Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean

Regional research priorities in brain and nervous system disorders

The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.

Advancing Research to Action in Global Child Mental Health

Most mental and substance use disorders begin during childhood and adolescence and are the leading cause of disability in this population. Prenatal and postnatal genetic, familial, social, and environmental exposures interact to influence risk for mental disorders and trajectories of cognitive development. Efforts to advance prevention and implement early interventions to reduce the burden of mental disorders require a global research workforce, intersectoral cooperation, attention to environmental contexts, and the development and testing of evidence-based interventions. The authors describe challenges and resources for building mental health research capacity that stands to influence children's mental health outcomes around the globe.

Learning from the past and looking to the future: Emerging perspectives for improving the treatment of psychiatric disorders

Modern neuropsychopharmacology commenced in the 1950s with the serendipitous discovery of first-generation antipsychotics and antidepressants which were therapeutically effective yet had marked adverse effects. Today, a broader palette of safer and better-tolerated agents is available for helping people that suffer from schizophrenia, depression and other psychiatric disorders, while complementary approaches like psychotherapy also have important roles to play in their treatment, both alone and in association with medication. Nonetheless, despite considerable efforts, current management is still only partially effective, and highly-prevalent psychiatric disorders of the brain continue to represent a huge personal and socio-economic burden. The lack of success in discovering more effective pharmacotherapy has contributed, together with many other factors, to a relative disengagement by pharmaceutical firms from neuropsychiatry. Nonetheless, interest remains high, and partnerships are proliferating with academic centres which are increasingly integrating drug discovery and translational research into their traditional activities. This is, then, a time of transition and an opportune moment to thoroughly survey the field. Accordingly, the present paper, first, chronicles the discovery and development of psychotropic agents, focusing in particular on their mechanisms of action and therapeutic utility, and how problems faced were eventually overcome. Second, it discusses the lessons learned from past successes and failures, and how they are being applied to promote future progress. Third, it comprehensively surveys emerging strategies that are (1), improving our understanding of the diagnosis and classification of psychiatric disorders; (2), deepening knowledge of their underlying risk factors and pathophysiological substrates; (3), refining cellular and animal models for discovery and validation of novel therapeutic agents; (4), improving the design and outcome of clinical trials; (5), moving towards reliable biomarkers of patient subpopulations and medication efficacy and (6), promoting collaborative approaches to innovation by uniting key partners from the regulators, industry and academia to patients. Notwithstanding the challenges ahead, the many changes and ideas articulated herein provide new hope and something of a framework for progress towards the improved prevention and relief of psychiatric and other CNS disorders, an urgent mission for our Century.

Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial

BACKGROUND

Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa.

METHODS/DESIGN

The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17.

DISCUSSION

The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa.

TRIAL REGISTRATION

Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013.

How are health research priorities set in low and middle income countries? A systematic review of published reports

BACKGROUND

Priority setting is increasingly recognised as essential for directing finite resources to support research that maximizes public health benefits and drives health equity. Priority setting processes have been undertaken in a number of low- and middle-income country (LMIC) settings, using a variety of methods. We undertook a critical review of reports of these processes.

METHODS AND FINDINGS

We searched electronic databases and online for peer reviewed and non-peer reviewed literature. We found 91 initiatives that met inclusion criteria. The majority took place at the global level (46%). For regional or national initiatives, most focused on Sub Saharan Africa (49%), followed by East Asia and Pacific (20%) and Latin America and the Caribbean (18%). A quarter of initiatives aimed to cover all areas of health research, with a further 20% covering communicable diseases. The most frequently used process was a conference or workshop to determine priorities (24%), followed by the Child Health and Nutrition Initiative (CHNRI) method (18%). The majority were initiated by an international organization or collaboration (46%). Researchers and government were the most frequently represented stakeholders. There was limited evidence of any implementation or follow-up strategies. Challenges in priority setting included engagement with stakeholders, data availability, and capacity constraints.

CONCLUSIONS

Health research priority setting (HRPS) has been undertaken in a variety of LMIC settings. While not consistently used, the application of established methods provides a means of identifying health research priorities in a repeatable and transparent manner. In the absence of published information on implementation or evaluation, it is not possible to assess what the impact and effectiveness of health research priority setting may have been.

