as neurodevelopmental, emotional, behavioural, and intellectual disorders (NDEBIDs) in this paper. Varying prevalence rates for NDEBID have been reported in developed countries, up to 15%, based on varying methodologies and definitions. NDEBIDs are commonly managed by either child health paediatricians or child/ adolescent mental health (CAMH) professionals, working within multidisciplinary teams alongside social care, education, allied healthcare practitioners and voluntary sector. Fragmented services are common problems for children and young people with multi-morbidity, and often complicated by sub-threshold diagnoses. Despite repeated reviews, limited consensus among clinicians about classification of the various NDEBIDs may hamper service improvement based upon research. The recently developed “Mental, Behavioural and Neurodevelopmental disorder” chapter of the International Classification of Diseases-11 offers a way forward. In this narrative review we search the extant literature and discussed a brief overview of the aetiology and prevalence of NDEBID, enumerate common problems associated with current classification systems and provide recommendations for a more integrated approach to the nosology and clinical care of these related conditions.

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

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

Pushing the bench: A mixed methods study of barriers to and facilitators of identification and referral into depression care by professional nurses in KwaZulu-Natal, South Africa

OBJECTIVE

Integration of mental health and chronic disease services in primary care could reduce the mental health treatment gap and improve associated health outcomes in low-resource settings. Low rates of nurse identification and referral of patients with depression limit the effectiveness of integrated mental health care; the barriers to and facilitators of identification and referral in South Africa and comparable settings remain undefined. This study explored barriers to and facilitators of nurse identification and referral of patients with depressive symptoms as part of integrated mental health service delivery in KwaZulu-Natal, South Africa.

DESIGN

Triangulation mixed methods study incorporating qualitative and quantitative data.

METHODS

Data collection, analysis, and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Participants were professional nurses at ten primary health care facilities in Amajuba, KwaZulu-Natal, South Africa. Qualitative data collection involved semi-structured interviews targeting specific CFIR constructs with high- and low-referring nurses. Deductive and inductive coding were used to derive primary themes related to barriers and facilitators. Quantitative data collection involved a structured questionnaire assessing determinants explored in the interviews. Qualitative comparative analysis was used to identify the necessary or sufficient conditions for high and low nurse referral.

RESULTS

Twenty-two nurses were interviewed. Primary themes related to insufficient training, supervision, and competency; emotional burden; limited human and physical resources; perceived patient need for integrated services; and intervention acceptability. Sixty-eight nurses completed questionnaires. Quantitative results confirmed and expanded upon the qualitative findings. Low self-assessed competency was a consistent barrier to appropriate service delivery.

CONCLUSIONS

To promote the success of integrated care in a context of severe staff shortages and over-burdened providers, implementation strategies including direct training, structured supervision, and routine behavioral health screening tools are warranted. Interventions to improve mental health literacy of patients as well as emotional support for nurses are also needed.

Educational and Training Interventions Aimed at Healthcare Workers in the Detection and Management of People With Mental Health Conditions in South and South-East Asia: A Systematic Review

Background: To bridge significant mental health treatment gaps, it is essential that the healthcare workforce is able to detect and manage mental health conditions. We aim to synthesise evidence of effective educational and training interventions aimed at healthcare workers to increase their ability to detect and manage mental health conditions in South and South-East Asia. Methods: Systematic review of six electronic academic databases from January 2000 to August 2020 was performed. All primary research studies were eligible if conducted among healthcare workers in South and South-East Asia and reported education and training interventions to improve detection and management of mental health conditions. Quality of studies were assessed using Modified Cochrane Collaboration, ROBINS-I, and Mixed Methods Appraisal Tools and data synthesised by narrative synthesis. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A review protocol was registered with the PROSPERO database (CRD42020203955). Findings: We included 48 of 3,654 screened articles. Thirty-six reported improvements in knowledge and skills in the detection and management of mental health conditions. Training was predominantly delivered to community and primary care health workers to identify and manage common mental health disorders. Commonly used training included the World Health Organization's mhGAP guidelines (n = 9) and Cognitive Behavioural Therapy (n = 8) and were successfully tailored and delivered to healthcare workers. Digitally delivered training was found to be acceptable and effective. Only one study analysed cost effectiveness. Few targeted severe mental illnesses and upskilling mental health specialists or offered long-term follow-up or supervision. We found 21 studies were appraised as low/moderate and 19 as high/critical risk of bias. Interpretation: In low resource country settings, upskilling and capacity building of primary care and community healthcare workers can lead to better detection and management of people with mental health disorders and help reduce the treatment gap. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020203955.

The graying of integrated health: the specialized role of psychology in geriatric primary care

OBJECTIVES

Integrating behavioral health services into primary care is an important global initiative to improve access to mental health services. Within the Veterans Health Administration (VHA), Geriatric Patient Aligned Care Teams (GeriPACTs) are one model of integrated care for frail older adults to serve older Veterans with geriatric syndromes and increased probability of cognitive impairment. Understanding of the role of psychology in GeriPACT is limited. This study examines this role, describes the practice of these psychologists, and evaluates the integration of psychology into geriatric primary care.

METHODS

A mixed-methods design was used. Recruitment occurred through two VHA listservs for GeriPACT and Primary Care Mental Health Integration (PC-MHI) psychologists. Surveys examined referral processes, service access, clinical services provision, and use of psychotherapy modalities. Twenty psychologists participated. Structured follow-up interviews were conducted with five participants.

RESULTS

A large minority of psychologists did not have FTE allotted for GeriPACT work they provided (40%). Sixty percent were assigned to one GeriPACT team. Twenty percent served four to seven GeriPACT teams. Eighty percent provided same-day services. Cognitive assessment was provided weekly by over sixty percent of providers who had FTE allotment to this role. Qualitative data provided a rich description of psychologists' perceptions of their role, team functioning, referral processes, visit structure, and other factors.

CONCLUSION

Findings are discussed in the context of the World Health Organization's guidelines for integrating mental health into primary care. Data suggest a need for an integrated model that adapts to the special needs of older adults in primary care.

