“Is there a medicine for these tensions?” Barriers to treatment-seeking for depressive symptoms in rural India: A qualitative study

'Impaired in life': Analyzing people's accounts of depression in Ethiopia - Implications for a cultural-eco social approach to global mental health

BACKGROUND

Depression is a global crisis and a major concern in mental health interventions, particularly in low- and middle-income countries (LMICs), where it significantly impacts disability, quality of life, and economic stability. These chronic stressors have been used to argue for scaling up the detection and treatment of depression as a public health and development priority.

AIM

This study aimed to explore illness narratives of depression among patients' and to gain insights into multifaceted suffering, its impact on persons' lives, and help seeking. This study is part the broader study which examined global mental health, biopolitics, and depression in Ethiopia, conducted in hospice setting to explore the conception of depression in Bahirdar city, Northern Ethiopia, among patients and health care providers. In this study, we focus on patients' accounts of depression.

METHOD

We employed an ethnography method using in-depth interviews, fieldnotes, and observation to collect the data. A thematic analysis was used to analyze the data. Drawing from cross-cultural and critical psychiatry perspectives, we situate depression within its cultural-eco social framework.

RESULTS

The study revealed that patients' experiences and conception of depression are deeply intertwined with Ethiopia's sociocultural, economic, and spiritual context. Depression was often described as a state of being 'impaired in life', reflecting the complex interplay of individual struggles and societal pressures. Integrating quotes from patients, we demonstrated in this analysis the ways in which biographically specific challenges, societal pressures, and mental well-being are understood by study participants in accordance with Ethiopian cultural and religious norms.

CONCLUSION

The study suggests moving beyond narrow interpretative frameworks in GMH praxis to understand and address the complex dimensions of depression in Ethiopia and similar contexts. The study advocates for a cultural-ecosocial approach to depression, emphasizing the need for mental health interventions that consider the broader social and cultural factors contributing to mental distress.

Impact, feasibility, and acceptability of CREATORS: An arts-based pilot intervention to reduce mental-health-related stigma among youth in Hyderabad, India

Background

Mental-health-related stigma prevents youth from seeking help for mental health problems. Limited studies in low- and middle-income countries assess the effect of arts-based education in reducing such stigma among youth, thereby leaving a gap in evidence-based, age- and culturally-appropriate interventions.

Objective

To evaluate the impact, feasibility, and acceptability of CREATORS, an arts-based educational program on reducing mental-health-related stigma among youth in India.

Methods

We conducted a mixed-methods, pre-post control group study among college-going adolescents in Hyderabad, India. At baseline and post-intervention (after six weeks), we examined differences in intended behavior towards people with mental health problems.

Results

Our study involved 432 participants across three study groups: participants creating art on the theme of mental-health-related stigma over six weeks (n = 123), a student audience viewing 2-h arts show by participants (n = 244), and a control group (n = 65). Between baseline and post-test, participants creating art showed significantly lower stigma towards people with mental health problems compared to members of the control group (coefficient = 1.55, 95%CI 0.06-3.04, p = 0.041). Participants found the intervention useful and enjoyable (>95%; n = 773 across six weeks). Participants identified that collaborative creation of art made the subject of mental health interesting and relatable.

Conclusions

Participating in an arts-based educational program was associated with significantly lower mental-health-related stigma among youth compared to a control group in the short term. High acceptability of the program demonstrates the utility of arts-based education to address mental-health-related stigma. With community partners and artists as facilitators, our program may support mental health specialists in mental health promotion.

Assessing the Effectiveness of Multilevel Intervention Sequences on "Tension" Among Men Living with HIV: A Randomized-Control Trial

BACKGROUND

Tension (often times called "Tenshun" in Hindi) is a cultural expression used to convey feelings of distress and common mental disorders in India and among South Asia communities. This study compared the effectiveness of different intervention sequences in reducing tension among alcohol-consuming men living with HIV in India.

