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Dao TT, Gaynes BN, Pence BW, Mphonda SM, Kulisewa K, Udedi M, Stockton MA, Kramer J, Faidas M, Mortensen H, Bhushan NL. Friendship Bench Intervention to Address Depression and Improve HIV Care Engagement Among Adolescents Living with HIV in Malawi: Study Protocol for a Pilot Randomized Controlled Trial. medRxiv 2024:2024.04.11.24305686. [PMID: 38645199 PMCID: PMC11030483 DOI: 10.1101/2024.04.11.24305686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Adolescents in Sub-Saharan Africa are disproportionately affected by the HIV epidemic. Comorbid depression is prevalent among adolescents living with HIV (ALWH) and poses numerous challenges to HIV care engagement and retainment. We present a pilot trial designed to investigate feasibility, fidelity, and acceptability of an a dapted and an e nhanced F riendship B ench intervention (henceforth: AFB and EFB) in reducing depression and improving engagement in HIV care among ALWH in Malawi. Methods Design: Participants will be randomized to one of three conditions: the Friendship Bench intervention adapted for ALWH (AFB, n=35), the Friendship Bench intervention enhanced with peer support (EFB, n=35), or standard of care (SOC, n=35). Recruitment is planned for early 2024 in four clinics in Malawi.Participants: Eligibility criteria (1) aged 13-19; (2) diagnosed with HIV (vertically or horizontally); (3) scored ≥ 13 on the self-reported Beck's Depression Inventory (BDI-II); (4) living in the clinic's catchment area with intention to remain for at least 1 year; and (5) willing to provide informed consent.Interventions: AFB includes 6 counseling sessions facilitated by young, trained non-professional counselors. EFB consists of AFB plus integration of peer support group sessions to facilitate engagement in HIV care. SOC for mental health in public facilities in Malawi includes options for basic supportive counseling, medication, referral to mental health clinics or psychiatric units at tertiary care hospitals for more severe cases.Outcomes: The primary outcomes are feasibility, acceptability, and fidelity of the AFB and EFB assessed at 6 months and 12 months and compared across 3 arms. The secondary outcome is to assess preliminary effectiveness of the interventions in reducing depressive symptoms and improving HIV viral suppression at 6 months and 12 months. Discussion This pilot study will provide insights into youth-friendly adaptations of the Friendship Bench model for ALWH in Malawi and the value of adding group peer support for HIV care engagement. The information gathered in this study will lead to a R01 application to test our adapted intervention in a large-scale cluster randomized controlled trial to improve depression and engagement in HIV care among ALWH. Trial registration ClinicalTrials.gov Identifier NCT06173544.
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Pence BW, Gaynes BN, Udedi M, Kulisewa K, Zimba CC, Akiba CF, Dussault JM, Akello H, Malava JK, Crampin A, Zhang Y, Preisser JS, DeLong SM, Hosseinipour MC. Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial. Lancet Glob Health 2024; 12:e652-e661. [PMID: 38408462 PMCID: PMC10995959 DOI: 10.1016/s2214-109x(23)00592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/02/2023] [Accepted: 12/11/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Although evidence-based treatments for depression in low-resource settings are established, implementation strategies to scale up these treatments remain poorly defined. We aimed to compare two implementation strategies in achieving high-quality integration of depression care into chronic medical care and improving mental health outcomes in patients with hypertension and diabetes. METHODS We conducted a parallel, cluster-randomised, controlled, implementation trial in ten health facilities across Malawi. Facilities were randomised (1:1) by covariate-constrained randomisation to either an internal champion alone (ie, basic strategy group) or an internal champion plus external supervision with audit and feedback (ie, enhanced strategy group). Champions integrated a three-element, evidence-based intervention into clinical care: universal depression screening; peer-delivered psychosocial counselling; and algorithm-guided, non-specialist antidepressant management. External supervision involved structured facility visits by Ministry officials and clinical experts to assess quality of care and provide supportive feedback approximately every 4 months. Eligible participants were adults (aged 18-65 years) seeking hypertension and diabetes care with signs of depression (Patient Health Questionnaire-9 score ≥5). Primary implementation outcomes were depression screening fidelity, treatment initiation fidelity, and follow-up treatment fidelity over the first 3 months of treatment, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03711786, and is complete. FINDINGS Five (50%) facilities were randomised to the basic strategy and five (50%) to the enhanced strategy. Between Oct 1, 2019, and Nov 30, 2021, in the basic group, 587 patients were assessed for eligibility, of whom 301 were enrolled; in the enhanced group, 539 patients were assessed, of whom 288 were enrolled. All clinics integrated the evidence-based intervention and were included in the analyses. Of 60 774 screening-eligible visits, screening fidelity was moderate (58% in the enhanced group vs 53% in the basic group; probability difference 5% [95% CI -38% to 47%]; p=0·84) and treatment initiation fidelity was high (99% vs 98%; 0% [-3% to 3%]; p=0·89) in both groups. However, treatment follow-up fidelity was substantially higher in the enhanced group than in the basic group (82% vs 20%; 62% [36% to 89%]; p=0·0020). Depression remission was higher in the enhanced group than in the basic group (55% vs 36%; 19% [3% to 34%]; p=0·045). Serious adverse events were nine deaths (five in the basic group and four in the enhanced group) and 26 hospitalisations (20 in the basic group and six in the enhanced group); none were treatment-related. INTERPRETATION The enhanced implementation strategy led to an increase in fidelity in providers' follow-up treatment actions and in rates of depression remission, consistent with the literature that follow-up decisions are crucial to improving depression outcomes in integrated care models. These findings suggest that external supervision combined with an internal champion could offer an important advance in integrating depression treatment into general medical care in low-resource settings. FUNDING The National Institute of Mental Health.