In search of 'community': a critical review of community mental health services for women in African settings

Community is deemed a central resource for the improvement of health, across disciplines, contexts and conditions. However, what is meant by this term is rarely critically explored. In Global Mental Health, considerable efforts in recent years have been directed towards scaling up 'community' approaches, with variable success, creating the need to better understand approaches to its use. Our study contributes to this need, through a critical review of studies engaging with the term 'community' in relation to women's mental health services in African settings. Our review explored 30 peer-reviewed articles from the past 15 years, which were systematically evaluated for quality of evidence. Studies were then analysed using a blend of conventional and directed content analysis to unpack perspectives on the term's use in intervention and phenomenological studies. We identified four broad categories of community: (1) place (shared geographical location or institutional affiliation), (2) practice (belongingness to a shared activity or profession), (3) symbols (meanings and experiences associated with shared community life) and (4) identity (diagnostic identity around a mental health condition). Analysis identified community of place as the most common primary focus of interest across the sample, with 80% of papers referencing this dimension. We noted that in studies where communities of practice were the focus, this was in relation to leveraging local knowledge to inform or support service delivery of intervention programmes, often designed by outsiders. Implications for future policy and mental health services research are discussed.

A consideration of the social dimensions and implications of neuroimaging research in global health, as related to the theory-ladened and theory-generating aspects of technology

Drawing on insights from sociology, anthropology, and the history of science and medicine, this paper considers some of the social dimensions and implications for neuroimaging research undertaken within low- and middle-income countries (LMICs). It highlights three key inter-connected issues: (1) technologies for enhancing understandings of ill-health are theory-laden; (2) such technologies are theory-generating; and (3) studies of mental ill-health can also introduce new idioms for understanding subjective distress. The paper unpacks and explores these issues. It argues that the use of neuroimaging technologies in population research has the potential to contribute to solidifying - or even introducing - a biological (and specifically brain-based) understanding of mental ill-health within the communities under study. Examples from studies of neuroscience and society in various high-income countries (HICs) where neuroimaging is popular within public discourse illustrates how this can happen, and with what effects. The social dimensions and implications of neuroimaging are issues that all researchers using these technologies need to not only anticipate, but also explicitly plan for (and potentially seek to mitigate). Without adequate consideration, neuroimaging research carries with it particular risks in relation to extending the epistemological coloniality associated with HIC-sponsored studies conducted within LMIC settings.

Pathways into and out of homelessness among people with severe mental illness in rural Ethiopia: a qualitative study

Background

Little is known about the pathways followed into and out of homelessness among people with experience of severe mental illness (SMI) living in rural, low-income country settings. Understanding these pathways is essential for the development of effective interventions to address homelessness and promote recovery. The aim of this study was to explore pathways into and out of homelessness in people with SMI in rural Ethiopia.

Methods

In-depth interviews were conducted with 15 people with SMI who had experienced homelessness and 11 caregivers. Study participants were identified through their participation in the PRIME project, which implemented a multi-component district level plan to improve access to mental health care in primary care in Sodo district, Ethiopia. People enrolled in PRIME who were diagnosed with SMI (schizophrenia, schizoaffective disorder or bipolar disorder) and who had reported experiencing homelessness at recruitment formed the sampling frame for this qualitative study. We used OpenCode 4.0 and Microsoft Excel for data management. Thematic analysis was conducted using an inductive approach.

Results

Study participants reported different patterns of homelessness, with some having experienced chronic and others an intermittent course. Periods of homelessness occurred when family resources were overwhelmed or not meeting the needs of the person with SMI. The most important pathways into homelessness were reported to result from family conflict and the worsening of mental ill health, interplaying with substance use in many cases. Participants also mentioned escape and/or wanting a change in environment, financial problems, and discrimination from the community as contributing to them leaving the home. Pathways out of homelessness included contact with (mental and physical) health care as a catalyst to the mobilization of other supports, family and community intervention, and self-initiated return.

Conclusions

Homelessness in people with SMI in this rural setting reflected complex health and social needs that were not matched by adequate care and support. Our study findings indicate that interventions to prevent and tackle homelessness in this and similar settings ought to focus on increasing family support, and ensuring access to acceptable and suitable housing, mental health care and social support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10629-8.

Strengthening mental health services in Sierra Leone: perspectives from within the health system

Though mental and substance use disorders are a leading cause of disability worldwide, mental health systems are vastly under-resourced in most low- and middle-income countries and the majority of people with serious mental health needs receives no formal treatment. Despite international calls for the integration of mental health into routine care, availability of outpatient mental health services and integration of mental health into the broader healthcare system remain weak in many countries. Efforts to strengthen mental healthcare systems must be informed by the local context, with attention to key health system components. The current study is a qualitative analysis of stakeholder perspectives on mental health system strengthening in one low-income country, Sierra Leone. It utilizes locally grounded knowledge from frontline healthcare providers to identify constraints and opportunities for strengthening mental health care within each component of the health system. In-depth semi-structured interviews were conducted with 43 participants including doctors, nurses, community health workers, mental health advocates, mental health specialists, and traditional healers recruited from the Bo, Moyamba and Western Area Urban Districts. Interview transcripts were content-coded in NVivo using both a priori and emergent codes and aggregated into broader themes, utilizing the World Health Organization Health Systems Framework. Participants described an extremely limited system of mental health care, with constraints and obstacles within each health system component. Participants identified potential strategies to help overcome these constraints. Findings reinforce the importance of factors outside of the healthcare system that shape the implementation of mental health initiatives, including pervasive stigma towards mental illness, local conceptualizations of mental illness and an emphasis on traditional treatment approaches. Implications for mental health initiatives in Sierra Leone and other low-income countries include a need for investment in primary care clinics to support integrated mental health services and the importance of engaging communities to promote the utilization of mental health services.