METHOD

This secondary data analysis paper utilized data from a randomized trial study titled "Alcohol and Antiretroviral Therapy (ART) Adherence: Assessment, Intervention, and Modeling in India." The multilevel interventions, including individual counseling (IC), group intervention (GI), and collective advocacy (CA), were conducted sequentially over three cycles at three ART centers. Additionally, another ART center, serving as a pilot site, received all three interventions simultaneously in the final cycle. Participants completed surveys assessing demographic characteristics, tension, and other variables including HIV stigma, a 4-day ART adherence, HIV symptoms, and depressive symptoms at four time points: baseline, 9 months, 18 months, and 24 months. General linear mixed models were employed to assess the intervention effects on tension.

RESULTS

Out of 940 participants, 666 reported experiencing tension, including 54% reporting high tension. At site 1, the GI-CA-IC sequence resulted in a slope of -0.06, indicating that this sequence reduced tension from T1 to T4 compared to the control group (p < 0.01). Additionally, the pilot site where the intervention package was conducted simultaneously had a slope of -0.06, indicating that the intervention package also reduced tension compared to the control group (p < 0.01). Conversely, the CA-IC-GI sequence resulted in a slope of 0.07, indicating that this sequence resulted in significantly higher tension levels than the control group (p = 0.008) contrary to the expectation that the sequence would reduce tension.

CONCLUSION

This study contributes valuable insights on the issue of tension among alcohol-consuming men living with HIV. The significant reduction in tension observed at the site using the GI-CA-IC sequence, which began with a group intervention, underscores the importance of intervention order and the importance of group intervention within multilevel intervention programs for tension reduction. Further research is needed to validate these observations and broaden our understanding of effective tension management strategies among people living with HIV in diverse settings.

TRIAL REGISTRATION

URL: clinicaltrials.gov.

REGISTRATION NUMBER

NCT03746457.

Diagnostic pattern of mental, neurological and substance use disorders at primary health care facilities in Uganda

Integration of diagnosis and treatment for mental, neurological, and substance use (MNS) disorders into primary health care is a recommended strategy to improve access to services in low-and middle-income countries. Despite numerous initiatives for integration of mental health care in Uganda, there has not been an evaluation of health management information system (HMIS) records to determine whether MNS disorders are routinely diagnosed. We sought to determine diagnostic pattern of MNS disorders at primary health facilities in Wakiso and Kampala districts, the most populous regions of Uganda. Lower-level primary health facilities were visited to obtain records from HMIS registers, to document diagnoses of MNS disorders. Secondary data analysis was conducted and descriptive statistics reported. A total of 40 primary health care facilities were visited representing 58.6% of the health facilities in the study districts. More than half (54.8%) and almost all (87.5%) of the lower-level health facilities in Wakiso district and Kampala district respectively were visited. The proportion of MNS disorders diagnosed at lower-level primary health facilities in Uganda is very low with Epilepsy the most common MNS diagnosis recorded. Reasons for such low numbers of diagnoses at primary health facilities are discussed as are possible solutions.

A Glossary of Distress Expressions Among Kannada-Speaking Urban Hindu Women

People's lived experiences of distress are complex, personal, and vary widely across cultures. So, too, do the terms and expressions people use to describe distress. This variation presents an engaging challenge for those doing intercultural work in transcultural psychiatry, global mental health, and psychological anthropology. This article details the findings of a study of common distress terminology among 63 Kannada-speaking Hindu women living in Mysuru, the second largest city in the state of Karnataka, South India. Very little existing scholarship focuses on cultural adaptation for speakers of Dravidian languages like Kannada; this study aims to fill this gap and support greater representation of this linguistic family in research on mental health, idioms of distress, and distress terminology. Between 2018 and 2019, we conducted a 3-phase study consisting of interviews, data reduction, and focus group discussions. The goal was to produce a non-exhaustive list of common Kannada distress terms that could be used in future research and practice to translate and culturally adapt mental health symptom scales or other global mental health tools.