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Affiliation(s)
- Brian W Pence
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bradley N Gaynes
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- Division of Non-Communicable Diseases and Mental Health, Ministry of Health, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | | | | | - Jullita K Malava
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Amelia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Ying Zhang
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John S Preisser
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie M DeLong
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; UNC Project Malawi, Lilongwe, Malawi
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Yanguela J, Pence BW, Udedi M, Banda JC, Kulisewa K, Zimba CC, Malava JK, Akiba C, Dussault JM, Morrison AM, Mphonda S, Hosseinipour MC, Gaynes BN, Wheeler SB. Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation. Lancet Glob Health 2024; 12:e662-e671. [PMID: 38408461 PMCID: PMC10958395 DOI: 10.1016/s2214-109x(23)00597-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Depression is a major contributor to morbidity and mortality in sub-Saharan Africa. Due to low system capacity, three in four patients with depression in sub-Saharan Africa go untreated. Despite this, little attention has been paid to the cost-effectiveness of implementation strategies to scale up evidence-based depression treatment in the region. In this study, we investigate the cost-effectiveness of two different implementation strategies to integrate the Friendship Bench approach and measurement-based care in non-communicable disease clinics in Malawi. METHODS The two implementation strategies tested in this study are part of a trial, in which ten clinics were randomly assigned (1:1) to a basic implementation package consisting of an internal coordinator acting as a champion (IC-only group) or to an enhanced package that complemented the basic package with quarterly external supervision, and audit and feedback of intervention delivery (IC + ES group). We included material costs, training costs, costs related to project-wide meetings, transportation and medication costs, time costs related to internal champion activities and depression screening or treatment, and costs of external supervision visits if applicable. Outcomes included the number of patients screened with the patient health questionnaire 2 (PHQ-2), cases of remitted depression at 3 and 12 months, and disability-adjusted life-years (DALYs) averted. We compared the cost-effectiveness of both packages to the status quo (ie, no intervention) using a micro-costing-informed decision-tree model. FINDINGS Relative to the status quo, IC + ES would be on average US$10 387 ($1349-$17 365) more expensive than IC-only but more effective in achieving remission and averting DALYs. The cost per additional remission would also be lower with IC + ES than IC-only at 3 months ($119 vs $223) and 12 months ($210 for IC + ES; IC-only dominated by the status quo at 12 months). Neither package would be cost-effective under the willingness-to-pay threshold of $65 per DALY averted currently used by the Malawian Ministry of Health. However, the IC + ES package would be cost-effective in relation to the commonly used threshold of three times per-capita gross domestic product per DALY averted. INTERPRETATION Investing in supporting champions might be an appropriate use of resources. Although not currently cost-effective by Malawian willingness-to-pay standards compared with the status quo, the IC + ES package would probably be a cost-effective way to build mental health-care capacity in resource-constrained settings in which decision makers use higher willingness-to-pay thresholds. FUNDING National Institute of Mental Health.
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Affiliation(s)
- Juan Yanguela
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- Non-Communicable Diseases and Mental Health Division, Malawi Ministry of Health and Population, Department of Clinical Services, Lilongwe, Malawi
| | - Jonathan Chiwanda Banda
- Non-Communicable Diseases and Mental Health Division, Malawi Ministry of Health and Population, Department of Clinical Services, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Jullita K Malava
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Karonga District, Malawi
| | | | | | - Abigail M Morrison
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Steve Mphonda
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Lilongwe, Malawi; Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Division of Global Mental Health, Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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Mpinga K, Rukundo T, Mwale O, Kamwiyo M, Thengo L, Ruderman T, Matanje B, Munyaneza F, Connolly E, Kulisewa K, Udedi M, Kachimanga C, Dullie L, McBain R. Depressive disorder at the household level: prevalence and correlates of depressive symptoms among household members. Glob Health Action 2023; 16:2241808. [PMID: 37554074 PMCID: PMC10413913 DOI: 10.1080/16549716.2023.2241808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Globally, an estimated five percent of adults have major depressive disorder. However, little is known about the relationship between these individuals' depressive symptoms and their household members' mental health and well-being. OBJECTIVES We aimed to investigate the prevalence and predictors of depressive symptoms among adult household members of patients living with major depressive disorder in Neno District, Malawi. METHODS As part of a cluster randomized controlled trial providing depression care to adults with major depressive disorder, we conducted surveys with patients' household members (n = 236) and inquired about their overall health, depressive symptoms, disability, and social support. We calculated prevalence rates of depressive disorder and conducted multivariable linear regression and multivariable logistic regression analyses to assess correlates of depressive symptom severity and predictors of having depressive disorder (PHQ-9), respectively, among household members. RESULTS We observed that roughly one in five household members (19%) screened positive for a depressive disorder (PHQ-9 > 9). More than half of household members endorsed six or more of the nine symptoms, with 68% reporting feeling 'down, depressed, or hopeless' in the prior two weeks. Elevated depression symptom severity was associated with greater disability (β = 0.17, p < 0.001), less social support (β = -0.04, p = 0.016), and lower self-reported overall health (β = 0.54, p = 0.001). Having depressive disorder was also associated with greater disability (adjusted Odds Ratio [aOR] = 1.12, p = 0.001) and less social support (aOR = 0.97, p = 0.024). CONCLUSIONS In the Malawian context, we find that depressive disorder and depression symptoms are shared attributes among household members. This has implications for both screening and treatment, and it suggests that mental health should be approached from the vantage point of the broader social ecology of the household and family unit. TRIAL REGISTRATION ClinicalTrials.gov (NCT04777006) - March 2, 2021.
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Affiliation(s)
- Kondwani Mpinga
- Monitoring and Evaluation, Medical Informatics, Information Technology and Research Department, Partners in Health, Neno, Malawi
| | - Temusa Rukundo
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, CA, USA
| | - Owen Mwale
- Clinical Department, Partners in Health, Neno, Malawi
| | | | - Limbani Thengo
- Monitoring and Evaluation, Medical Informatics, Information Technology and Research Department, Partners in Health, Neno, Malawi
| | - Todd Ruderman
- Clinical Department, Partners in Health, Neno, Malawi
| | | | - Fabien Munyaneza
- Monitoring and Evaluation, Medical Informatics, Information Technology and Research Department, Partners in Health, Neno, Malawi
| | | | - Kazione Kulisewa
- College of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael Udedi
- Clinical Services, Ministry of Health, Lilongwe, Malawi
| | | | | | - Ryan McBain
- Healthcare Delivery, RAND Corporation, Washington, DC, USA
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Lawrie S, Hanlon C, Manda-Taylor L, Knapp M, Pickersgill M, Stewart RC, Ahrens J, Allardyce J, Amos A, Bauer A, Breuer E, Chasweka D, Chidzalo K, Gondwe S, Jain S, Kokota D, Kulisewa K, Liwimbi O, MacBeth A, Mkandawire T, Sefasi A, Sibande W, Udedi M, Umar E. Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol. PLoS One 2023; 18:e0293370. [PMID: 38032862 PMCID: PMC10688724 DOI: 10.1371/journal.pone.0293370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 12/02/2023] Open
Abstract
Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.
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Affiliation(s)
- Stephen Lawrie
- Division of Psychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry Psychology & Neuroscience, King’s College, London, United Kingdom
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lucinda Manda-Taylor
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Martyn Pickersgill
- Centre for Biomedicine, Self and Society, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Robert C. Stewart
- Division of Psychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Jen Ahrens
- Tower Hamlets Early Intervention Service, East London NHS Foundation Trust, London, United Kingdom
| | - Judith Allardyce
- Division of Psychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Action Amos
- Pan African Network for Persons with Psychosocial Disabilities (PANPPD), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Annette Bauer
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Erica Breuer
- College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Dennis Chasweka
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kate Chidzalo
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Saulos Gondwe
- Saint John of God (SJOG) Hospital Services, Lilongwe, Malawi
| | - Sumeet Jain
- School of Social & Political Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Demoubly Kokota
- Division of Psychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Kazione Kulisewa
- Department of Psychiatry & Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Olive Liwimbi
- Zomba Mental Hospital, Ministry of Health, Zomba, Malawi
| | - Angus MacBeth
- Division of Psychiatry, University of Edinburgh, Edinburgh, United Kingdom
| | - Thandiwe Mkandawire
- Mental Health Users and Carers Association (MeHUCA), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Anthony Sefasi
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Wakumanya Sibande
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael Udedi
- Curative and Medical Rehabilitation Services Directorate, Ministry of Health, Lilongwe, Malawi
- African Mental Health Research Initiative (AMARI), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Eric Umar
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
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Kokota D, Stewart RC, Bandawe C, Chorwe-Sungani G, Liwimbi O, Mwale CM, Kulisewa K, Udedi M, Gondwe S, Sefasi A, Banda R, Mkandawire T, Lawrie SM. Pathways to care for psychosis in Malawi. BJPsych Int 2023; 20:84-89. [PMID: 38029442 PMCID: PMC10659844 DOI: 10.1192/bji.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/15/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.