Enhancing agency for health providers and pregnant women experiencing intimate partner violence in South Africa

Global policy frameworks call for strengthening the role of health systems to address intimate partner violence (IPV) and support women's agency, yet the evidence of health system responses remains slender in low- and middle-income countries (LMICs). In South Africa, 25-35% of pregnant women experience IPV, posing long-term health risks. We utilised agency as a theoretical construct, applying qualitative methods to investigate health professionals' experiences of a randomised controlled trial intervention to address IPV in pregnant women in five antenatal clinics (ANC) in Johannesburg (2011-2016). In-depth interviews (n = 16) were supplemented by participant observation, debriefing and field notes. Health providers viewed the intervention as enhancing health promotion agency and advancing help-seeking agency for IPV-exposed patients. Intervention nurses reported their own self-efficacy improved, and their relational and collective agency expanded. On-going supervision, mentorship and feedback were essential to establish the knowledge and skill-building necessary for providers to improve self-efficacy in intervention delivery. Integrating mental health services into primary ANC services is recommended. Findings offer insight into the untapped potential for LMIC health settings to become transformative, gender-responsive social systems, for patients and health professionals, in ways that advance women's agency, health, human rights and SDGs.

The ethical, social, and cultural dimensions of screening for mental health in children and adolescents of the developing world

Despite their burden and high prevalence, mental health disorders of children and adolescents remain neglected in many parts of the world. In developing countries, where half of the population is younger than 18 years old, one of every five children and adolescents is estimated to suffer from a mental health disorder. It is then essential to detect these conditions through screening in a timely and accurate manner. But such screening is fraught with considerable ethical, social, and cultural challenges. This study systematically identifies, for the first time, these challenges, along with potential solutions to address them. We report on the results of an international multi- and inter-disciplinary three-round Delphi survey completed by 135 mental health experts from 37 countries. We asked these experts to identify and rank the main ethical, social, and cultural challenges of screening for child and adolescent mental health problems in developing nations, and to propose solutions for each challenge. Thirty-nine significant challenges emerged around eight themes, along with 32 potential solutions organized into seven themes. There was a high degree of consensus among the experts, but a few interesting disagreements arose between members of the panel from high-income countries and those from low- and middle-income nations. The panelists overwhelmingly supported mental health screening for children and adolescents. They recommended ensuring local acceptance and support for screening prior to program initiation, along with careful and comprehensive protection of human rights; integrating screening procedures into primary care; designing and implementing culturally appropriate screening tools, programs, and follow-up; securing long-term funding; expanding capacity building; and task-shifting screening to local non-specialists. These recommendations can serve as a guide for policy and decision-making, resource allocation, and international cooperation. They also offer a novel approach to reduce the burden of these disorders by encouraging their timely and context-sensitive prevention and management.

Developing a Theory of Change model of service user and caregiver involvement in mental health system strengthening in primary health care in rural Ethiopia

BACKGROUND

The involvement of service users and caregivers is recommended as a strategy to strengthen health systems and scale up quality mental healthcare equitably, particularly in low-and-middle-income countries. Service user and caregiver involvement is complex, and its meaningful implementation seems to be a worldwide challenge. Theory of Change (ToC) has been recommended to guide the development, implementation and evaluation of such complex interventions. This paper aims to describe a ToC model for service user and caregiver involvement in a primary mental health care in rural Ethiopia.

METHODS

The ToC was developed in two workshops conducted in (i) Addis Ababa with purposively selected psychiatrists (n = 4) and multidisciplinary researchers (n = 3), and (ii) a rural district in south-central Ethiopia (Sodo), with community stakeholders (n = 24). Information from the workshops (provisional ToC maps, minutes, audio recordings), and inputs from a previous qualitative study were triangulated to develop the detailed ToC map. This ToC map was further refined with written feedback and further consultative meetings with the research team (n = 6) and community stakeholders (n = 35).

RESULTS

The experiential knowledge and professional expertise of ToC participants combined to produce a ToC map that incorporated key components (community, health organisation, service user and caregiver), necessary interventions, preconditions, assumptions and indicators towards the long-term outcomes. The participatory nature of ToC by itself raised awareness of the possibilities for servicer user and caregiver involvement, promoted co-working and stimulated immediate commitments to mobilise support for a grass roots service user organization.

CONCLUSIONS

The ToC workshops provided an opportunity to co-produce a ToC for service user and caregiver involvement in mental health system strengthening linked to the planned model for scale-up of mental health care in Ethiopia. The next steps will be to pilot a multi-faceted intervention based on the ToC and link locally generated evidence to published evidence and theories to refine the ToC for broader transferability to other mental health settings.

Psychologist and Physician Inter-Professional Collaborative Experiences in Primary Care Integration

In recent years, the subject of integrated healthcare, including the integration of behavioral health services into primary care, within the healthcare field has been increasingly of interest to researchers, providers, and policy makers. However, little is known about the experiences of providers within integrated care and the impact of these experiences on inter-professional relationships and collaboration. The researchers aimed to explore differences in providers' perspectives, including inter-professional collaboration and overall job satisfaction, by provider type and level of integration. The current study uses a mixed method exploratory approach, gathering both qualitative and quantitative data to investigate the perspectives of providers (both psychologists and physicians) on their work together. This study included 30 psychologists and 30 primary care physicians from three levels of healthcare integration (traditional/coordinated, co-located, and integrated). As hypothesized, results indicated that providers in integrated settings were the most satisfied with their collaboration with other providers. Furthermore, the providers' narratives revealed promising insights which contribute to a broader understanding of how to improve the relationships between psychologists and primary care physicians in integrated healthcare and other settings.

Experiences of mental healthcare providers regarding integration of mental healthcare into primary healthcare at the iLembe health district in KwaZulu-Natal province

Background

Institutionalisation of mental healthcare users was a prevalent treatment approach in the apartheid era in South Africa. The introduction of community-based mental healthcare is aimed at improving mental healthcare services. The integration into primary healthcare improves access to mental health services. This integration is implemented by professional nurses working in the primary healthcare clinics.

Aim

The aim of this study was to explore and describe experiences of professional nurses regarding integration of mental health into primary healthcare at the iLembe district of KwaZulu-Natal.

Setting

This study was conducted at a public hospital in the iLembe health district of KwaZulu-Natal province.