Longitudinal patterns of natural hazard exposures and anxiety and depression symptoms among young adults in four low- and middle-income countries

We estimated the effect of community-level natural hazard exposure during prior developmental stages on later anxiety and depression symptoms among young adults and potential differences stratified by gender. We analyzed longitudinal data (2002-2020) on 5585 young adults between 19 and 26 years in Ethiopia, India, Peru, and Vietnam. A binary question identified community-level exposure, and psychometrically validated scales measured recent anxiety and depression symptoms. Young adults with three exposure histories ("time point 1," "time point 2," and "both time points") were contrasted with their unexposed peers. We applied a longitudinal targeted minimum loss-based estimator with an ensemble of machine learning algorithms for estimation. Young adults living in exposed communities did not exhibit substantially different anxiety or depression symptoms from their unexposed peers, except for young women in Ethiopia who exhibited less anxiety symptoms (average causal effect [ACE] estimate = - 8.86 [95% CI: - 17.04, - 0.68] anxiety score). In this study, singular and repeated natural hazard exposures generally were not associated with later anxiety and depression symptoms. Further examination is needed to understand how distal natural hazard exposures affect lifelong mental health, which aspects of natural hazards are most salient, how disaster relief may modify symptoms, and gendered, age-specific, and contextual differences.

Treatment for Insomnia Symptoms is Associated with Reduced Depression Among Older Adults: A Propensity Score Matching Approach

OBJECTIVES

The study aimed to investigate the effect of utilization of treatment for insomnia symptoms on the prevalence of major depressive disorder among older adults in India.

METHODS

We used the data from the Longitudinal Ageing Study in India (LASI), 2017-18. The sample included 10,911 older individuals who reported insomnia symptoms. The propensity score matching (PSM) approach was used to compare the depressive disorder among those who received vs. not received treatment.

RESULTS

Only 5.7% of older adults reporting insomnia symptoms received treatment. On average, prevalence of depressive disorder among men and women who received treatment for insomnia symptoms was lesser by 0.79 and 0.33 points, respectively, than those who did not receive treatment. In the matched sample, treatment for insomnia symptoms was significantly associated with lesser prevalence of depression for both older men (β= -0.68, p < .001) and older women (β= -0.62, p < .001).

CONCLUSIONS

The current findings suggest that treatment for insomnia symptoms can reduce the risk of depressive disorder among older adults and the effects are higher among older men than women.

Barriers and Facilitators to Medical Help-seeking in Rural Patients with Mental Illness: A Qualitative Meta-synthesis

PURPOSE

Numerous barriers hinder individuals with mental illness from seeking medical assistance in rural regions, yet a comprehensive understanding of these challenges remains elusive. This meta-synthesis aims to understand the barriers and facilitators in medical help-seeking among rural individuals with mental illness.

METHODS

We systematically searched seven databases [PubMed, CINAHL, Medline (OVID), PsycINFO (OVID), Cochrane, Embase, and ProQuest] in May 2023 and included the studies if they reported the barriers or/and facilitators to seek healthcare in rural patients with mental illness. We conducted hand search and citation search on Google Scholar for literature supplements. Thematic analysis was employed.

RESULTS

The study included 27 articles reporting on the barriers and facilitators to seeking medical help in this population from 2007 to 2023. We ultimately identified themes at three levels: navigating the terrain of vulnerability and empowerment (the individual with mental illness), navigating the terrain of external environment (the external environment) and connectivity within the healthcare ecosystem for mental health (the health service system).

CONCLUSIONS

We must design more effective strategies to improve mental healthcare access for rural patients, considering cultural nuances and health service utilization patterns. This requires a multi-level approach, tailored to the unique needs of diverse populations.