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Affiliation(s)
- Demoubly Kokota
- Postdoctoral Fellow, Division of Psychiatry, University of Edinburgh, Edinburgh, UK.
| | - Robert C Stewart
- Senior Clinical Research Fellow, Division of Psychiatry, University of Edinburgh, Scotland
| | - Chiwoza Bandawe
- Professor of Clinical Psychology, Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Genesis Chorwe-Sungani
- Associate Professor, Mental Health Nursing, Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Olive Liwimbi
- Consultant Psychiatrist, Zomba Mental Hospital, Zomba, Malawi
| | | | - Kazione Kulisewa
- Consultant Psychiatrist, Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael Udedi
- Mental Health Desk Officer, NCDs & Mental Health Unit, Ministry of Health, Lilongwe, Malawi
| | - Saulos Gondwe
- Consultant Psychiatrist, Saint John of God Hospitaller Services, Lilongwe, Malawi
| | - Anthony Sefasi
- Head Mental Health Nursing, Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Banda
- Mental Health Clinical Officer, Saint John of God Hospitaller Services, Mzuzu, Malawi
| | - Thandiwe Mkandawire
- Clinical Social Worker, Mental Health Users and Carers Association, Blantyre, Malawi
| | - Stephen M Lawrie
- Professor of Psychiatry, Division of Psychiatry, University of Edinburgh, Edinburgh, UK
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Mpinga K, Lee SD, Mwale O, Kamwiyo M, Nyirongo R, Ruderman T, Connolly E, Kayira W, Munyaneza F, Matanje B, Kachimanga C, Zaniku HR, Kulisewa K, Udedi M, Wagner G, McBain R. Prevalence and correlates of internalized stigma among adults with HIV and major depressive disorder in rural Malawi. AIDS Care 2023; 35:1775-1785. [PMID: 37001058 PMCID: PMC10544700 DOI: 10.1080/09540121.2023.2195609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
Internalized stigma is common among individuals with sexually transmitted infections such as HIV and among those with mental health conditions such as major depressive disorder (MDD). As part of a cluster randomized trial, we investigated the prevalence and correlates of internalized stigma among adults living with comorbid HIV and MDD in rural Malawi (n = 339). We found heightened stigma toward HIV and mental illness among those in the cohort: more than half of respondents (54%) endorsed negative perceptions associated with each health condition. Internalized HIV-related stigma was higher among those with no education (p = 0.04), younger adults (p = 0.03), and those with less social support (p = 0.001). Mental illness-related stigma was elevated among those with no source of income (p = 0.001), and it was also strongly associated with HIV-related stigma (p < 0.001). Our findings highlight potential avenues for reducing internalized stigma associated with high-prevalence health conditions in Malawi.Trial registration: ClinicalTrials.gov identifier: NCT04777006.
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Affiliation(s)
| | - Sarita D. Lee
- Healthcare Delivery, RAND Corporation, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | - Haules Robbins Zaniku
- College of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
- Ministry of Health, Neno District Office, Neno, Malawi
| | - Kazione Kulisewa
- College of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael Udedi
- Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Glenn Wagner
- Healthcare Delivery, RAND Corporation, Washington DC, USA
| | - Ryan McBain
- Healthcare Delivery, RAND Corporation, Washington DC, USA
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8
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Bengtson AM, Filipowicz TR, Mphonda S, Udedi M, Kulisewa K, Meltzer-Brody S, Gaynes BN, Go VF, Chibanda D, Verhey R, Hosseinipour MC, Pence BW. An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial. AIDS Behav 2023; 27:3559-3570. [PMID: 37084104 PMCID: PMC10119837 DOI: 10.1007/s10461-023-04070-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.
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Affiliation(s)
- Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
| | - Teresa R Filipowicz
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | | | - Michael Udedi
- Mental Health Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
- Department of Psychiatry, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Dixon Chibanda
- Department of Psychiatry & Research Support Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Brian Wells Pence
- Department of Epidemiology, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
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Mphonda S, Dussault J, Bengtson A, Gaynes BN, Go V, Hosseinipour MC, Kulisewa K, Kutengule A, Meltzer-Brody S, Udedi M, Pence B. Preferences for enhanced treatment options to address HIV care engagement among women living with HIV and perinatal depression in Malawi. BMC Public Health 2023; 23:1922. [PMID: 37794350 PMCID: PMC10552213 DOI: 10.1186/s12889-023-16835-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/25/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Option B + offers lifelong ART to pregnant or breastfeeding mothers, but postpartum loss to HIV care, partially driven by perinatal depression (PND), threatens the impact of this policy. This study aims to understand women's and providers' preferences for developing a feasible intervention to address PND and support engagement in HIV care among women living with PND and HIV. METHODS We conducted a total of 6 focus group discussions (FGDs) involving 4 clinics in Lilongwe District from December 2018 through February 2019. We conducted 2 FGDs each among 3 stakeholder groups: clinical staff, prenatal women, and postnatal women. Perinatal participants were living with HIV and screened positively for PND using the validated Edinburgh Postnatal Depression Scale (EPDS). Clinical staff were nurses who were trained antiretroviral therapy (ART) providers. Interviewers led FGDs in Chichewa using a semi-structured guide. Data were analyzed using deductive and inductive coding in NVivo 12 software. RESULTS Women favored ART linkage services, but providers said they already offered such services, with mixed results. Individual counselling was universally supported. A perceived benefit of group counselling was peer support, but there were concerns among women regarding confidentiality and stigma. Women liked mobile appointment reminders but identified low phone ownership as a barrier. Participants recommended home visits as an additional care engagement strategy. Women consistently discussed the need for social support from family members and friends to address PND and support engagement in HIV care. CONCLUSION This study highlights the importance of peer encouragement to support perinatal HIV care engagement among women with HIV and PND. The results from this study can be used to support intervention development to increase HIV care engagement and improve long-term HIV outcomes in women with PND.
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Affiliation(s)
- Steve Mphonda
- UNC-Project Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Josée Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela Bengtson
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, RI, USA
| | - Bradley N Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- UNC-Project Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kazione Kulisewa
- Department of Psychiatry and Mental health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Samantha Meltzer-Brody
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- Department of Psychiatry and Mental health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Ministry of Health, Lilongwe, Malawi
| | - Brian Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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10
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Landrum KR, Akiba CF, Pence BW, Akello H, Chikalimba H, Dussault JM, Hosseinipour MC, Kanzoole K, Kulisewa K, Malava JK, Udedi M, Zimba CC, Gaynes BN. Assessing suicidality during the SARS-CoV-2 pandemic: Lessons learned from adaptation and implementation of a telephone-based suicide risk assessment and response protocol in Malawi. PLoS One 2023; 18:e0281711. [PMID: 36930620 PMCID: PMC10022777 DOI: 10.1371/journal.pone.0281711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/26/2023] [Indexed: 03/18/2023] Open
Abstract
The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.