Contributions of general hospital psychiatric units to psychiatric research in India

BACKGROUND

General hospital psychiatric units (GHPUs) are one of the major service and training providers in the field of mental health in India. However, there has not been any systematic attempt at their contributions toward research.

AIM

The present paper reports on contributions of the GHPUs toward the psychiatric research based on analysis of publications in the Indian Journal of Psychiatry (IJP).

MATERIALS AND METHODS

All the issues of IJP of the last 25 years (1989-2013) were manually searched for original research papers, brief reports, and case reports. A semi-structured performa was used to collect information on various parameters.

RESULTS

About two-thirds of the papers were contributed by the GHPUs, most being multi-authored and from tertiary care centers. The research covered a variety of psychiatric disorders including schizophrenia, mood disorders, and common mental disorders. Most of the research reported was self-funded.

CONCLUSION

GHPUs have contributed significantly to psychiatric research in India in the last 25 years.

Knowledge and attitudes towards mental illness among college students: insights into the wider English-speaking Caribbean population

BACKGROUND

Mental illness is a significant contributor to global disease burden and this is expected to increase over the coming decades. Traditionally mental illness has not been well understood by the general public, resulting in poor attitudes towards persons with mental illness and stigmatization. Such conditions are common in the Caribbean where less than 5% of the health budget is allocated to mental illness.

AIMS

To assess knowledge and attitudes towards mental illness among college students within the English-speaking Caribbean.

METHODS

A self-report questionnaire was adapted from previous studies designed to measure knowledge and attitudes of mental illness. Students were sampled from the University of the West Indies campuses in Jamaica, Barbados and Trinidad & Tobago.

RESULTS

Responses were collected from 673 persons with a response rate of 84%. While participants were agreed that particular diseases were mental illnesses, overall knowledge scores were low. Knowledge was higher among those persons who knew someone with a mental illness. Attitude scores were suggestive of stigmatization, with drug abuse and schizophrenia seen in a particularly poor light.

CONCLUSIONS

These results suggest that widespread educational campaigns need to be implemented across the region, designed to both increase knowledge about mental illness and reduce discrimination towards persons suffering with mental illness.

The association between substance use and common mental disorders in young adults: results from the South African Stress and Health (SASH) Survey

Introduction

Although substance use is commonly associated with mental disorders, limited data on this association are available from low and middle income countries such as South Africa. The aims of the study were i) to determine patterns of substance use in young adults, ii) to identify trends of common psychiatric disorders in relation to use of specific substances, and iii) to determine whether specific psychiatric disorders were associated with use of specific substances in the South African population.

Methods

Data were drawn from the South African Stress and Health (SASH) study, a nationally-representative, cross-sectional survey of South African households that forms part of a World Health Organisation (WHO) World Mental Health (WMH) initiative to standardise information on the global burden of mental illness and its correlates. Data from a subset (n = 1766; aged 18 to 30 years) of the SASH sample of 4351 individuals were analysed. The Composite International Diagnostic Interview Version 3 (CIDI 3.0) was used to elicit basic demographic details and information regarding mental illness and substance use. Multiple regression analyses, adjusted for age and gender, were used to identify associations between mental disorders and substance use.

Results

Significant associations were found between substance use and mood and anxiety disorders, with a particularly strong relationship between cannabis use and mental disorder.

Conclusion

The results are consistent with those from previous studies, and reinforce the argument that comorbid substance use and mental disorders constitute a major public health burden.

Helping the decision maker effectively promote various experts' views into various optimal solutions to China's institutional problem of health care provider selection through the organization of a pilot health care provider research system

BACKGROUND

The main aim of China's Health Care System Reform was to help the decision maker find the optimal solution to China's institutional problem of health care provider selection. A pilot health care provider research system was recently organized in China's health care system, and it could efficiently collect the data for determining the optimal solution to China's institutional problem of health care provider selection from various experts, then the purpose of this study was to apply the optimal implementation methodology to help the decision maker effectively promote various experts' views into various optimal solutions to this problem under the support of this pilot system.

METHODS

After the general framework of China's institutional problem of health care provider selection was established, this study collaborated with the National Bureau of Statistics of China to commission a large-scale 2009 to 2010 national expert survey (n = 3,914) through the organization of a pilot health care provider research system for the first time in China, and the analytic network process (ANP) implementation methodology was adopted to analyze the dataset from this survey.