Reflections on the trends of suicide in Sri Lanka, 1997-2022: The need for continued vigilance

Despite reductions in suicide rates in Sri Lanka during the past decades, largely by introduction of national bans on highly hazardous pesticides, the country continues to record a higher than global average rate of suicide. With the changing availability of methods of suicide over time, we aimed to examine the age-standardized suicide rates in Sri Lanka by sex, age, and method between 1997 to 2022 using national police suicide data to identify trends. The rate of suicide in Sri Lanka in 2022 was 27/100,000 and 5/100,000, in males and females respectively, with an overall suicide rate of 15/100,000 population. When considering the previous decades, the overall rate of suicide has declined from 1997 until about 2015, in both sexes, driven by a drop in the numbers of suicides due to pesticide ingestion. In females the overall rates of suicide plateaued around 2015, but in males there has been an upward trend in overall suicide that started in 2016, mostly due to an increase in rates of hanging. Since 2016 rates of suicide by hanging have increased among older males, and young females (17-25 years). Whilst the current suicide rate in Sri Lanka is substantially lower than it was during the 1990s, the upward trend in hanging seen in the last few years, particularly among older men and young women, is of concern. Ongoing monitoring of suicide rates should be a priority during the next few years, to detect and respond to changes as soon as possible. There is an urgent need to address current risk factors for suicide in Sri Lanka, such as significant financial insecurity, unemployment, depression, alcohol misuse, and domestic violence, and to minimize media glamourization of hanging by suicide.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Living with depression and diabetes: A qualitative study in Bangladesh and Pakistan

Diabetes and depression are both serious health conditions. While their relationship is bidirectional and each condition adversely affects outcomes for the other, they are treated separately. In low and middle income countries, such as Bangladesh and Pakistan, health systems are already stretched and the integration of diabetes and depression care is rarely a priority. Within this context through interviews with patients, healthcare workers and policy makers the study explored: lived experiences of people living with depression and diabetes, current practice in mental health and diabetes care and barriers and perspectives on integrating a brief psychological therapy into diabetes care. The findings of the study included: differing patient and practitioner understandings of distress/depression, high levels of stigma for mental health and a lack of awareness and training on treating depression. While it was apparent there is a need for more holistic care and the concept of a brief psychological intervention appeared acceptable to participants, many logistical barriers to integrating a mental health intervention into diabetes care were identified. The study highlights the importance of context and of recognising drivers and understandings of distress when planning for more integrated mental and physical health services, and specifically when adapting and implementing a new intervention into existing services.

Multiple Mental Health Literacies in a Traditional Temple Site in Kerala: The Intersection Between Beliefs, Spiritual and Healing Regimes

The notion of 'mental health literacy' has been proposed as a way of improving mental health problem recognition, service utilisation and reducing stigma. Yet, the idea embodies a number of medical-model assumptions which are often at odds with diverse communities' spiritual traditions and local belief systems. Twenty participants were recruited to this study consisting of mental health service users (N = 7), family carers (N = 8) and community members (N = 5) in a temple town in Kerala, South India participated in semi-structured interviews exploring the variety of beliefs and practices relating to mental health. Our findings indicate that the issue may be better understood in terms of multiple mental health literacies which people deploy in different circumstances. Even those sceptical of traditional and spiritual approaches are knowledgeable about them, and the traditional practices themselves often involve detailed regimes of activities aimed at effecting an improvement in the person's mood or condition. Therefore, we argue it is appropriate to consider mental health literacy not as a unitary universal phenomenon but instead as a mosaic of different literacies which may be deployed in different settings and in line with different experiences and which may operate in synergy with each other to enable treatment but also facilitate a sense of meaning and purpose in life.

Establishing community mental health clinics increased the number of patients receiving care in rural Western Uganda

Background

Mental, neurological, and substance-use disorders cause medium to long term disability in all countries. They are amenable to treatment but often treatment is only available in hospitals, as few staff feel competent to give treatment. The WHO developed the "Mental Health GAP" (mhGAP) course to train non-specialist clinical staff in basic diagnosis and treatment. At Bwindi Community Hospital, in south-west Uganda, mental health care was initially only provided at the hospital. It was extended outside the hospital in two implementation phases, initially by establishing 17 clinics in the community, run by qualified mental health staff from the hospital. In the second implementation phase staff in 12 health centers were trained using mhGAP and ran their own clinics under supervision.