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Affiliation(s)
- Kelsey R. Landrum
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Christopher F. Akiba
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Brian W. Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Josée M. Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health, Blantyre, Malawi
| | | | - Michael Udedi
- Noncommunicable Disease and Mental Health Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Bradley N. Gaynes
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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11
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Kulisewa K, Minnick CE, Stockton MA, Gaynes BN, Hosseinipour MC, Mphonda S, Sansbury G, Udedi MM, Pence BW. The acceptability of antidepressant treatment in people living with HIV in Malawi: A patient perspective. Glob Public Health 2023; 18:2201327. [PMID: 37088107 PMCID: PMC10465971 DOI: 10.1080/17441692.2023.2201327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
Depression is common among people living with HIV (PLWH). Measurement-based care models that measure depression severity and antidepressant side effects, and use an algorithm to guide antidepressant prescription by non-specialized health workers represent an evidence-based treatment for severe depression in sub-Saharan Africa. We conducted in-depth interviews from June to December 2018 with eleven patients enrolled in Project SOAR-Mental Health, a pilot project integrating depression treatment into HIV care in Malawi. Patients treated with amitriptyline or fluoxetine participated in interviews exploring antidepressant acceptability through patient knowledge, side effect severity, pill burden, adherence, perceived efficacy, and tolerability. Patients described a lack of detailed antidepressant education from their providers. Variable, typically self-limiting side effects were reported from both amitriptyline and fluoxetine. While most side effects were mild, three patients reported functional impairment. Patients reported high adherence, though the additional pill burden was a challenge. Most patients found the antidepressants efficacious, tolerable, beneficial and acceptable. Although patient psychoeducation is notably lacking as a facet of clinical management, antidepressant prescription by primary care providers appears acceptable for comorbid severe depression in PLWH initiating HIV care in sub-Saharan Africa. Health workers should be mindful of dosing to minimise side effects and considerate of the additional pill burden.Trial registration: ClinicalTrials.gov ID [NCT03555669]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Caroline E. Minnick
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Mina C. Hosseinipour
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Steven Mphonda
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Griffin Sansbury
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
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12
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Landrum KR, Pence BW, Gaynes BN, Dussault JM, Hosseinipour MC, Kulisewa K, Malava JK, Masiye J, Akello H, Udedi M, Zimba CC. The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi. PLoS One 2022; 17:e0279619. [PMID: 36584142 PMCID: PMC9803137 DOI: 10.1371/journal.pone.0279619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022] Open
Abstract
Depressive disorders are a leading cause of global morbidity and remain disproportionately high in low- and middle-income settings. Stressful life events (SLEs) are known risk factors for depressive episodes and worsened depressive severity, yet are under-researched in comparison to other depression risk factors. As depression is often comorbid with hypertension, diabetes, and other noncommunicable diseases (NCDs), research into this relationship among patients with NCDs is particularly relevant to increasing opportunities for integrated depression and NCD care. This study aims to estimate the cross-sectional association between SLEs in the three months preceding baseline interviews and baseline depressive severity among patients with at least mild depressive symptoms who are seeking NCD care at 10 NCD clinics across Malawi. SLEs were measured by the Life Events Survey and depressive severity (mild vs. moderate to severe) was measured by the Patient Health Questionnaire-9. The study population (n = 708) was predominately currently employed, grand multiparous (5-8 children) women with a primary education level. Two thirds (63%) had mild depression while 26%, 8%, and 3% had moderate, moderately severe, and severe depression, respectively. Nearly all participants (94%) reported at least one recent SLE, with the most common reported SLEs being financial stress (48%), relationship changes (45%), death of a family member or friend (41%), or serious illness of a family member or friend (39%). Divorce/separation, estrangement from a family member, losing source of income, and major new health problems were significant predictors of greater (moderate or severe) depressive severity compared to mild severity. Having a major new health problem or experiencing divorce/separation resulted in particularly high risk of more severe depression. After adjustment, each additional SLE was associated with a 9% increased risk of moderate or worse depressive severity compared to mild depressive severity (RR: 1.09; (95% CI: 1.05, 1.13), p<0.0001). Among patients with NCDs with at least mild depressive symptoms, SLEs in the prior 3 months were associated with greater depressive severity. While many SLEs may not be preventable, this research suggests that assessment of SLEs and teaching of positive coping strategies when experiencing SLEs may play an important role in integrated NCD and depression treatment models.
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Affiliation(s)
- Kelsey R. Landrum
- University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Brian W. Pence
- University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Bradley N. Gaynes
- University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
- University of North Carolina at Chapel Hill, Department of Psychiatry, Chapel Hill, North Carolina, United States of America
| | - Josée M. Dussault
- University of North Carolina at Chapel Hill, Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina at Chapel Hill, Department of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Project Malawi, UNC Project, Tidziwe Centre, Lilongwe, Malawi
| | - Kazione Kulisewa
- Kamuzu University of Health, Department of Psychiatry and Mental Health, Blantyre, Malawi
| | | | - Jones Masiye
- Malawi Ministry of Health, Noncommunicable Diseases and Mental Health Unit, Lilongwe, Malawi
| | - Harriet Akello
- UNC Project Malawi, UNC Project, Tidziwe Centre, Lilongwe, Malawi
| | - Michael Udedi
- Malawi Ministry of Health, Noncommunicable Diseases and Mental Health Unit, Lilongwe, Malawi
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13
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Kulisewa K, Dussault JM, Gaynes BN, Hosseinipour MC, Go VF, Kutengule A, LeMasters K, Meltzer-Brody S, Midiani D, Mphonda SM, Udedi M, Pence BW, Bengtson AM. The feasibility and acceptability of a task-shifted intervention for perinatal depression among women living with HIV in Malawi: a qualitative analysis. BMC Psychiatry 2022; 22:833. [PMID: 36581849 PMCID: PMC9798611 DOI: 10.1186/s12888-022-04476-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 12/15/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. METHODS We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. RESULTS Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. CONCLUSION Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.
