Barriers and facilitators to treatment seeking behaviors for depression, epilepsy, and schizophrenia in low- and middle-income countries: A systematic review

Barriers to treatment seeking for depression among elderly service users at Butabika National Referral and Teaching hospital, Kampala- Uganda

OBJECTIVES

Depression among the elderly is a significant public health concern in Uganda, where cultural, social, and healthcare-related barriers hinder access to treatment and support. This study examines the barriers to mental health service access faced by elderly service-users in Uganda.

METHOD

Using an interpretive phenomenological approach, in-depth interviews were conducted to capture the lived experiences of elderly Baganda service users receiving treatment at Butabika National Referral and Teaching hospital.

RESULTS

The findings reveal an intricate interaction between cultural, social, economic, and healthcare system-related barriers. Key barriers include limited mental health awareness, financial constraints, fragmentation, drug shortage and geographical access. Social and cultural stigma further exacerbate these challenges contributing to delayed or avoided help-seeking behaviours among the elderly.

CONCLUSION

The study highlights the intersectionality of aging and mental health issues, underscoring the urgent need for a comprehensive, integrated approach to mental health care for the elderly. This research calls for targeted interventions to reduce stigma, increase mental health literacy, and improve the accessibility and affordability of care for vulnerable elderly populations in Uganda. Such services can improve mental health outcomes and quality of life for the elderly in Uganda.

Treatment for Depression Among Adults: An Evidence and Gap Map of Systematic Reviews

OBJECTIVE

To identify and map systematic reviews on the effectiveness of treatment for depressive disorders among adults.

METHODS

We retrieved systematic reviews and meta-analyses of randomized controlled trials involving adults with depressive symptoms from twelve English and four Chinese databases (June 21, 2022). Using an interactive map, we visualized the effectiveness of evidence on depression based on an intervention-outcome framework. The interventions included psychotherapy, pharmacotherapy, complementary and alternative treatments, and others. The outcomes included the remission of depressive symptoms, symptoms of depressive disorder, life and social skills, and adverse events.

RESULTS

We included 994 systematic reviews and meta-analyses, including 32 that were review protocols, highlighting the distribution of psychotherapy, pharmacotherapy, and complementary and alternative treatments. However, the evidence and gap map (EGM) revealed significant gaps in evidence for specific interventions, populations, outcomes, and regions. While psychotherapy, pharmacotherapy, and complementary and alternative treatments dominate the landscape, the review highlighted a lack of research on interventions for specific types of depression, such as depression in people with bipolar disorder and treatment-resistant depression. It was a similar situation for underserved populations, including young and middle-aged adults, males, sexual minority individuals, and people with disabilities. The map also suggested the need for more research on the potential risks and side effects associated with both pharmacological and nonpharmacological treatments.

CONCLUSIONS

The contribution of this EGM was to present the available evidence on psychotherapy, pharmacotherapy, and complementary and alternative treatments for depression in adults, making available an evidence base that could inform future policy decisions and practice. It also identified evidence gaps in interventions, outcomes, population, regions, and evidence confidence. The need for further research on tailored treatments for specific populations was highlighted.

Cost Utility Analysis of Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder: Randomized Controlled Trial

BACKGROUND

Unguided internet-based cognitive behavioral therapy (ICBT) has been proven effective for major depressive disorder (MDD). However, few studies have examined its cost-effectiveness in low-resource countries and under nonspecialist routine care.

OBJECTIVE

This study aimed to evaluate the short- and long-term cost utility of unguided ICBT compared to a waitlist control for persons with MDD from the perspectives of society and the health care system.

METHODS

This analysis was implemented alongside an 8-week 2-arm randomized controlled trial with a 12-month follow-up period conducted in Shenzhen, China. Outcomes including cost and health utility were collected at the pretreatment and posttreatment time points and 3, 6, and 12 months after the intervention. Direct medical costs and indirect costs were prospectively collected using the hospital information system and the Sheehan Disability Scale. Health outcomes were measured using the Chinese version of the Short-Form Six-Dimension health index. The primary outcome was incremental cost utility ratio (ICUR) expressed as the difference in costs between 2 therapies by the difference in quality-adjusted life years (QALYs). The seemingly unrelated regression model and the bootstrap method were performed to estimate adjusted ICURs. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate uncertainty. A series of scenario analyses were conducted to verify the robustness of base-case results.