Methods

Using routine data the defined data variables for the individuals attending the clinics was extracted.

Results

A total of 2,617 people attended a mental health care clinic in the study period between January 2016 and March 2020. Of these 1,051 people attended more than once. The number of patients attending clinics increased from 288 during the baseline to 693 in the first implementation phase then to 839 patients in the second implementation phase. After mhGAP training, about 30% of patients were seen locally by mhGAP trained healthcare personnel. The average number of mental health patients seen each month increased from 12 to 65 over the time of the study. The number of patients living >20 km from the hospital increased from 69 in the baseline to 693 in the second implementation phase. The proportion of patients seen at the hospital clinic dropped from 100% to 27%.

Conclusions

Providing mental health care in the community at a distance from the hospital substantially increased the number of people accessing mental health care. Training health center-based staff in mhGAP contributed to this. Not all patients could appropriately be managed by non-specialist clinical staff, who only had the five-day training in mhGAP. Supplies of basic medicines were not always adequate, which probably contributed to patients being lost to follow-up. About 50% of patients only attend the clinic once. Further work is required to understand the reasons.

Determinants of Health-Seeking Behavior in Major Depressive Disorder: An Observational Study

BACKGROUND

Major depressive disorder (MDD) is one of the most common illnesses in the world and a major cause of years lived with disability. It is necessary to diagnose and treat depression promptly.

OBJECTIVES

To identify and compare factors affecting health-seeking behavior in patients suffering from MDD.

METHODS

An observational cross-sectional study was conducted. The study population was divided into two groups: early and late health seekers (cut off: three months). Patient Health Questionnaire - 9 (PHQ-9) as well as Perceived and Personal Depression Stigma Scores were calculated. Data were analyzed and the chi-square test and z-test were used to calculate statistical significance.

RESULTS

There were 102 participants. The majority were female (62.75%) and the maximum number of participants were from the age group of 26-45 years (65.69%). There were more early help seekers (61.76%) than late help seekers (38.24%). The majority of early help seekers were married individuals. Distance played a vital role in help-seeking behavior. A significant association was also found between participants' personal stigma and late treatment seeking. The most common reason for delaying medical attention was that patients thought that they could cure themselves, followed by a lack of awareness.

CONCLUSION

Delay and hesitance observed concerning health-seeking behavior are assumed to be associated with factors such as gender, income, family or marital status, stigma, lack of awareness, beliefs and practices, and deficient health facilities causing delays in the diagnosis and management of MDD. The research supported that involving primary health care centers, spreading awareness about the disease, and increasing psychiatric facilities, along with a special emphasis on factors as mentioned like gender, marital status, stigma, and feasibility of reaching facility as distance plays a major role in causing delay, and can help decrease the duration of symptom from the onset, initiating appropriate treatment, and improving prognosis.

Understandings of depression among community members and primary healthcare attendees in rural Ethiopia: A qualitative study

Available evidence in Africa suggests that the prevalence of depression in primary care settings is high but it often goes unrecognized. In this study, we explored how depression is conceptualized and communicated among community members and primary care attendees diagnosed with depression in rural Ethiopia with the view to informing the development of interventions to improve detection. We conducted individual interviews with purposively selected primary care attendees with depression (n = 28; 16 females and 12 males) and focus group discussions (FGDs) with males, females, and priests (n = 21) selected based on their knowledge of their community. Data were analyzed using thematic analysis. None of the community members identified depression as a mental illness. They considered depressive symptoms presented in a vignette as part of a normal reaction to the stresses of life. They considered medical intervention only when the woman's condition in the vignette deteriorated and "affected her mind." In contrast, participants with depression talked about their condition as illness. Symptoms spontaneously reported by these participants only partially matched symptoms listed in the current diagnostic criteria for depressive disorders. In all participants' accounts, spiritual explanations and traditional healing were prominent. The severity of symptoms mediates the decision to seek medical help. Improved detection may require an understanding of local conceptualizations in order to negotiate an intervention that is acceptable to affected people.