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Affiliation(s)
- Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Faculty of Medicine, Private Bag 360, Blantyre, Malawi
| | - Josée M Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bradley N Gaynes
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- UNC-Project Malawi, Lilongwe, Malawi
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Katherine LeMasters
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samantha Meltzer-Brody
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela M Bengtson
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, Rhode Island, USA
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14
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Bhushan NL, Stockton MA, Harrington BJ, DiPrete BL, Maliwichi M, Jumbe AN, Kulisewa K, Chagomerana MB, Pence BW, Gaynes BN, Hosseinipour MC. Probable perinatal depression and social support among women enrolled in Malawi's Option B+ Program: A longitudinal analysis. J Affect Disord 2022; 306:200-207. [PMID: 35314248 PMCID: PMC9681029 DOI: 10.1016/j.jad.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 11/19/2021] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malawi's PMTCT Option B+ program has expanded the reach of ART services among pregnant and breastfeeding women, but retention in lifelong HIV care remains challenging. Given that depression can undermine retention, it is important to understand how depression changes over the perinatal period, varies across treatment and retention groups, and could be buffered by social support. METHODS Data are from an observational study conducted among women enrolled in Malawi's PMTCT Option B+ program. We used multilevel generalized linear models to estimate the odds of probable depression by time, treatment and retention group, and social support. Probable depression was assessed with the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9. RESULTS Of 468 women, 15% reported probable depression at antenatal enrollment and prevalence differed across newly diagnosed individuals, second line therapy users, and previous defaulters (18%, 21%, 5%, p = 0.001). Odds of probable perinatal depression decreased over time (OR per month: 0.87, 95% CI: 0.82-0.92) but were higher among those newly diagnosed (OR: 3.25, 95% CI: 1.59-6.65) and on second line therapy (OR: 3.39, 95% CI: 1.44-7.99) as compared to previous defaulters. Odds of probable postpartum depression were lower for participants with high social support (OR: 0.19, 95% CI: 0.09-0.39). LIMITATIONS Lack of diagnostic psychiatric evaluation precludes actual diagnosis of depression. CONCLUSIONS Probable depression varied across the perinatal period and across treatment and retention groups. Social support was protective for postpartum depression among all participants. Depression screening and provision of social support should be considered in PMTCT programs.
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Affiliation(s)
- Nivedita L. Bhushan
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | - Bethany L. DiPrete
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | | | | | | | - Brian W. Pence
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bradley N. Gaynes
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Mina C. Hosseinipour
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA,UNC Project, Lilongwe, Malawi
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15
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Kip EC, Udedi M, Kulisewa K, Go VF, Gaynes BN. Stigma and mental health challenges among adolescents living with HIV in selected adolescent-specific antiretroviral therapy clinics in Zomba District, Malawi. BMC Pediatr 2022; 22:253. [PMID: 35524228 PMCID: PMC9077887 DOI: 10.1186/s12887-022-03292-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Of the 1.8 million adolescents between the ages of 10 and 19 living with HIV globally in 2020; approximately 1.5 million of these live in sub-Saharan Africa. These adolescents living with HIV (ALHIV) are at higher risk of experiencing mental health problems than those without; in Malawi, 18.9% have a depressive disorder. ALHIV can face numerous psychosocial challenges, but little is known about how ALHIV in Malawi perceive these stressors. Understanding psychosocial challenges of ALHIV is a key step in ensuring good mental health care. The aim of this study was to assess the psychosocial challenges faced by ALHIV attending adolescent-specific ART program in Zomba, Malawi. METHODS Between April and May 2019, we engaged a purposive sample of ALHIV ages 12-18 (n = 80) in a series of eight focus groups drawing from four Teen Clubs linked to an adolescent-specific ART program. Data were analyzed inductively and deductively to identify themes related to ALHIV psychosocial experiences. RESULTS Two themes that emerged from the study include: 1) stigma and discrimination within communities and families; 2) non-adherence to medications. HIV-related stigma was associated with increased psychological distress; physical and emotional/verbal abuse; low social support, isolation, and a feeling of rejection; and risky health behaviors such as medication hiding and non-adherence to ART. Discriminatory actions were manifested in a form of being given separate utensils for their meals and mistreatment at school. Furthermore, some parents did not allow their children to play with the participants out of fear that HIV transmission. CONCLUSIONS Stigma and discrimination are overlooked potential barriers to HIV treatment and care. If HIV services are to effectively meet ALHIVs' needs, mental health interventions are needed to prevent and manage depression and improve adherence to ART. These findings highlight the crucial need to develop culturally relevant mental interventions aimed at helping ALHIV to cope with these diverse challenges.
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Affiliation(s)
- Esther C Kip
- Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi.
| | - Michael Udedi
- Malawi Ministry of Health, P.O. Box 30377, Lilongwe 3, Malawi
| | - Kazione Kulisewa
- Malawi College of Medicine, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Vivian F Go
- University of North Carolina, Chapel Hill, USA
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16
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Kip EC, Udedi M, Kulisewa K, Go VF, Gaynes BN. Barriers and facilitators to implementing the HEADSS psychosocial screening tool for adolescents living with HIV/AIDS in teen club program in Malawi: health care providers perspectives. Int J Ment Health Syst 2022; 16:8. [PMID: 35101066 PMCID: PMC8805413 DOI: 10.1186/s13033-022-00520-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescents living with HIV (ALHIV) are at high risk of experiencing mental health problems. Depression is a major contributor to the burden of HIV-related disease amongst ALHIV and is significantly linked to non-adherence to anti-retroviral therapy (ART), yet it is under-recognized. In 2015, the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) recommended that the psychosocial screening tool Home, Education, Activities, Drugs, Sexuality, Suicide/Depression (HEADSS) be used to screen ALHIV in Malawi who were part of an adolescent antiretroviral therapy program termed "Teen Club". However, the HEADSS tool has been substantially under-utilized. This study assessed barriers and facilitators to implementing HEADSS for ALHIV attending Teen Club Program in four selected health facilities in Malawi. METHODS We conducted a qualitative study using semi-structured interviews at four program sites (one district hospital and one health center each in two districts) between April and May 2019. Twenty key informants were purposively selected to join this study based on their role and experiences. We used the five domains of the Consolidated Framework for Implementation Research (CFIR) to guide the development of the interview guides, analysis and interpretation of results. RESULTS Barriers included inadequate planning for integration of the HEADSS approach; concerns that the HEADSS tool was too long, time consuming, lacked appropriate cultural context, and increased workload; and reports by participants that they did not have knowledge and skills to screen ALHIV using this tool. Facilitators to implementing the screening were that health care providers viewed screening as a guide to better systematic counselling, believed that screening could build better client provider relationship, and thought that it could fit into the existing work practice since it is not complex. CONCLUSIONS A culturally adapted screening tool, especially one that can be used by non-clinicians such as lay health workers, would improve the ability to address mental health needs of ALHIV in many primary care and social service settings where resources for professional mental health staff are limited. These findings are a springboard for efforts to culturally adapt the HEADSS screening tool for detection of mental and risky behaviors among ALHIV attending ART program in Malawi.
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Affiliation(s)
- Esther C Kip
- Malawi College of Medicine, Private Bag 360, Blantyre, Malawi.
| | - Michael Udedi
- Malawi College of Medicine, Private Bag 360, Blantyre, Malawi
- Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Vivian F Go
- University of North Carolina, Chapel Hill, NC, USA
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17
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Stockton MA, Minnick CE, Kulisewa K, Mphonda SM, Hosseinipour MC, Gaynes BN, Maselko J, Pettifor AE, Go V, Udedi M, Pence BW. A Mixed-Methods Process Evaluation: Integrating Depression Treatment Into HIV Care in Malawi. Glob Health Sci Pract 2021; 9:611-625. [PMID: 34593585 PMCID: PMC8514021 DOI: 10.9745/ghsp-d-20-00607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. METHODS We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability. RESULTS Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors. CONCLUSIONS Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Caroline E Minnick
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joanna Maselko
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Audrey E Pettifor
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian Go
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Noncommunicable Diseases and Mental Health Unit, Ministry of Health, Lilongwe, Malawi
| | - Brian W Pence
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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McBain RK, Mwale O, Ruderman T, Kayira W, Connolly E, Chalamanda M, Kachimanga C, Khongo BD, Wilson J, Wroe E, Raviola G, Smith S, Coleman S, Kelly K, Houde A, Tebeka MG, Watson S, Kulisewa K, Udedi M, Wagner G. Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial. Trials 2021; 22:630. [PMID: 34530894 PMCID: PMC8444539 DOI: 10.1186/s13063-021-05601-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. METHODS We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model. DISCUSSION This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence. TRIAL REGISTRATION ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021.