RESULTS

The market-oriented health care provider approach was the optimal solution to China's institutional problem of health care provider selection from the doctors' point of view; the traditional government's regulation-oriented health care provider approach was the optimal solution to China's institutional problem of health care provider selection from the pharmacists' point of view, the hospital administrators' point of view, and the point of view of health officials in health administration departments; the public private partnership (PPP) approach was the optimal solution to China's institutional problem of health care provider selection from the nurses' point of view, the point of view of officials in medical insurance agencies, and the health care researchers' point of view.

CONCLUSIONS

The data collected through a pilot health care provider research system in the 2009 to 2010 national expert survey could help the decision maker effectively promote various experts' views into various optimal solutions to China's institutional problem of health care provider selection.

A practice-based tool for engaging stakeholders in future research: a synthesis of current practices

OBJECTIVE

A major goal of patient-centered outcomes and comparative effectiveness research is to increase the involvement of stakeholders throughout the research process to provide relevant and immediately actionable information. In this report, we review the current practices for engaging stakeholders in prioritizing research.

STUDY DESIGN AND SETTING

To evaluate the range of approaches to stakeholder engagement, we reviewed the relevant literature and conducted semistructured interviews with (1) leading research organizations in the United States, Canada, and the United Kingdom; and (2) eight Evidence-based Practice Centers that engage stakeholders in comparative effectiveness research.

RESULTS

We identified 56 articles related to stakeholder engagement in research prioritization. Studies and research organizations interviewed frequently used mixed methods approaches combining in-person venues with structured ranking or voting processes such as Delphi. EPCs similarly used group web/conference calls combined with Delphi ranking or voting. Research organizations reported difficulties engaging the public and policy makers, and EPCs reported challenges engaging federal stakeholders.

CONCLUSION

Explicit and consistent use of terminology about stakeholders was absent. In-person techniques were useful to generate ideas and clarify issues, and quantitative methods were important in the prioritization of research. Recommendations for effective stakeholder engagement and a reporting checklist were developed from the accumulation of findings.

Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention

Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs.

Classification of mental disorders: the importance of inclusive decision-making

With DSM-V and ICD-11 on the horizon, now is an excellent time to consider the process leading on to the revision of classificatory systems in psychiatry. The challenges of classification in psychiatry are not inconsiderable. Among these are the controversies about what constitutes a 'disorder' and the appropriate place to draw the line between 'normality' and abnormal psychological status. In the absence of validating biomarkers for most mental disorders, judgements are required about the emphasis to put on available empirical data in the revision of existing classifications. In this review we propose that, given the salience of factors such as culture and contextual social experience to the experience and nature of mental disorders, there is an important need for inclusiveness in the process of leading to the revisions of classifications of mental disorders.

Antepartum depression and anxiety associated with disability in African women: cross-sectional results from the CDS study in Ghana and Côte d'Ivoire

BACKGROUND

Common mental disorders, particularly unipolar depressive disorders, rank among the top 5 with respect to the global burden of disease. As a major public health concern, antepartum depression and anxiety not only affects the individual woman, but also her offspring. Data on the prevalence of common mental disorders in pregnant women in sub-Saharan Africa are scarce. We provide results from Ghana and Côte d'Ivoire.

METHODS

We subsequently recruited and screened n = 1030 women in the third trimester of their pregnancy for depressed mood, general anxiety, and perceived disability using the Patient Health Questionnaire depression module (PHQ-9), the 7-item Anxiety Scale (GAD-7), and the World Health Organisation Disability Assessment Schedule II (WHO-DAS 2.0, 12-item version). In addition to estimates of means and prevalence, a hierarchical linear regression model was calculated to determine the influence of antepartum depression and anxiety on disability.

RESULTS

In Ghana, 26.6% of women showed substantially depressed mood. In Côte d'Ivoire, this figure was even higher (32.9%). Clear indications for a generalized anxiety disorder were observed in 11.4% and 17.4% of pregnant women, respectively. Comorbidity of both conditions was common, affecting about 7.7% of Ghanaian and 12.6% of Ivorian participants. Pregnant women in both countries reported a high degree of disability regarding everyday activity limitations and participation restrictions. Controlled for country and age, depression and anxiety accounted for 33% of variance in the disability score.