Methods

An explorative, descriptive and contextual qualitative research study was conducted. Semi-structured interviews were conducted with 15 professional nurses. Data were transcribed verbatim, organised into codes and finally analysed thematically using Tesch’s method of data analysis.

Results

This study revealed that majority of participants experienced and faced challenges regarding integration of mental health into primary healthcare. Professional nurses stated that they require support from the management and training to equip themselves with knowledge and skills to render effective mental healthcare services.

Conclusion

The integration of mental healthcare into primary healthcare is pivotal to ensure easy and accessible mental healthcare services to its users. This strategy requires planning and implementations of available policies and guidelines regarding mental healthcare. Furthermore, adequate funding is required to secure human and material resources to aid the integration of mental healthcare into primary healthcare.

A worldwide survey on training provisions for psychiatric trainees in WPA member associations

This World Psychiatric Association (WPA) global survey of its WPA member society presidents using an online self-administered 15-item questionnaire successfully recruited 47 WPA member countries or regions (response rate = 39.8%) to provide responses about training provisions of psychiatric education at undergraduate, postgraduate, and post-qualified levels in their respective countries. There were significantly fewer responses from the low and middle income countries (LMIC) than the high income countries (HIC). At undergraduate level, the median duration of psychiatric education during medical school education was 4.0%. However, the current allocated time for psychiatric education was only around one-third to one-half of the time considered as optimal by the member countries or regions (optimal mean = 8.9%; optimal median = 10%). At the postgraduate level, the duration of training varied widely from 12-72 months, with a mean duration of 48 months. In 31% of the respondent countries, psychiatrists only required 36 or fewer months of post-graduate training. The number of months of training required for training a psychiatrist was significantly fewer in the LMIC than HIC. At post-qualified continuing medical education level, all respondents reported providing post-qualified continuing medical education. With the advent of internet technology, many respondents prefer having online training.

Participatory action research to pilot a model of mental health service user involvement in an Ethiopian rural primary healthcare setting: study protocol

BACKGROUND

Involvement of service-users at all levels of the mental health system is a policy imperative in many countries internationally. However, putting policy into practice seems complex; little is known about how best to involve service users and efforts are often criticized for being tokenistic. In low-and-middle income countries, less attention has been given to the roles of service users within mental health systems. The proposed study is part of a larger project intended to develop service-user involvement in mental health system strengthening in Ethiopia. A Theory of Change (ToC) model has already been developed through a participatory approach. This study protocol aims to describe the theoretical background and methods to pilot this model using participatory action research (PAR) and explore participants' experience of involvement.

METHODS

The proposed study will apply a PAR approach situated in critical social theory and conduct a phenomenological case study to find out participants' experience of involvement. This will be conducted in three stages. The focus of Stage 1 will be to(i) establish a Research Advisory Group (RAG), and Research Participant Group (RPG) at district and primary healthcare facility levels, respectively, and (ii) identify and prioritize potential areas of concern for involvement in the domains of advocacy, service planning and development, monitoring and improving service quality. In Stage 2, we will work with the RPG to develop a plan of action for the selected area. Stage 3 will aim to assist the RPG to implement and evaluate the plan of action. Process indicators and observation will be combined with in-depth interviews with participants to elicit their experiences of involvement. Thematic content analysis will be used.

DISCUSSION

The participatory approach to mental health service user involvement in health system strengthening employed by this study will support the implementation of solutions through locally relevant and contextualized actions. Findings from this study will contribute to the body of knowledge towards understanding the complexity of implementation of service user involvement and refine the ToC model for transferability to similar settings.

Demographic and clinical profiles of admitted psychiatric patients of the East London Mental Health Unit in the Eastern Cape, South Africa

Integration of psychiatric care at the Primary Health Care (PHC) could be an important strategy towards addressing the shortages of in-patient mental health care services in South Africa. This study describes the profiles of admitted psychiatric patients at the East London Mental Health Unit (ELMHU) of the Eastern Cape from January 2016 to December 2016.In this retrospective cross-sectional study, an audit of medical records of all psychiatric in-patients managed at the ELMHU during the study period was undertaken. Simple descriptive and inferential statistics were used to describe the profiles and examine the associations with the common psychiatric conditions.Of the participants with complete data (n = 186), the majority were males (n = 108); single (72.6%) and had secondary education (45.7%). The majority of in-patients were psychotic (38%), violent (31%), manic (16%) or suicidal (9.2%) at the time of admission. Patients who were 35 years and above, resided in urban areas, and presented with suicidal and depressive symptoms were more likely to be admitted voluntarily. Schizophrenia (31.6%), cannabis-related psychiatric disorders (31.6%), bipolar Type-1 disorder (21.9%) and alcohol related disorders (15.5%) were the main reasons for admission. There was a significant association between demographic characteristics and the common psychiatric disorders of the patients.Schizophrenia, bipolar 1 disorder, cannabis-related disorders and alcohol-related disorders are the predominant disorders leading to in- patient mental health care services being utilized in the study setting. Findings might inform training of health care workers at the PHCs with a view to integrating mental health care services in the Eastern Cape.

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.

Functional impairment among people diagnosed with depression in primary healthcare in rural Ethiopia: a comparative cross-sectional study

Background

There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). The aim of this study was to identify factors associated with functional impairment among people diagnosed with depression in PHC in Ethiopia as part of implementation of a task-shared model of mental healthcare.

Methods

A comparative cross-sectional study was conducted. As part of the Programme for Improving Mental health carE (PRIME), PHC clinicians were trained to diagnose depression using an adapted version of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP). A total of 2038 adult consecutive PHC attendees were screened for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9). Those who scored five or above on the PHQ-9 (n = 131) were assessed by PHC workers. Of these, 92 were diagnosed to have depression (“PHC diagnosed cases”) and the remaining 39 people were PHQ positive but considered not to have depression (“non-diagnosed controls”). PHC diagnosed cases were also compared to a community representative sample of adult healthy controls (n = 197; “community controls”). The 12-item version of the WHO Disability Assessment Schedule (WHODAS-2.0) was used to assess functional impairment. Multivariable negative binomial regression models were fitted to examine the association of demographic, social, economic and clinical characteristics with functional impairment.