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Affiliation(s)
- Ryan K McBain
- RAND Corporation, Boston, 20 Park Plz, Boston, MA, 02116, USA.
- Partners In Health, Boston, MA, USA.
| | - Owen Mwale
- Partners in Health, Neno District, Malawi
| | | | | | - Emilia Connolly
- Partners in Health, Neno District, Malawi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Emily Wroe
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Giuseppe Raviola
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephanie Smith
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Manda-Taylor L, Umar E, Stewart RC, Kufankomwe M, Chorwe-Sungani G, Mwale OC, Kokota D, Nyirenda J, Kulisewa K, Pickersgill M. Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns. Ethics Hum Res 2021; 43:11-19. [PMID: 34196502 PMCID: PMC7613173 DOI: 10.1002/eahr.500095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Interest in maternal mental health research is growing around the world. Maternal mental health research studies in Malawi have, for instance, sought to determine and establish the incidence and prevalence of depression and anxiety in pregnant people and the factors that contribute to experiences of these states. This article reports stakeholder perspectives on potential community concerns with biopsychosocial mental health research (which might include collecting blood samples) in Malawi. These perspectives were generated through a town hall event that featured five focus group discussions with various participants. In this article, we reflect on key themes from these discussions, demonstrating the endurance of long-standing concerns and practices around autonomy, consent, and the drawing of blood. We conclude by arguing that, while maternal mental health research conducted in Malawi could benefit Malawian women and children, consultation with community stakeholders is necessary to inform whether and how such research should be conducted.
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Affiliation(s)
- Lucinda Manda-Taylor
- Senior lecturer in the Department of Health Systems and Policy in the School of Public Health and Family Medicine in the College of Medicine at the University of Malawi
| | - Eric Umar
- Associate professor in the School of Public Health and Family Medicine in the College of Medicine at the University of Malawi
| | - Robert C Stewart
- Honorary Senior Clinical Research Fellow in the Division of Psychiatry in the College of Medicine and Veterinary Medicine at the University of Edinburgh
| | | | | | - Owen C Mwale
- Project coordinator in the College of Medicine at the University of Malawi
| | - Demoubly Kokota
- Fellow in the Department of Mental Health at the Faculty of Medicine in the College of Medicine at the University of Malawi
| | - Joyce Nyirenda
- Research assistant in the College of Medicine at the University of Malawi
| | - Kazione Kulisewa
- Lecturer in the Department of Mental Health at the Faculty of Medicine in the College of Medicine at the University of Malawi
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Gaynes BN, Akiba CF, Hosseinipour MC, Kulisewa K, Amberbir A, Udedi M, Zimba CC, Masiye JK, Crampin M, Amarreh I, Pence BW. The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol. Psychiatr Serv 2021; 72:812-821. [PMID: 33291973 PMCID: PMC8187465 DOI: 10.1176/appi.ps.202000003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi. METHODS Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team. RESULTS The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity. NEXT STEPS This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.
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Affiliation(s)
- Bradley N Gaynes
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Christopher F Akiba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mina C Hosseinipour
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Kazione Kulisewa
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Alemayehu Amberbir
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Michael Udedi
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Chifundo C Zimba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Jones K Masiye
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mia Crampin
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Ishmael Amarreh
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Brian W Pence
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
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Zimba CC, Akiba CF, Matewere M, Thom A, Udedi M, Masiye JK, Kulisewa K, Go VFL, Hosseinipour MC, Gaynes BN, Pence BW. Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers. Int J Ment Health Syst 2021; 15:59. [PMID: 34116699 PMCID: PMC8196431 DOI: 10.1186/s13033-021-00480-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services. Methods Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers. Results Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow. Conclusion Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge. Trial registration This study reports finding of part of the formative phase of “The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building—A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi” registered as NCT03711786
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Affiliation(s)
| | - Christopher F Akiba
- Gillings School of Global and Public Health, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | | | - Annie Thom
- Malawi Ministry of Health, Lilongwe, Malawi
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22
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Stockton MA, Gaynes BN, Hosseinipour MC, Pettifor AE, Maselko J, Mphonda SM, Kulisewa K, Udedi M, Pence BW. Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi. AIDS Behav 2021; 25:826-835. [PMID: 32970274 PMCID: PMC7886828 DOI: 10.1007/s10461-020-03041-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA.
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Audrey E Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Kazione Kulisewa
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Brian W Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
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Chorwe-Sungani G, Mwagomba M, Kulisewa K, Chirwa E, Jere D, Chipps J. Protocol for assessing feasibility, acceptability and fidelity of screening for antenatal depression (FAFSAD) by midwives in Blantyre District, Malawi. Pilot Feasibility Stud 2021; 7:32. [PMID: 33494838 PMCID: PMC7836563 DOI: 10.1186/s40814-021-00775-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/18/2021] [Indexed: 12/21/2022] Open
Abstract
Background Depression is often underdiagnosed by treating health professionals. This is a situation in Malawi where there is no routine screening of depression at antenatal clinics. Recently, a Screening Protocol for Antenatal Depression (SPADe) that can be used by midwives to screen for antenatal depression was developed in Blantyre District. SPADe proposes multistage screening of antenatal depression by midwives which may enable early detection and treatment of pregnant women with depression. Proper treatment of antenatal depression can assist in achieving Sustainable Development Goals (SDGs). However, utilisation of SPADe in clinical practice to screening for depression in antenatal clinics has not been established yet. Therefore, the primary aim of this study is to assess feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. The secondary aim was to assess acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. Methods This will be a feasibility study which will consist of scientific investigations that will support movement of evidence-based, effective health care approach, SPADe, from the clinical knowledge base into routine use. This study will consist three phases: phase 1 will introduce SPADe in antenatal clinics in Blantyre District where screening of depression is almost none existent; phase 2 will implement screening of depression using SPADe in antenatal clinics in Blantyre District; and phase 3 will evaluate the screening of antenatal depression using SPADe to establish its feasibility, acceptability and fidelity in antenatal clinics in Blantyre District. Discussion This study will establish and document feasibility, acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. It is expected that midwives will develop more confidence in detecting and dealing with antenatal depression. Consequently, there will be increased numbers of pregnant women detected with depression by midwives and increased accessibility to mental health care by pregnant women in antenatal clinics. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00775-6.