Mobile Mental Health in Women's Community-Based Organizations: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Of every 10 women in rural India, 1 suffers from a common mental disorder such as depression, and untreated depression is associated with significant morbidity and mortality. Several factors lead to a large treatment gap, specifically for women in rural India, including stigma, lack of provider mental health workforce, and travel times. There is an urgent need to improve the rates of detection and treatment of depression among women in rural India without overburdening the scarce mental health resources.

OBJECTIVE

We propose to develop, test, and deploy a mental health app, MITHRA (Multiuser Interactive Health Response Application), for depression screening and brief intervention, designed for use in women's self-help groups (SHGs) in rural India.

METHODS

We will use focus groups with SHG members and community health workers to guide the initial development of the app, followed by iterative modification based on input from a participatory design group consisting of proposed end users of the app (SHG members). The final version of the app will then be deployed for testing in a pilot cluster randomized trial, with 3 SHGs randomized to receive the app and 3 to receive enhanced care as usual.

RESULTS

This study was funded in June 2021. As of September 2022, we have completed both focus groups, 1 participatory design group, and app development.

CONCLUSIONS

Delivering app-based depression screening and treatment in community settings such as SHGs can address stigma and transportation-related barriers to access to depression care and overcome cultural and contextual barriers to mobile health use. It can also address the mental health workforce shortage. If we find that the MITHRA approach is feasible, we will test the implementation and effectiveness of MITHRA in multiple SHGs across India in a larger randomized controlled trial. This approach of leveraging community-based organizations to improve the reach of depression screening and treatment is applicable in rural and underserved areas across the globe.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42919.

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

Despite the severe consequences, the treatment gap for depression, epilepsy, and schizophrenia continues to be a major concern in low and middle-income countries (LMICs). We conducted a systematic review of literature on barriers and facilitators of treatment-seeking behaviors from the perspective of individuals living with depression, epilepsy, and schizophrenia and stakeholders in LMICs. Knowledge deficits, beliefs, and stigma were barriers to treatment-seeking across disorders. The most cited facilitators were demographics, socioeconomic status, and collaboration with traditional healers. Culturally sensitive interventions in collaboration with stakeholders within the community can facilitate treatment-seeking behaviors among people living with depression, epilepsy, and schizophrenia.

A scoping review of community-based mental health intervention for children and adolescents in South Asia

Children and adolescents in South Asia are exposed to significant mental health risks. Yet, policy to prevent or treat youth mental health problems in this context is underdeveloped, and services are difficult to access. Community-based mental health treatment may offer a potential solution, by increasing resource capacity in deprived settings. However, little is known about the current community-based mental health provision for South Asian youth. A scoping review was conducted across six scientific databases and hand searching of reference lists to identify relevant studies. Study selection and data extraction were performed by three independent reviewers using predefined criteria, an adapted version of the template for intervention description and replication checklist and the Cochrane Risk of Bias Tool. The search identified 19 relevant studies published from January 2000 to March 2020. Studies most frequently addressed PTSD and autism, were conducted in India and Sri Lanka, used education-based intervention and were based in urban school settings. Community-based mental health provision for the South Asian youth is in its infancy, but holds promise for providing essential resources to treat or prevent mental health disorder. New insights on approaches are discussed, which are valuable for South Asian settings, primarily task-shifting and stigma reduction, with implications for policy, practice and research.