CONCLUSIONS

Antepartum depression and anxiety were highly prevalent in our sample and contributed substantially to perceived disability. These serious threats to health must be further investigated and more data are needed to comprehensively quantify the problem in sub-Saharan Africa.

Schizophrenia in women and children: a selective review of literature from developing countries

Women and children with psychotic disorders in developing countries may be vulnerable and have considerable social disadvantages. Gender disadvantage has implications for all health outcomes including mental illnesses. In the more relevant gender-related context we discuss several important issues which affect women with schizophrenia, namely stigma, caregiver burden, functional outcome, marriage, victimization and help-seeking. The findings indicate that there are variations in clinical and functional outcomes and age of onset of illness between different regions. Drug side effects, such as metabolic syndrome appear to be quite common, adding to disease burden in women from developing countries. Victimization and coercion may contribute to poor quality of life and health concerns such as STIs and HIV. Stigma among women with schizophrenia appears to play a major role in help-seeking, caregiver burden and issues such as marriage and parenting. Gender-sensitive care and practices are few and not well documented. Research in the area of psychoses in children and adolescents from LAMI countries is sparse and is mainly restricted to a few clinic-based studies. More research is needed on organic and medical factors contributing to childhood psychoses, pathways to care, help-seeking, and impact of early detection and community care.

Experience of low mood and suicidal behaviors among adolescents in Vietnam: findings from two national population-based surveys

PURPOSE

To date, no population-based data about experiences of low mood and suicidal behaviors among adolescents in Vietnam have been published in the English peer-reviewed literature. The aim was to establish the prevalence of self-reported symptoms of low mood, acts of self-harm, and suicidal thoughts and their correlates among adolescents from two national population-based surveys, Survey Assessment of Vietnamese Youth (SAVY) I (2003-2004) and II (2009-2010).

METHODS

Data from the subset of participants aged 14-19 years from the two structured SAVYs were analyzed. Descriptive and bivariate statistics were used to test for between-group comparisons. Multiple logistic regressions were performed to determine factors associated with low mood and suicidal ideation. A weighting factor was used in all analyses.

RESULTS

Prevalence of experiences of low mood was 34.06% in SAVY I and 37.34% in SAVY II; prevalence of suicidal behaviors was 5.28% (SAVY I) and 12.21% (SAVY II). Significant risk factors were being female, an ethnic minority, illiterate, or exposed to violence; perceiving study load as too heavy; following a religion other than Buddhism; or living in wealthier families. Better family cohesion protected adolescents from these unfavorable outcomes. Alcohol use co-occurred significantly with experiences of low mood and suicidal behaviors.

CONCLUSIONS

Self-reported lifetime experiences of low mood are common among Vietnamese adolescents, with signs of an increasing trend. Suicidal behaviors are less prevalent than in other settings but are also increasing. Further research is warranted to elucidate these findings and to inform interventions to optimize the mental health of adolescents in Vietnam.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BACKGROUND

Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau.

METHODS

We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively.

RESULTS

The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5).

CONCLUSIONS

A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

The structure and reliability of the amharic version of the hospital anxiety and depression scale in orphan adolescents in addis ababa

Background

The Hospital Anxiety and Depression Scale was developed as a self-assessment tool to identify anxiety and depression in patients of age 16–65 years. Its use in younger age groups and illiterate populations is not well examined. The purpose of this study was to examine the structure, reliability, and applicability of its Amharic version in a community sample of early orphan adolescents.

Methods

Secondary data primarily collected from randomly selected 804 orphans using the Amharic version of the Hospital Anxiety and Depression Scale by interview technique in March 2010 in Addis Ababa was used with permission. Confirmatory factor analysis with principal components extraction and oblique rotation (delta=0) was computed. The internal consistency of the subscales was assessed using Cronbach's alpha and the correlation between the subscales was assessed using Pearson correlation.