Results

No significant difference in functional impairment was found between diagnosed cases and non-diagnosed controls. PHC diagnosed cases were found to have higher depressive symptom severity and suicidality, but lower social support compared to non-diagnosed controls (P < 0.05). In the multivariable model, greater functional impairment was associated with higher depressive symptoms (RR = 1.04; 95% CI 1.02, 1.05) and lower social support (RR = 0.96; 95% CI 0.95, 0.98). Diagnosed cases were found to have higher functional impairment compared to community controls (RR = 1.91; 95% CI 1.74, 2.09).

Conclusion

In this study, PHC clinicians identified cases of depression with high symptom burden, suicidality and functional impairment. These findings support current initiatives to scale-up mental health services at the PHC level; and indicate that social support is an important target for intervention.

Collaborative care for child and youth mental health problems in a middle-income country: study protocol for a randomized controlled trial training general practitioners

BACKGROUND

Child and youth mental health problems are leading causes of disability and particular problems in low- and middle-income countries where populations are young and child mental health services are in short supply. Collaborative care models that support primary care providers' efforts to detect and treat child mental health problems offer one way to address this need. However, collaborative care for child mental health can be more complex than collaboration for adults for a number of reasons, including two-generational aspects of care, high degrees of co-morbidity, and variations in presentation across developmental stages.

METHODS

The study takes advantage of an existing collaborative care network in Tehran, Iran, in which general practitioners are supported by community mental health centers to care for adult mental health problems. At present, those practitioners are asked to refer children with mental health problems to the collaborating centers rather than treating them themselves. We are conducting a cluster randomized trial in which practitioners in the network will be randomized to receive training in child/youth mental health treatment or a booster training on recognition and referral. Children/youth aged 5-15 years making visits to the practitioners will be screened using the Strengths and Difficulties Questionnaire; those found positive will be followed for six months to compare outcomes between those treated by trained or control practitioners.

DISCUSSION

If the trial demonstrates superior outcomes among children treated by trained practitioners, it will support the feasibility of expanding collaborative care networks to include children.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03144739 . Registered on 8 May 2017.

Quality of life of older Chinese adults receiving primary care in Wuhan, China: a multi-center study

Background

Quality of life (QOL) is an important primary care outcome, but the QOL of older adults treated in primary care is understudied in China. This study examined QOL and its associated factors in older adults treated in Chinese primary care.

Methods

A total of 752 older patients (65+ years) were consecutively recruited from 13 primary care centers in Wuhan, China, and interviewed with a standardized questionnaire, concerning socio-demographics, major medical conditions, loneliness, and depression. QOL and depression were measured with the Chinese six-item QOL questionnaire and the shortened Geriatric Depression Scale, respectively. Multiple linear regression was used to identify factors associated with poor QOL.

Results

The average QOL score of primary care older adults was (20.7 ± 2.5), significantly lower than that of the Chinese general population. Factors significantly associated with poor QOL of Chinese primary care older adults included engaging in manual labor before older adulthood (unstandardized coefficient [β]: −0.702, P < 0.001), no living adult children (β: −1.720, P = 0.001), physical inactivity (β: −0.696, P < 0.001), having ≥ four major medical conditions (β: −1.813, P < 0.001), hearing problem (β: −1.004, P = 0.017), depression (β: −1.153, P < 0.001), and loneliness (β: −1.396, P < 0.001).

Conclusions

Older adults treated in Chinese primary care have poorer QOL than the general population. Addressing psychosocial problems at Chinese primary care settings could be helpful in improving QOL in Chinese older adults.

Pluralism and practicality: village health workers' responses to contested meanings of mental illness in Southern Malawi

The individual and social construction of psychological distress is fundamental to help-seeking and the extent to which interventions are seen as credible. Where pluralistic attributions for mental health problems predominate, the development of global mental health (GMH) interventions in the form of task-shifting approaches create increased access to new ways of understanding and responding to distress. However, little is known about how participants in these initiatives manage these encounters. This qualitative study in Malawi explored village-based health workers' (HSAs) and patients' and carers' views of the causes of distress and how these beliefs influenced help-seeking and the health workers' response.Eight HSAs and nine paired patients/carers were interviewed separately to enable each of nine experiences of distress to be explored. Findings revealed a complex set of personal, social and cultural influences that informed causative attributions and help-seeking decisions. Patients/carers viewed psychosocial stresses as compelling explanations and readily reported others attributing their distress to supernatural causes (bewitchment). Yet attributional beliefs alone were not the only influence over help-seeking, which evolved pragmatically in response to the impact of treatments and social pressure for conformity. In turn HSAs navigated the interactions with patients/carers by emphasising the biomedical approach and discrediting bewitchment attributions. This caused tensions when biomedical interventions were unhelpful or the traditional healers' approach proved beneficial.Conclusions add to the call for such task-shifting approaches to work with communities to discern authentic and practical responses to mental distress that mirror the 'pluralism and pragmatism' found in the communities they serve.

Trauma-Informed Psychoeducation for Somali Refugee Youth in Urban Kenya: Effects on PTSD and Psychosocial Outcomes

The current study developed and implemented a trauma-informed psychoeducation (TIPE) intervention that is culturally relevant to urban Somali refugees in Nairobi, Kenya. A total of 141 Somali refugee youth completed 12 sessions of peer-led TIPE intervention. A series of pre- and post-tests revealed that TIPE made positive impacts on PTSD symptoms and psychosocial factors, with a differential effect observed according to baseline PTSD symptom report. Participants with high baseline PTSD scores (i.e. above clinical threshold) reported a significant decrease in PTSD symptoms and increase in perceived social support. In the meantime, those with no to mild baseline PTSD symptoms showed an increase in self-awareness of trauma responses and thus PTSD symptom report within the range of normalcy. This research supports the effect of a culturally relevant psychoeducation intervention in addressing the high mental health and psychosocial needs of the marginalized urban Somali refugee community in low resource settings.