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Affiliation(s)
- Genesis Chorwe-Sungani
- Kamuzu College of Nursing, University of Malawi, Chipatala Avenue, P. O. Box 415, Blantyre, Malawi.
| | - Modesta Mwagomba
- Blantyre District Health Office, Chipatala Avenue, P/Bag 66, Blantyre, Malawi
| | - Kazione Kulisewa
- College of Medicine, University of Malawi, Mahatma Ghandi Rd, P/Bag, 360, Blantyre, Malawi
| | - Ellen Chirwa
- Kamuzu College of Nursing, University of Malawi, Chipatala Avenue, P. O. Box 415, Blantyre, Malawi
| | - Diana Jere
- Kamuzu College of Nursing, University of Malawi, Chipatala Avenue, P. O. Box 415, Blantyre, Malawi
| | - Jennifer Chipps
- University of the Western Cape, Robert Sobukwe Rd, Bellville, Cape Town, 7535, South Africa
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LeMasters K, Dussault J, Barrington C, Bengtson A, Gaynes B, Go V, Hosseinipour MC, Kulisewa K, Kutengule A, Meltzer-Brody S, Midiani D, Mphonda S, Udedi M, Pence B. "Pain in my heart": Understanding perinatal depression among women living with HIV in Malawi. PLoS One 2020; 15:e0227935. [PMID: 32502150 PMCID: PMC7274419 DOI: 10.1371/journal.pone.0227935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Perinatal depression (PND) can interfere with HIV care engagement and outcomes. We examined experiences of PND among women living with HIV (WLWH) in Malawi. METHODS We screened 73 WLWH presenting for perinatal care in Lilongwe, Malawi using the Edinburgh Postnatal Depression Scale (EPDS). We conducted qualitative interviews with 24 women experiencing PND and analyzed data using inductive and deductive coding and narrative analysis. RESULTS Women experienced a double burden of physical and mental illness, expressed as pain in one's heart. Receiving an HIV diagnosis unexpectedly during antenatal care was a key contributor to developing PND. This development was influenced by stigmatization and social support. CONCLUSIONS These findings highlight the need to recognize the mental health implications of routine screening for HIV and to routinely screen and treat PND among WLWH. Culturally appropriate mental health interventions are needed in settings with a high HIV burden.
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Affiliation(s)
- Katherine LeMasters
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
| | - Josée Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Clare Barrington
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Angela Bengtson
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Bradley Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Mina C. Hosseinipour
- UNC-Project Malawi, Lilongwe, Malawi
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Samantha Meltzer-Brody
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Michael Udedi
- College of Medicine, University of Malawi, Lilongwe, Malawi
- Ministry of Health, Lilongwe, Malawi
| | - Brian Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Stockton MA, Udedi M, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Maselko J, Pettifor AE, Verhey R, Chibanda D, Lapidos-Salaiz I, Pence BW. The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi. PLoS One 2020; 15:e0231872. [PMID: 32374724 PMCID: PMC7202614 DOI: 10.1371/journal.pone.0231872] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/01/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical. METHODS A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group. RESULTS Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)]. CONCLUSIONS While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.
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Affiliation(s)
- Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Lilongwe, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Audrey E. Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Ruth Verhey
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Dixon Chibanda
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Ilana Lapidos-Salaiz
- United States Agency for International Development (USAID), Arlington, VA, United States of America
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
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Barnett BS, Kusunzi V, Magola L, Borba CPC, Udedi M, Kulisewa K, Hosseinipour MC. Risk factors for readmission among a cohort of psychiatric inpatients in Lilongwe, Malawi. Int J Psychiatry Clin Pract 2020; 24:25-30. [PMID: 31799886 PMCID: PMC7085440 DOI: 10.1080/13651501.2019.1699116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Inpatient psychiatric capacity is limited in Malawi and no published studies have assessed psychiatric readmissions there. Information about factors associated with readmission may help guide strategies to reduce readmission rates and keep patients stabilised in the community. Our goal was to determine factors associated with readmission among a cohort of psychiatric inpatients in Lilongwe, Malawi.Methods: We conducted a retrospective chart review of all patients admitted to an inpatient psychiatric unit in Lilongwe, Malawi from January 1 to December 31, 2011. We used logistic regression to test for associations between readmissions during the study period and patient variables.Results: 419 patients were hospitalised during the study period. Twenty-nine patients (6.9%) were readmitted at least once during the study period. Readmission was associated only with intentional medication non-adherence at home (aOR: 3.33, p = 0.02).Conclusions: Intentional medication non-adherence is a potentially modifiable behaviour associated with psychiatric readmission. Efforts to improve medication adherence among patients following hospital discharge may help decrease the risk of readmission.KEY POINTSThe prevalence of readmission among psychiatric inpatients in Lilongwe, Malawi was 6.9% during the 1-year study period.Readmission was associated with intentional medication non-adherence at home.Future research efforts in Malawi should focus on improving medication adherence among psychiatric patients in the community to help decrease rates of readmission.
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Affiliation(s)
- Brian S Barnett
- Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.,University of North Carolina Project, Lilongwe, Malawi
| | - Veronica Kusunzi
- Bwaila Psychiatric Unit, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Lucy Magola
- Bwaila Psychiatric Unit, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Christina P C Borba
- Department of Psychiatry, Boston Medical Center, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Michael Udedi
- Ministry of Health, Lilongwe, Malawi.,Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kazione Kulisewa
- Bwaila Psychiatric Unit, Kamuzu Central Hospital, Lilongwe, Malawi
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Pence BW. The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study. BMC Public Health 2019; 19:827. [PMID: 31242877 PMCID: PMC6595692 DOI: 10.1186/s12889-019-7132-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries. METHODS This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success. DISCUSSION We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs and Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Melissa A. Stockton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Mina C. Hosseinipour
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Brian W. Pence
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Barnett BS, Kusunzi V, Magola L, Borba CPC, Udedi M, Kulisewa K, Hosseinipour MC. Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi. Soc Psychiatry Psychiatr Epidemiol 2019; 54:235-242. [PMID: 30349960 PMCID: PMC6586467 DOI: 10.1007/s00127-018-1611-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Studies of factors affecting length of stay during psychiatric hospitalization in sub-Saharan Africa are sparse. A better understanding of such factors may lead to interventions resulting in quicker patient stabilization and discharge, freeing up needed psychiatric beds and reducing health care system expenditures. Therefore, we sought to identify factors associated with long length of stay in Malawi. METHODS We reviewed the charts of 417 patients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi from January 1 to December 31, 2011. Multivariate logistic regression analysis was employed to test for associations between patient factors and long length of stay (defined as more than 28 days). RESULTS Mean length of stay was 22.08 ± 27.70 days (range 0-243). 21.82% (91/417) of patients stayed longer than 28 days. Long length of stay was associated with living outside of Lilongwe district [aOR: 3.65 (1.66-8.01), p = 0.001] and treatment for antipsychotic extrapyramidal side effects (EPS) during hospitalization [aOR: 3.45 (1.32-9.03), p = 0.012]. Patients who had more interactions with medical providers for this episode of illness prior to presentation at the unit were less likely to have a long length of stay [aOR: 0.35 (0.16-0.76), p = 0.008]. CONCLUSIONS Our findings demonstrate areas of possible intervention to reduce length of stay, including securing means for patient transport home, rapid identification and treatment of EPS, and reducing the risk of EPS by decreased use of high potency first-generation antipsychotics.