Results

In the whole sample (age 11–18 years), two factors: anxiety and depression, explaining a total of 45.9% of the variance were found. In the 11–15 years sub-sample, the same two factors were extracted explaining a total of 45.7% of the variance. The Amharic-HADS had Cronbach's alpha of 0.81 and 0.76 in the whole sample for the anxiety and depression sub-scales, respectively. In the 11–15 years sub-sample the corresponding alpha values for anxiety and depression scales were 0.80 and 0.77, respectively. The correlation between the anxiety and the depression subscales were 0.66 (p<0.001) and 0.67 (p< 0.001) for the whole sample and for the 11–15 years group, respectively.

Conclusion

Administering the Amharic version of the Hospital Anxiety and Depression Scale by interviewers gave meaningful data starting from the age of 11 suggesting successful applicability of the scale with further validation.

The roads less traveled: mapping some pathways on the global mental health research roadmap

The global mental health (GMH) research agenda should include both culture-general and culture-specific perspectives to ensure ecological validity of findings. Despite its title, the current GMH research agenda appears to be using a monocultural model that is individualistic, illness-oriented, and focused on intrapsychic processes. Ironically, issues of culture are prominently absent in many discussions of global mental health. This paper highlights some issues and concerns considered key to conducting ecologically valid and socially responsible GMH research. The concerns are particularly directed at researchers from dominant cultures who are working in low-income countries. Central to these issues is the balance between etic and emic perspectives in assessment, diagnosis, and intervention, as well as language, engagement of stakeholders and their agendas, and evaluation of the benefit of interventions to the community. New terminology is proposed that identifies broad cultural groups, and recommendations provided for a research agenda to encourage both basic and applied research that mutually benefits all stakeholders in the GMH research endeavor.

Depression in adolescence

Unipolar depressive disorder in adolescence is common worldwide but often unrecognised. The incidence, notably in girls, rises sharply after puberty and, by the end of adolescence, the 1 year prevalence rate exceeds 4%. The burden is highest in low-income and middle-income countries. Depression is associated with substantial present and future morbidity, and heightens suicide risk. The strongest risk factors for depression in adolescents are a family history of depression and exposure to psychosocial stress. Inherited risks, developmental factors, sex hormones, and psychosocial adversity interact to increase risk through hormonal factors and associated perturbed neural pathways. Although many similarities between depression in adolescence and depression in adulthood exist, in adolescents the use of antidepressants is of concern and opinions about clinical management are divided. Effective treatments are available, but choices are dependent on depression severity and available resources. Prevention strategies targeted at high-risk groups are promising.

Australian mental health consumers' priorities for research: qualitative findings from the SCOPE for Research project

BACKGROUND

There is growing acceptance of the importance of the consumer viewpoint in mental health research. Previous studies have identified differences in research priorities between researchers and mental health consumers in Australia defined broadly. However, little is known about the research priorities of consumers with specific mental health conditions.

OBJECTIVE

The aim of this study was to explore Australian mental health consumers' priorities for depression and bipolar disorder research.

DESIGN

Focus groups with consumers and individual telephone interviews with consumer advocates. Participants were asked to discuss the topics they believed were priorities for depression or bipolar disorder research. Transcripts were thematically analysed using NVivo 7.

SETTING AND PARTICIPANTS

Ten people with depression and 19 with bipolar disorder participated in face-to-face focus groups held in three Australian capital cities. Five participants with each disorder participated in online focus groups. Five Australian consumer advocates with experience of depression and six with experience of bipolar disorder were individually interviewed by telephone.

RESULTS

Participants raised a broad variety of topics for research. The most salient themes included the need for research on medication, and lifestyle and psychosocial influences on depression and bipolar disorder.

CONCLUSIONS

Participants' priorities reflect an interest in a holistic approach to mental health research that examines the influences of everyday life and psychosocial influences both on the development and on the management of these disorders. Their focus was on research that explores individualized care and the active role that consumers can play in their own care and recovery.

Adolescent health care in India: progressive, regressive or at the cross-roads?

India has a sizeable adolescent population. Adolescents constitute a vulnerable population for both mental and physical illnesses, and yet their health-care needs and delivery systems are neither well defined nor developed. Many of the mental, reproductive and nutritional health needs of this population are required to be addressed and can be addressed in the primary-care pediatric setting itself if the current system of health-care can be re-organized. This restructuring will be more effective for this population if adolescent friendly approaches, public-private partnership and policy as well as sectoral linkage between the NRHM and other national programs are achieved. The health program for this age group should have promotive and preventive as well as remedial and curative components. Also, improving the availability of trained personnel in these areas of health, culturally sensitive evidence based approaches and capacity building in the primary-care approach is essential to ensure the viability of adolescent health-care in this country.