Programmes that bring mental health services to primary care populations in the international setting

The last decade has witnessed an exponential growth of evidence-based care packages for mental, neurological, and substance use disorders (MNS) aimed at primary care populations; however, few have been taken to scale. Several barriers to successful integration and scale-up, such as low acceptability, poor clinical engagement process, lack of targeted resources, and poor stakeholder and policy support have been cited. This review describes and highlights common features of some of the promising programmes that deliver mental health services through primary health clinics, communities, and digital platforms, with an emphasis on those that show some evidence of complete or partial scale-up. Three distinct overarching themes and initiatives are discussed in relation to the above; primary health facilities, community (outside of primary healthcare), and digital/internet-based platforms, with a focus on how the three may interact synergistically to enhance successful integration and scale-up.

Building back better? Taking stock of the post-earthquake mental health and psychosocial response in Nepal

BACKGROUND

The World Health Organization's 'building back better' approach advocates capitalizing on the resources and political will elicited by disasters to strengthen national mental health systems. This study explores the contributions of the response to the 2015 earthquake in Nepal to sustainable mental health system reform.

METHODS

We systematically reviewed grey literature on the mental health and psychosocial response to the earthquake obtained through online information-sharing platforms and response coordinators (168 documents) to extract data on response stakeholders and activities. More detailed data on activity outcomes were solicited from organizations identified as most active in the response. To triangulate and extend findings, we held a focus group discussion with key governmental and non-governmental stakeholders in mental health system development in Nepal (n = 10). Discussion content was recorded, transcribed, and subjected to thematic analysis.

RESULTS

While detailed documentation of response activities was limited, available data combined with stakeholders' accounts suggest that the post-earthquake response accelerated progress towards national mental health system building in the areas of governance, financing, human resources, information and research, service delivery, and medications. Key achievements in the post-earthquake context include training of primary health care service providers in affected districts using mhGAP and training of new psychosocial workers; appointment of mental health focal points in the government and World Health Organization Country Office; the addition of new psychotropic drugs to the government's free drugs list; development of a community mental health care package and training curricula for different cadres of health workers; and the revision of mental health plans, policy, and financing mechanisms. Concerns remain that government ownership and financing will be insufficient to sustain services in affected districts and scale them up to non-affected districts.

CONCLUSIONS

Building back better has been achieved to varying extents in different districts and at different levels of the mental health system. Non-governmental organizations and the World Health Organization Country Office must continue to support the government to ensure that recent advances maximally contribute to realising the vision of a national mental health care system in Nepal.

Adolescent and nurse perspectives of psychotherapeutic interventions for PTSD delivered through task-shifting in a low resource setting

BACKGROUND

This investigation compared the perceived effectiveness of supportive counselling (SC) and prolonged exposure for adolescents (PE-A) by treatment users (adolescents with PTSD) and non-specialist treatment providers (supervised nurses).

METHOD

Adolescent participants and nurse providers were purposively recruited to share their experiences of trial participation through face to face semi-structured in-depth interviews and treatment-specific focus groups (all recorded). Twelve adolescent participant transcripts (ten interviews and two focus groups) and three nurse provider transcripts were doubly transcribed. Thematic content analysis was applied using Atlas.ti software. Two emerging themes are presented in this paper: 1) Perceptions of the intervention and 2) Usefulness of the intervention.

RESULTS

Regardless of treatment arm, adolescents experienced warm counselling relationships and described the process of extending trust to the counselor. Adolescents in the PE-A arm provided clear descriptions of session structure and treatment rationale compared with adolescents receiving SC. The most helpful tools were breathing retraining and imaginal exposure for PE-A and creation of distraction strategies during non-directive SC. Adolescents in both arms continued to use the techniques acquired during treatment and reported symptom improvement. Participants who received SC acknowledged ongoing reexperiencing. Nurses perceived SC to be an immediately transferable skill, but feedback on their preference for one intervention over the other was inconclusive.

CONCLUSION

Both PTSD treatment strategies, implemented by non-specialists, were perceived as helpful. Overall, adolescents reported warm therapeutic relationships and a reduction in PTSD symptoms. Nurses stated that they would require institutional support to ensure delivery of these interventions in a scalable and sustainable manner.

An evaluation of a common elements treatment approach for youth in Somali refugee camps

BACKGROUND

This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention.

METHODS

This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors.

RESULTS

Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d  =  1.37), externalizing (d  =  0.85), and posttraumatic stress (d  =  1.71), and improvements in well-being (d  =  0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility.

CONCLUSIONS

This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.

Mental health in primary care: an evaluation using the Item Response Theory

OBJECTIVE To determine the items of the Brazilian National Program for Improving Access and Quality of Primary Care that better evaluate the capacity to provide mental health care. METHODS This is a cross-sectional study carried out using the Graded Response Model of the Item Response Theory using secondary data from the second cycle of the National Program for Improving Access and Quality of Primary Care, which evaluates 30,523 primary care teams in the period from 2013 to 2014 in Brazil. The internal consistency, correlation between items, and correlation between items and the total score were tested using the Cronbach's alpha, Spearman's correlation, and point biserial coefficients, respectively. The assumptions of unidimensionality and local independence of the items were tested. Word clouds were used as one way to present the results. RESULTS The items with the greatest ability to discriminate were scheduling of the agenda according to risk stratification, keeping of records of the most serious cases of users in psychological distress, and provision of group care. The items that required a higher level of mental health care in the parameter of location were the provision of any type of group care and the provision of educational and mental health promotion activities. Total Cronbach's alpha coefficient was 0.87. The items that obtained the highest correlation with total score were the recording of the most serious cases of users in psychological distress and scheduling of the agenda according to risk stratification. The final scores obtained oscillated between -2.07 (minimum) and 1.95 (maximum). CONCLUSIONS There are important aspects in the discrimination of the capacity to provide mental health care by primary health care teams: risk stratification for care management, follow-up of the most serious cases, group care, and preventive and health promotion actions.

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.

Strengthening mental health system governance in six low- and middle-income countries in Africa and South Asia: challenges, needs and potential strategies

Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using framework analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries.