RESULTS

In total, 244 participants with MDD were randomly allocated to the ICBT (n=122, 50%) or waitlist control (n=122, 50%) groups. At the pretreatment time point, no statistically significant difference was observed in direct medical cost (P=.41), indirect cost (P=.10), or health utility (P=.11) between the 2 groups. In the base-case analysis, the ICBT group reported higher direct medical costs and better quality of life but lower total costs at the posttreatment time point. The adjusted ICURs at the posttreatment time point were CN ¥-194,720.38 (US $-26,551.50; 95% CI CN ¥-198,766.78 to CN ¥-190,673.98 [US $-27,103.20 to US $-25,999.70]) and CN ¥49,700.33 (US $6776.99; 95% CI CN ¥46,626.34-CN ¥52,774.31 [US $6357.83-$7196.15]) per QALY from the societal and health care system perspectives, respectively, with a probability of unguided ICBT being cost-effective of 75.93% and 54.4%, respectively, if the willingness to pay was set at 1 time the per-capita gross domestic product. In the scenario analyses, the probabilities increased to 76.85% and 77.61%, respectively, indicating the potential of ICBT to be cost-effective over the long term.

CONCLUSIONS

Unguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD improve clinically but also generates societal savings. These findings provide health economic evidence for a potential scalable MDD treatment method in low- and middle-income countries.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ChiCTR2100046425; https://tinyurl.com/bdcrj4zv.

Exploring barriers to seek mental health services among patients with severe mental illness and their caregivers in a modified assertive community treatment program: A qualitative thematic analysis

Background

Affordability, lack of public mental healthcare facilities, inadequate insurance coverage, and stigma and discrimination are barriers to mental healthcare utilization in India. There is limited research on these barriers and the factors influencing the use of mental health services.

Aim

To explore the barriers to seeking mental healthcare for individuals with severe mental illness and their caregivers in a modified assertive community treatment program.

Methods

In a qualitative study using a descriptive thematic analysis, we conducted in-depth interviews with 19 adults, including seven individuals with severe mental illness and twelve caregivers. All the participants had been in the modified assertive community treatment program for at least two years. Using thematic analysis, we identified and grouped codes into subthemes and then clustered into themes.

Results

Three major themes on barriers to seeking mental health services emerged: service-related factors, societal-related factors, and illness-related factors. Service-related factors included affordability, accessibility and geographical disparity, and noncoverage under insurance schemes. Societal-related factors included social stigma and discrimination, lack of mental health service knowledge and seeking other forms of treatment, and poor social support. Illness-related factors included poor insight into the illness and no relief from the symptoms despite medication.

Conclusions

Barriers to seeking mental healthcare can be categorized as service-related, societal-related, and illness-related. Identifying these factors will improve mental health service delivery.

Human rights and support groups to improve quality of life, self-care and disability in epilepsy: [Rights and support groups for epilepsy]

BACKGROUND

People with epilepsy have multiple barriers to recovering their quality of life. The objective of the present study was to determine the impact of a community group intervention focused on the components of mutual aid and human rights, to improve the quality of life in people with epilepsy.

METHODS

Prospective quasi-experimental study, incorporating pre- and post-intervention evaluations. There were 102 people who underwent an intervention focused on the central components of mutual aid groups (Active agency, Coping strategies, Emotion recognition and management, Problem solving, Supportive interaction, Identity construction, Trust, and Social networks) and in the QualityRights strategy. As evaluation instruments, scales were used to determine quality of life (QOLIE-10), treatment adherence (Morisky Test), self-care behaviors, perception of disability and quality in the provision of health services.

RESULTS

Correlations were shown between the variables proposed for quality of life. The intervention showed an improvement in all variables and a moderate to large effect in the self-care domain. There was a significant effect size in the self-care and quality of life variables with the intervention. Pharmacological adherence showed a moderate effect size in young people, adults and older adults. Regarding the perception of disability, the effect size was found only in adults. The pharmacological adherence variable also had a moderate effect size. This does specify the age groups, but not in the general sample.