Capacity building in global mental health research

Research-generated information about mental disorders is crucial in order to establish the health needs in a given setting, to propose culturally apt and cost-effective individual and collective interventions, to investigate their implementation, and to explore the obstacles that prevent recommended strategies from being implemented. Yet the capacity to undertake such research in low- and middle-income countries is extremely limited. This article describes two methods that have proved successful in strengthening, or that have the potential to strengthen, mental health research capacity in low-resource settings. We identify the central challenges to be faced, review current programs offering training and mentorship, and summarize the key lessons learned. A structured approach is proposed for the career development of research staff at every career stage, to be accompanied by performance monitoring and support. A case example from the Mental Health and Poverty Project in sub-Saharan Africa illustrates how this approach can be put into practice-in particular, by focusing upon training in core transferrable research skills.

Research priorities for mental health and psychosocial support in humanitarian settings

Wietse Tol and colleagues lay out a a consensus-based research agenda for mental health and psychosocial support in humanitarian settings.

Optimizing mental health services in low-income and middle-income countries

PURPOSE OF REVIEW

Against the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs.

RECENT FINDINGS

Key strategies and actions are as follows: (i) the adoption of a decentralized stepped care approach embracing task shifting to nonspecialists for those disorders for which it has been shown to be effective; (ii) ensuring adequate numbers of mental health specialists to provide a supportive supervisory framework and referral pathways; (iii) ensuring adequate infrastructure to support decentralized care; (iv) promoting mental health literacy; (v) adoption of a social inclusion and developmental model of disability in caring for people with chronic mental illness; and (vi) embracing a multisectoral community collaborative approach.

SUMMARY

Optimizing mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions. Studies demonstrating the cost-effectiveness of integrated stepped packages of care embracing a task-shifting approach, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors, can assist this process. Specialist mental health training programmes in LMICs also need to be responsive to the changing demands on service providers, incorporating a public health approach and equipping specialists for diversification of their roles within the task shifting model.

Mental health and childhood adversities: a longitudinal study in Kabul, Afghanistan

OBJECTIVE

To identify prospective predictors of mental health in Kabul, Afghanistan.

METHOD

Using stratified random-sampling in schools, mental health and life events for 11-to 16-year-old students and their caregivers were assessed. In 2007, 1 year after baseline, the retention rate was 64% (n = 115 boys, 119 girls, 234 adults) with no evidence of selection bias. Self- and caregiver-rated child mental health (Strengths and Difficulties Questionnaire), depressive (Depression Self-Rating Scale), and posttraumatic stress (Child Revised Impact of Events Scale) symptoms and caregiver mental health (Self-Report Questionnaire) were assessed. Lifetime trauma and past-year traumatic, stressful, and protective experiences were assessed.

RESULTS

With the exception of posttraumatic stress, one-year trajectories for all mental health outcomes showed significant improvement (p < .001). Family violence had a striking impact on the Strengths and Difficulties Questionnaire data, raising caregiver-rated scores by 3.14 points (confidence interval [CI] 2.21-4.08) or half a standard deviation, and self-rated scores by 1.26 points (CI 0.50-2.03); past-year traumatic beatings independently raised self-rated scores by 1.85 points (CI 0.03-3.66). A major family conflict raised depression scores by 2.75 points (CI 0.89-4.61), two thirds of a standard deviation, whereas improved family life had protective effects. Posttraumatic stress symptom scores, however, were solely contingent on lifetime trauma, with more than three events raising scores by 5.38 points (CI 1.76-9.00).

CONCLUSIONS

Family violence predicted changes in mental health problems other than posttraumatic stress symptoms in a cohort that showed resilience to substantial socioeconomic and war-related stressors. The importance of prospectively identifying impacts of specific types of childhood adversities on mental health outcomes is highlighted to strengthen evidence on key modifiable factors for intervention in war-affected populations.