Reducing the treatment gap for mental, neurological and substance use disorders in Africa: lessons from the Friendship Bench in Zimbabwe

Mental, neurological and substance use disorders (MNS) are a leading cause of disability in Africa. In response to the large treatment gap for MNS, a growing body of evidence-based treatments (EBTs) is emerging from Africa; however, there is a dearth of knowledge on how to scale up EBT. The Friendship Bench intervention is a brief psychological treatment delivered through the primary health care system in Zimbabwe by trained lay health workers. It has contributed significantly towards narrowing the treatment gap for common mental disorders in Zimbabwe where it has been scaled up to over 70 primary health care facilities. A three-pronged approach consisting of community engagement, use of EBTs and a government endorsed scale-up plan is described as part of the key strategy leading to the scale up of the Friendship Bench.

Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh

The Rohingya of Myanmar are a severely persecuted minority who form one of the largest groups of stateless people; thousands of them reside in refugee camps in southeastern Bangladesh. There has been little research into the mental health consequences of persecution, war, and other historical trauma endured by the Rohingya; nor has the role of daily environmental stressors associated with continued displacement, statelessness, and life in the refugee camps, been thoroughly researched. This cross-sectional study examined: trauma history, daily environmental stressors, and mental health outcomes for 148 Rohingya adults residing in Kutupalong and Nayapara refugee camps in Bangladesh. Results indicated high levels of mental health concerns: posttraumatic stress disorder (PTSD), depression, somatic complaints, and associated functional impairment. Participants also endorsed local idioms of distress, including somatic complaints and concerns associated with spirit possession. The study also found very high levels of daily environmental stressors associated with life in the camps, including problems with food, lack of freedom of movement, and concerns regarding safety. Regression and associated mediation analyses indicated that, while there was a direct effect of trauma exposure on mental health outcomes (PTSD symptoms), daily environmental stressors partially mediated this relationship. Depression symptoms were associated with daily stressors, but not prior trauma exposure. These findings indicate that daily stressors play a pivotal role in mental health outcomes of populations affected by collective violence and statelessness. It is, therefore, important to consider the role and effects of environmental stressors associated with life in refugee camps on the mental health and psychosocial well-being of stateless populations such as the Rohingya, living in protracted humanitarian environments.

Empowering patients of a mental rehabilitation center in a low-resource context: a Moroccan experience as a case study

Mental, neurological and substance use (MNS) disorders represent a major source of disability and premature mortality worldwide. However, in developing countries patients with MNS disorders are often poorly managed and treated, particularly in marginalized, impoverished areas where the mental health gap and the treatment gap can reach 90%. Efforts should be made in promoting help by making mental health care more accessible. In this article, we address the challenges that psychological and psychiatric services have to face in a low-resource context, taking our experience at a Moroccan rehabilitation center as a case study. A sample of 60 patients were interviewed using a semi-structured questionnaire during the period of 2014-2015. The questionnaire investigated the reactions and feelings of the patients to the rehabilitation program, and their perceived psychological status and mental improvement, if any. Interviews were then transcribed and processed using ATLAS.ti V.7.0 qualitative analysis software. Frequencies and co-occurrence analyses were carried out. Despite approximately 30 million inhabitants within the working age group, Morocco suffers from a shortage of specialized health workers. Our ethnographic observations show that psychiatric treatment can be ensured, notwithstanding these hurdles, if a public health perspective is assumed. In resource-limited settings, working in the field of mental health means putting oneself on the line, exposing oneself to new experiences, and reorganizing one's own skills and expertise. In the present article, we have used our clinical experience at a rehabilitation center in Fes as a case study and we have shown how to use peer therapy to overcome the drawbacks that we are encountered daily in a setting of limited resources.

Mental ill health in structural pathways to women's experiences of intimate partner violence

Background

Depression, post-traumatic stress disorder (PTSD), and binge drinking are among mental health effects of child abuse and intimate partner violence (IPV) experiences among women. Emerging data show the potential mediating role of mental ill health in the relationship of child abuse and IPV. There is evidence that PTSD, depression and alcohol abuse are comorbid common mental disorders and that a bidirectional relationship exists between depression and IPV in some settings. Furthermore, the temporal direction in the relationship of alcohol abuse and women’s IPV experiences from different studies is unclear. We undertook a study with women from the general population to investigate the associations of child abuse, mental ill health and IPV; and describe the underlying pathways between them.

Methods

Data is from a household survey employing a multi-stage random sampling approach with 511 women from Gauteng, South Africa. IPV was measured using the WHO Multi-country Study on Women's Health and Domestic Violence Questionnaire. Child abuse was measured using a short form of the Childhood Trauma Questionnaire. Depression was measured using the Centre for Epidemiologic Studies Depression Scale (CESD). PTSD symptoms were measured using the Harvard Trauma Questionnaire. Binge drinking was measured using the Alcohol Use Disorders Identification Test (AUDIT) scale. All data analyses were conducted in Stata 13. Regression modelling was used to test the association between variables. Structural equation modelling with full information maximum likelihood estimation accounting for missing data was done to analyse the underlying pathways between variables.

Results

Fifty percent of women experienced IPV in their lifetime and 18% experienced IPV in the 12 months before the survey. Twenty three percent of women were depressed, 14% binge drank and 11.6% had PTSD symptoms. Eighty six percent of women had experienced some form of child abuse. Sociodemographic factors associated with recent IPV in multivariate models were younger age and foreign nationality. Depression, PTSD and binge drinking mediated the relationship of child abuse and recent IPV. Depression, PTSD and binge drinking were also effects of recent IPV. Other factors associated with recent IPV experience included relationship control, having a partner who regularly consumed alcohol and experiencing other life traumatic experiences

Conclusion

Mental ill health plays a mediating role in the relationship of child abuse and recent IPV experiences among women. Conversely, IPV also negatively affects women’s mental health. Interventions to reducing the incidence of IPV could help alleviate the burden of mental ill health among women and vice versa. Effective integration of mental health services in primary health care, detection of symptoms, brief interventions and strengthened referral mechanisms for sustained community-based care are necessary in responding to victims of intimate partner violence. Response for abused children needs to take similar approaches and reduce the long-term mental health effects associated with violent exposures.