CONCLUSION

Seizure-free time constitutes a fundamental element in recovery. However, psychosocial conditions constitute key elements to achieve a better quality of life in people with epilepsy.

Perceived and self-stigma in people with epilepsy in East Africa: Systematic review and meta-analysis

BACKGROUND

People with stigmatizing conditions associated with epilepsy encounter many difficulties in their daily lives and are more likely to have low self-esteem, low levels of hope, internalize negative attitudes, decrease adherence to treatment, and experience unemployment. The purpose of this study was to quantify the extent of perceived stigma and self-stigma among people with epilepsy.

METHODOLOGY

This systematic review and meta-analysis followed the Preferred Reporting Item Review and Meta-analysis (PRISMA) guideline. PubMed, PsycINFO, Web of Science, Cochrane Library, Google Scholar, and HINARI were major search databases. The included literature reports the prevalence of perceived stigma and self-stigma among people with epilepsy in East Africa. The quality of each study was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Data were extracted using a Microsoft Excel spreadsheet, and data analysis was performed using STATA version 11. The pooled prevalence of perceived stigma and self-stigma was determined using a random effect model. Heterogeneity between studies was checked using the I2 statistical test. Publication bias was checked using Egger's statistical test and funnel plot.

RESULTS

The pooled prevalence of perceived stigma and self-stigma in people with epilepsy was 43.9 % with a 95 % CI (29.2, 58.7) and 41.2 % with a 95 % CI (12.1, 70.3), respectively. Based on the country, sub-group analysis revealed that the prevalence of perceived stigma among people with epilepsy shows a notable difference between the countries. In Ethiopia, the prevalence was 51.8 % with a 95 % CI of 29.8 to 73.8; in Uganda, 39.4 % with a 95 % CI of 27.1 to 51.3; in Tanzania, 27.4 % with a 95 % CI of 27.9 to 36.9; and in Kenya, 33.2 % with a 95 % CI of 28.2 to 38.2.

CONCLUSION

Roughly 30 % of people with epilepsy experience self-stigma, while approximately 44 % of people with epilepsy experience perceived stigma. As a result, the relevant authorities ought to focus on reducing the prevalence of stigma among people who have epilepsy.

Examination of internalized stigma, quality of life, and happiness in patients with schizophrenia

BACKGROUND

Happiness in patients with schizophrenia is a neglected concept that needs to be developed. Determining the relationship between internalized stigma, quality of life, and happiness, which is important for the prognosis of schizophrenia, will reveal why it is necessary to focus on activities that will increase happiness in patients with schizophrenia.

AIM

This study aimed to compare the levels of internalized stigma, quality of life, and happiness in patients with schizophrenia.

METHODS

A descriptive and correlational research design was used. The research population consisted of patients who applied to the psychiatry outpatient clinic of a hospital in eastern Turkey during the research period and were diagnosed with schizophrenia according to the DSM-5 diagnostic criteria; 87 voluntary patients who agreed to participate in the study constituted the research sample. A personal information form, the Internalized Stigma of Mental Illness Scale (ISMI), the World Health Organization Quality-of-Life Scale (WHOQOL-BREF), and the Subjective Happiness Scale (SHS) were used for data collection.

RESULTS

According to the patients' ISMI, WHOQOL-BREF-TR, and SHS scores, patients perceived internalized stigma above the moderate level in all sub-dimensions. In general, their quality of life was moderate (the highest mean score was on the national environment domain and the lowest mean score was on the social domain); the mean SHS score was 13.02 ± 5.53. There was a strong and negative correlation between the mean SHS score and the total ISMI score and a strong and positive correlation between SHS and the physical, mental, social, and national environment domains of WHOQOL-BREF-TR.

CONCLUSIONS

It was determined that the mean internal stigma score of the patients decreased and their mean quality of life score increased as their mean subjective happiness score increased. It is recommended clinical studies be carried out to increase happiness in patients with schizophrenia.