Setting implementation research priorities to reduce preterm births and stillbirths at the community level

Asha George and colleagues from the GAPPS group report the implementation research priorities to address prematurity and stillbirths at the community level that resulted from their recent expert consensus exercise.

Increasing the priority of mental health in Africa: findings from qualitative research in Ghana, South Africa, Uganda and Zambia

Despite the high prevalence of mental illness, mental health remains a low priority in Africa. There has been no investigation of the views of stakeholders in Africa on why this is and what can be done. This paper reports a comparison of the views of stakeholders in Ghana, South Africa, Uganda and Zambia, focusing on the priority given to mental health by the government at the national and regional/province levels. We conducted semi-structured interviews with key stakeholders and used a two-stage approach to analysis: firstly framework analysis in each study country, followed by comparative analysis of the country data. Mental health was largely considered a low priority at national and regional/provincial levels in all four countries. We identified nine factors affecting the priority of mental health, which were grouped into three categories: legitimacy of the problem, feasibility of response and support for response. Respondents put forward a range of experiences and suggestions for increasing the priority given to mental health. We conclude with broad suggestions to raise the priority of mental health. These suggestions are particularly relevant as mental health increases in priority on the international agenda, in order to inform advocacy for increased priority for mental health in Africa.

Challenges in international collaboration in child and adolescent psychiatry

International collaboration in child and adolescent psychiatry has historically been weak and fragmented. The field has also lagged in developing remedies for improving collaboration. This article identifies barriers to successful collaboration and examines problems in the areas of finance, professional development, knowledge dissemination, professional organisations, public policy and the political environment, priority setting, nomenclature, as well as ethical challenges. The article then identifies some promising initiatives and proposes solutions to improve international collaboration in child and adolescent mental health.

Troubled minds in the Gulf: mental health research in the United Arab Emirates (1989-2008)

This article aims to describe the characteristics of the United Arab Emirates (UAE) mental health research published from 1989 to 2008 in PubMed indexed journals to identify gaps and to suggest recommendations. Our sensitive PubMed search for general and mental health publications in Gulf Cooperation Council (GCC) countries and the UAE revealed a total of 192 mental health studies published in GCC countries over the past 20 years, which constituted less than 1% of the GCC total biomedical research. Most of the studies were from the UAE University and were either epidemiologic (48.98%) or psychometric (24.49%) with no studies addressing mental health systems research. Underrepresented were studies on health promotion and interdisciplinary, cross-cultural, ethnic, and gender research. There is a need for more international collaboration and for policies that link research conducted to services provided with longitudinal studies to test the long-term impact of early preventive interventions.

Shared challenges in psychiatric research in India and Sri Lanka

The need for good research in psychiatry has never been more important than in this era of 'Evidence-based medicine' (EBM).[1] The countries in south Asia have to rise to the challenge and abandon the emphasis placed on 'Experiencebased medicine', as was popular in the traditional systems of medicine - the art was handed down from father to son or guru to shishya (student).Evidence-based medicine does not abandon clinician experience, skills, and judgment, but rather complements it with the best available evidence and patient choice.[2] This article explores the challenges in obtaining the best available evidence in the south Asian context.

Research priorities for Indian psychiatry

This article summarises the findings of recent priority setting exercises for psychiatric research and of a mapping of research capacity and resources in south Asia. The priorities for research in the region, as in other developing countries, are related to 'implementation' science, i.e. the field of inquiry investigating acceptable and affordable methods of delivering effective treatments for mental disorders, which aims to help close the large treatment gap. "Discovery" research which aims to strengthen our understanding of the nature of mental disorders through well-designed epidemiological and descriptive clinical studies, and expand the armamentarium of effective treatments by mapping and evaluating indigenous approaches to mental health care is also an important priority. However, research capacity and resources in the region are scarce and need strengthening by action from diverse stakeholders including the Indian Psychiatric Society.

Invited commentary on... Mental health research priorities in low- and middle-income countries

There are huge inequalities in health research within and between countries. It is argued that this may hinder the process of setting and tackling mental health priorities. If this were true, establishing research priorities would be important. However, this is not a simple process and one must be aware of its limitations. Despite a plethora of declarations, funding for mental health research in low- and middle-income countries remains hard to find. In the absence of funding, establishing research priorities is seen by many as an exercise of lesser importance.