Barriers and facilitators for treatment-seeking in adults with a depressive or anxiety disorder in a Western-European health care setting: a qualitative study

BACKGROUND

Previous research on barriers and facilitators regarding treatment-seeking of adults with depressive and anxiety disorders has been primarily conducted in the Anglosphere. This study aims to gain insight into treatment-seeking behaviour of adults with depressive and anxiety disorders in a European healthcare system.

METHODS

In-depth semi-structured interviews were conducted with 24 participants, aged ≥18 years and diagnosed with an anxiety disorder and/or depressive disorder according to DSM-IV. Participants were purposively sampled from an outpatient department for mental health care in the Netherlands. The seven steps of framework analysis were used to identify relevant themes emerging from the interviews.

RESULTS

Data analysis suggested an interplay between individual aspects, personal social system, healthcare system and sociocultural context influences. Amongst the most relevant themes were mental health illiteracy, stigma, a negative attitude toward professional help, the influence of significant others and general practitioner, and waiting time. Financial barriers were not of relevance.

CONCLUSIONS

Even in a country with a well-developed mental health care system and in absence of financial barriers, there are many barriers to treatment-seeking in adult patients with depressive and anxiety disorders. National campaigns to increase awareness and decrease stigma in the general population, and to empower the social environment might reduce the treatment gap.

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

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

Leveraging Systems Science to Promote the Implementation and Sustainability of Mental Health and Psychosocial Interventions in Low- and Middle-Income Countries

ABSTRACT

Advancements in global mental health implementation research have revealed promising strategies for improving access to evidence-based mental health care. These advancements have not translated, however, into a reduced prevalence of mental disorders. In this review we examine the relationships between determinants (i.e., barriers and facilitators) and outcomes of mental health services in low- and middle-income countries to identify opportunities for improving the population-level impact and sustainability of innovations in global mental health. We identified three key implementation and services outcomes that influenced the prevalence of mental disorders in the 56 included review articles: supply (access, implementation), demand (help seeking, utilization), and quality (effectiveness, quality of care) of mental health services. Determinants of these outcomes revealed seven themes: community stakeholder engagement; cultural relevance; stigma; human resource capacity; organization of services; governance, policy, and financing; and sociopolitical and community context. We developed a causal loop diagram to illustrate the relationships among these determinants and outcomes. The causal loop diagram revealed the central role of community stakeholder engagement in bridging implementation and patient outcomes, the importance of addressing stigma and social determinants of mental health, and the need to complement supply-side implementation strategies with approaches to equilibrate demand and improve the quality of services. Applying systems science methodologies to global mental health research presents an opportunity to examine the complex relationships among community and health system factors that influence implementation of evidence-based interventions in order to identify sustainable approaches to improve the population-level impact of mental health services in low- and middle-income countries.

Health care use and treatment-seeking for depression symptoms in rural India: an exploratory cross-sectional analysis

BACKGROUND

There is a large "treatment gap" for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression.

METHODS

Data were analysed from a two round cross-sectional community survey conducted in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors using univariable regression.

RESULTS

86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals (p < 0.0001). Private providers were most frequently consulted by screen-positive adults (32%), while only 19% consulted traditional providers. Structural barriers to healthcare use such as cost and distance to services were frequently reported (54 and 52%, respectively) but were not associated with treatment-seeking for depression. The following factors were found to be positively associated with treatment-seeking for depression: higher symptom severity; lack of energy, lack of interest/pleasure, low self-esteem, or slow movements/restlessness on more than 7 days in the past 2 weeks; being married; having discussed depression symptoms; and reporting problems with medication availability and supply as a barrier to healthcare. No evidence was found for an association between treatment-seeking for depression and most socio-economic, demographic or attitudinal factors.

CONCLUSIONS

These findings suggest that the majority of adults who screen positive for depression seek healthcare, although not primarily for depression symptoms, indicating the need to improve detection of depression during consultations about other complaints. Private providers may need to be considered in programmes to improve depression treatment in this setting. Further research should test the hypotheses generated in this descriptive study, such as the potential role of marriage in facilitating treatment-seeking.