Identifying risks for mental health problems in HIV positive adolescents accessing HIV treatment in Johannesburg

BACKGROUND

Mental health problems of adolescents are underserved in low and middle-income countries where they account for a significant proportion of disease burden. Perinatally infected HIV-positive adolescents have a high prevalence of mental health disorders; however, little is known about those retained in care in South Africa.

METHODS

HIV-positive adolescents aged 13-19 years (n = 343) accessing five paediatric antiretroviral clinics in Johannesburg were assessed using standardized measures for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidality. Descriptive and bivariate analyses were conducted on all variables using Statistica v13.

RESULTS

Twenty-seven percent were symptomatic for depression, anxiety, or PTSD; 24% reported suicidality. Peer violence was significantly correlated to all mental health problems, as was hunger, being inappropriately touched, being hit, and being female. Those reporting sickness in the past year were more symptomatic. High exposure to violence was evident. Additionally, not feeling safe at home or in the community increased risk for all mental health disorders. Knowing one's HIV status was protective as was having dreams for the future.

CONCLUSION

HIV-positive adolescents accessing care demonstrated high levels of mental health problems that are largely unrecognized and could potentially be addressed within health systems. Mental health difficulties are driven by social challenges that require attention.

Harm Reduction and Tensions in Trust and Distrust in a Mental Health Service: A Qualitative Approach

BACKGROUND

People seeking care for substance use (PSCSU) experience deep social and health inequities. Harm reduction can be a moral imperative to approach these persons. The purpose of this study was to explore relationships among users, health care providers, relatives, and society regarding harm reduction in mental health care, using a trust approach rooted in feminist ethics.

METHODS

A qualitative study was conducted in a mental health service for PSCSU, and included fifteen participants who were health care providers, users, and their relatives. Individual in-depth and group interviews, participant observation, and a review of patients' records and service reports were conducted.

RESULTS

Three nested levels of (dis)trust were identified: (dis)trust in the treatment, (dis)trust in the user, and self-(dis)trust of the user, revealing the interconnections among different layers of trust. (Dis)trust at each level can amplify or decrease the potential for a positive therapeutic response in users, their relatives' support, and how professionals act and build innovations in care. Distrust was more abundant than trust in participants' reports, revealing the fragility of trust and the focus on abstinence within this setting.

CONCLUSION

The mismatch between wants and needs of users and the expectations and requirements of a society and mental health care system based on a logic of "fixing" has contributed to distrust and stigma. Therefore, we recommend policies that increase the investment in harm reduction education and practice that target service providers, PSCSU, and society to change the context of distrust identified.

Local terms and understandings of mental health problems in Burundi

A pilot study and two intensive studies were conducted to document the local vocabularies used by Burundians to describe mental health problems and their understandings about the causes. The pilot study-in which 14 different large groups of community members awaiting appointments at a village health clinic were engaged in open-ended discussions of the local terminology and causal beliefs about mental health problems-suggested three key syndromes: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In Study 1 ( N = 542), individual interviews or surveys presented participants with the names of these syndromes and asked what they considered to be the symptoms and causes of them. Study 2 ( N = 143) cross-validated these terms with a different sample (also in individual interviews/surveys), by presenting the symptom clusters and asking what each would be called and about their causes. Findings of both studies validated this set of terms and yielded a rich body of data about causal beliefs. The influence of education level and gender on familiarity with these terms was also assessed. Implications for the development of mental health services and directions for future research are discussed.

Integrating mental health in primary healthcare in low-income countries: changing the future for people with mental disorders

BACKGROUND

Untreated mental disorders are a huge challenge for healthcare systems worldwide. Treatment possibilities are particularly scarce in low-income countries (LICs). WHO estimates that up to 85% of all people with a mental disorder in LICs do not have access to evidence-based treatment.

AIMS

This paper seeks to explore the rationale behind the WHO recommendations for improving mental health services in LICs. At the core of these recommendations is an integration of mental health services into existing primary healthcare. This article presents available research supporting this approach. Furthermore, it highlights challenges needing special attention and opportunities demanding additional research to guide a comprehensive restructuring of a healthcare system.

METHODS

A literature review of WHO documents and searches on PubMed for relevant supporting literature.

RESULTS

Research from LICs that investigate mental health interventions is scarce. The evidence that does exist favours integration into primary healthcare. There is evidence that collaborative- and stepped-care interventions can provide viable treatment options for patients.

CONCLUSION

Integration of mental health services into primary healthcare seems like a viable solution to ensure that treatment becomes more available, even though the evidence is limited. Locally conducted research is needed to guide the development of sustainable evidence-based mental health treatment, involving relevant healthcare providers, with optimal task-sharing and possibilities for referral of complex cases. Furthermore, to achieve this, comprehensive political will and investments are necessary pre-requisites.

Building capacity for community mental health care in rural Malawi: Findings from a district-wide task-sharing intervention with village-based health workers

BACKGROUND

The mental health 'treatment gap' is at its widest in low-resource countries where the vast majority of its people have no access to mental health services and where developing effective models of primary mental health care that can expand from research pilot sites to large-scale population-based services is a major research and practice imperative.

AIM

The Mental Health in Zomba initiative builds upon an earlier pilot project to establish and sustain a district-wide scale-up of a village-based health workers' mental health task-sharing intervention in Southern Malawi across a population of more than 600,000 people.

METHODS

The article describes the development, implementation and structured evaluation of the impact of this task-sharing initiative.

RESULTS

Results from an examination of the care for 240 consecutive attendees show how the village-based workers recognised and responded to the needs of people experiencing both common and severe mental health problems and how they facilitated 850 mental health promotion events to more than 40,000 people within their communities.

CONCLUSION

A new and essential district-wide tier of mental health service was established at the crucial intersection between health centre and the community. Within the socio-cultural context of rural Malawi with its diverse explanatory models for psychological distress, the approach of the village-based health worker was found to be both credible and practical in meeting the needs of the population and therefore responding to both the 'supply' and 'demand' elements of the mental health treatment gap.