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Affiliation(s)
- Brian S Barnett
- Department of Psychiatry, McLean Hospital Outpatient Clinic, 115 Mill Street, Belmont, MA, 02478, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA.
- Vanderbilt University School of Medicine, Nashville, TN, 37232-0740, USA.
- University of North Carolina Project, Lilongwe, Malawi.
| | - Veronica Kusunzi
- Department of Mental Health, Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Lucy Magola
- Department of Mental Health, Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Christina P C Borba
- Department of Psychiatry, Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA
- Department of Psychiatry, Boston University School of Medicine, 72 East Concord St, Boston, MA, 02118, USA
| | - Michael Udedi
- Non Communicable Diseases and Mental Health Unit, Clinical Services Department, Ministry of Health, PO Box 30377, Lilongwe, Malawi
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
- Department of Psychiatry, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project, Lilongwe, Malawi
- UNC Project Private Bag A104, Kamuzu Central Hospital, Tidziwe Clinic, Lilongwe, Malawi
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Barnett BS, Kusunzi V, Magola L, Borba CP, Udedi M, Kulisewa K, Hosseinipour MC. Factors associated with the use of seclusion in an inpatient psychiatric unit in Lilongwe, Malawi. Malawi Med J 2018; 30:197-204. [PMID: 30627356 PMCID: PMC6307050 DOI: 10.4314/mmj.v30i3.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/07/2018] [Accepted: 05/14/2018] [Indexed: 11/17/2022] Open
Abstract
Background Data on the use of seclusion for psychiatric inpatients in sub-Saharan Africa are extremely limited. Though seclusion is sometimes necessary for patients that pose a threat to themselves or others, adverse physical and psychological sequelae from the experience are increasingly being recognized, leading to efforts to reduce its use. The purpose of this study was to calculate the frequency of seclusion in patients hospitalized in an inpatient psychiatric unit in Lilongwe, Malawi, and to identify factors associated with its use. Methods Records of 419 psychiatric inpatients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi, from January 1, 2011 to December 31, 2011, were reviewed. Multivariate logistic regression analysis was employed to identify factors associated with the use of seclusion. Results Seclusion was used for 30.3% (127/419) of patients during the study period. Male patients had increased odds of being secluded (aOR: 2.22, p=0.02). Assaulting other patients on the unit (aOR 7.92, p<0.01) and presenting to the unit in mechanical restraints (aOR 2.33, p<0.01) were also associated with seclusion. There was no association between seclusion and age; diagnosis of alcohol use disorder, marijuana use disorder, or schizophrenia; involuntary admission; presence of extra pyramidal side effects; presence of hallucinations; suicidality; or commission of violent acts prior to admission. Conclusions Documentation about the rationale for the use of seclusion on the unit was minimal. Improved record keeping requirements will be essential to future efforts to study seclusion and reduce its use. Development of strategies to address patient violence on the unit could decrease the use of seclusion for aggressive patients. Patients arriving to the unit in restraints would benefit from increased efforts by staff to apply behavioural interventions or administer medications, in order to deescalate these individuals and limit the use of seclusion in their treatment.
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Affiliation(s)
- Brian S Barnett
- Department of Psychiatry, McLean Hospital; Department of Psychiatry, Harvard Medical School, Boston, USA
- Vanderbilt University School of Medicine, Nashville, USA
- University of North Carolina Project, Lilongwe, Malawi
| | | | - Lucy Magola
- Bwaila Psychiatric Unit, Kamuzu Central Hospital, Malawi
| | - Christina Pc Borba
- Department of Psychiatry, Boston Medical Center; Boston, University School of Medicine, 72 East Concord St, Boston, USA
| | - Michael Udedi
- Ministry of Health, Lilongwe, Malawi
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
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30
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Mwagomba BM, Mazenga AC, Pence BW. Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program. BMC Health Serv Res 2018; 18:593. [PMID: 30064418 PMCID: PMC6069990 DOI: 10.1186/s12913-018-3388-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/12/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation. METHODS We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned. RESULTS We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care. CONCLUSIONS This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Ministry of Health, P. O. Box 30377 Capital City, Lilongwe 3, Malawi
| | - Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Ministry of Health, Kamuzu Central Hospital and Bwaila Psychiatric Hospital, Private Bag, 149 Lilongwe, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
| | | | - Alick C. Mazenga
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Kamuzu Central Hospital, Private Bag, B-397 Lilongwe, Malawi
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Barnett BS, Kusunzi V, Magola L, Borba CP, Udedi M, Kulisewa K, Hosseinipour MC. Description of the inpatient population and care received at a psychiatric unit in Lilongwe, Malawi. Int J Cult Ment Health 2018; 11:574-582. [PMID: 32863863 PMCID: PMC7450978 DOI: 10.1080/17542863.2018.1448424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 02/17/2018] [Indexed: 06/11/2023]
Abstract
Like in much of Sub-Saharan Africa, descriptive data about psychiatric inpatients and inpatient psychiatric care in Malawi is limited. This study describes the inpatient population at the Bwaila Hospital Psychiatric Unit in Lilongwe, Malawi, as well as treatments received and treatment outcomes. Records of 419 psychiatric inpatients hospitalized from January 1, 2011 to December 31, 2011 were reviewed. Patients were primarily male (73.0%) and were most commonly referred from district hospitals (46.4%). Nearly all patients were involuntarily hospitalized under Malawi's Mental Treatment Act (94.2%). Schizophrenia (30.1%), cannabis use disorder (27.9%) and alcohol use disorder (25.1%) were the most common diagnoses. Suicidal ideation was reported by 4.8% of patients and 2.4% had attempted suicide prior to admission. Homicidal ideation was reported by 7.3% of patients and 5.1% of patients assaulted another patient during their hospitalization. Mean length of stay was 22.1 ± 27.7 days (range: 1.0-243.0). Chlorpromazine (81.3%), diazepam (75.8%), carbamazepine (59.8%) and fluphenazine (56.0%) were the most commonly used medications on the ward. Stabilization and discharge to home was the most common outcome (68.0%), followed by transfer to another hospital (19.5%), discharge against medical advice (8.2%), abscondment (3.4%) and death (1.0%).
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Affiliation(s)
- Brian S. Barnett
- Department of Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
- Vanderbilt University School of Medicine, Nashville, TN, 37232-0740, USA
- University of North Carolina Project, Lilongwe, Malawi
| | - Veronica Kusunzi
- Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Lucy Magola
- Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
| | - Christina P.C. Borba
- Department of Psychiatry, Boston Medical Center, 720 Harrison Ave, Boston, MA 02118 USA ; Boston University School of Medicine, 72 East Concord St, Boston, MA 02118 USA
| | - Michael Udedi
- Ministry of Health, Lilongwe, Malawi
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kazione Kulisewa
- Bwaila Hospital Psychiatric Unit, Kamuzu Central Hospital, PO Box 149, Lilongwe, Malawi
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