Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact

Multi-sector determinants of implementation and sustainment for non-specialist treatment of depression and post-traumatic stress disorder in Kenya: a concept mapping study

BACKGROUND

The global shortage of trained mental health workers disproportionately impacts mental health care access in low- and middle-income countries. In Kenya, effective strategies are needed to scale-up the workforce to meet the demand for depression and post-traumatic stress disorder treatment. Task-shifting - delegating specific tasks to non-specialist workers - is one workforce expansion approach. However, non-specialist workers remain underutilized in Kenya due to a paucity of research on how to scale-up and sustain such service models.

METHODS

Purposive sampling was used to recruit experts from policy, healthcare practice, research, and mental health advocacy roles in Kenya (N = 30). Participants completed concept mapping activities to explore factors likely to facilitate or hinder a collaborative Ministry of Health-researcher training of the mental health non-specialist workforce. Participants brainstormed 71 statements describing determinants and implementation strategies, sorted and rated the importance and changeability of each. Multidimensional scaling and hierarchical cluster analysis quantified relationships between statements. The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework guided cluster interpretation activities.

RESULTS

Twelve determinant clusters were identified: 1) Current workforce characteristics, 2) Exploration considerations, 3) Preparation considerations, 4) Sustainment considerations, 5) Inner context implementation processes and tools, 6) Local capacity and partnerships, 7) Financing for community health teams, 8) Outer context resource allocation/policy into action, 9) Workforce characteristics to enhance during implementation, 10) Workforce implementation strategies, 11) Cross-level workforce strategies, and 12) Training and education recommendations. Cluster 8 was rated the most important and changeable.

CONCLUSION

Concept mapping offers a rapid, community-engaged approach for identifying determinants and implementation strategies to address workforce shortages. Organizing results by EPIS phases can help prioritize strategy deployment to achieve implementation goals. Scale-up and sustainment of the non-specialist workforce in Kenya requires formal partnerships between the Ministry of Health and community health worker teams to distribute financial resources and collaboratively standardize training curriculum.

An App-Based WHO Mental Health Guide for Depression Detection: A Cluster Randomized Clinical Trial

Importance

Depression detection in primary care remains limited in low- and middle-income countries despite increasing use of the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG).

Objective

To test an app version of the mhGAP-IG (e-mhGAP-IG) in Nepal and Nigeria to improve depression detection.

Design, Setting, and Participants

In this feasibility cluster randomized clinical trial conducted from February 14, 2021, to March 25, 2022, primary care facilities (unit of clustering) in Nepal and Nigeria were randomized to the standard mhGAP-IG training arm (control) or to training using the e-mhGAP-IG app (intervention). Primary care workers (PCWs) received training based on the arm assignment of their health care facility. Statistical analysis was conducted from July 20, 2022, through September 27, 2024.

Intervention

Training using standard mhGAP-IG vs training using the e-mhGAP-IG.

Main Outcomes and Measures

Analysis was performed on an intention-to-treat basis. The main outcome was accuracy of depression detection rates by PCWs, evaluated prior to mhGAP training and 5 to 8 months after training, measured as the percentage of patients who received a depression diagnosis by their PCWs compared with the number of patients who scored 10 or more on the locally validated 9-item Patient Health Questionnaire. Costs per patient detected were calculated.

Results

In Nepal, 25 facilities (67 PCWs; mean [SD] age, 35.3 [9.2] years; 52 men [78%]) were randomized: 13 facilities to standard mhGAP-IG training (36 PCWs) and 12 facilities to e-mhGAP-IG (31 PCWs). In Nigeria, 10 facilities (47 PCWs; mean [SD] age, 46.9 [7.5] years; 44 women [94%]) were randomized: 5 facilities to standard mhGAP-IG (25 PCWs) and 5 facilities to e-mhGAP-IG (22 PCWs). In Nepal, depression detection by PCWs in the standard mhGAP-IG arm increased from 0 of 43 patients before training to 15 of 92 patients after training (adjusted mean change [AMC], 16% [95% CI, 5%-28%]), and depression detection in the e-mhGAP-IG arm increased from 0 of 49 before training to 22 of 91 after training (AMC, 24% [95% CI, 12%-36%]). In Nigeria, depression detection in the standard mhGAP-IG arm increased from 5 of 36 patients before training to 25 of 75 patients after training (AMC, 19% [95% CI, 2%-37%]), and depression detection in the e-mhGAP-IG arm increased from 6 of 35 patients before training to 67 of 76 patients after training (AMC, 71% [95% CI, 57%-85%]). In facilities in the e-mhGAP-IG arm, the app was used for 59 of 616 assessments (10% of patients) in Nepal and 883 of 1077 assessments (82% of patients) in Nigeria. Cost per patient with depression detected using the e-mhGAP-IG was Nepali Rupiya (NPR) 1980 (US $14.79) in Nepal and naira (₦) 1462 (US $0.91) in Nigeria.

Conclusions and Relevance

This feasibility cluster randomized clinical trial demonstrated that the use, cost, and potential clinical benefit of the e-mhGAP-IG varied by setting, highlighting the importance of multisite feasibility studies when evaluating digital innovations intended for health care systems worldwide.

Trial Registration

ClinicalTrials.gov Identifier: NCT04522453.

Effectiveness of the caregiver support intervention on child psychosocial wellbeing among Syrian refugees in Lebanon: Mediation and secondary analysis of a Randomized Controlled Trial

BACKGROUND

War and violence have a serious negative impact on the wellbeing and mental health of many children. Caregivers play an important role in mitigating or exacerbating this impact.

OBJECTIVE

This study evaluates the impact of the nine session Caregiver Support Intervention on improving children's wellbeing and examines putative mediators of changes in children's psychosocial wellbeing.

PARTICIPANTS AND SETTING

240 female caregivers were randomly allocated (1:1) to the CSI or a waitlist control comparison condition. The study was implemented in Lebanon, in an area characterized by high levels of poverty and a high number of the Syrian refugees.

METHODS

A parallel group Randomized Controlled Trial reporting on caregiver-reported child-level wellbeing. We used a combination of the Kid- and Kiddy-KINDL (parent version) for index children ages three to 12. Putative mediators of the CSI on children's psychosocial wellbeing included harsh parenting, caregiver psychological distress, caregiver wellbeing. Measurements were conducted at baseline, post-intervention and 3-months follow-up.

RESULTS

We demonstrated a statistically significant change in caregiver reported children's psychosocial wellbeing at post-intervention (Mdiff =4.39, 95 % CI = 1.12, 7.65, p < 0.01, d = 0.28) but not at follow-up (Mdiff = -0.97, 95 % CI = -4.27, 2.32, p > 0.05). The proportion of the total effect of the CSI intervention on child psychosocial wellbeing mediated by caregiver distress, caregiver wellbeing and harsh parenting was 77 %.

CONCLUSION

The CSI holds potential for down-stream short-term effect on improving children's psychosocial wellbeing, beyond the previously reported positive caregiver outcomes. This effect was not sustained three months post intervention. The study confirms caregiver wellbeing and parenting support as dual pathways mediating child psychosocial wellbeing. Prospective trial registration: ISRCTN22321773.

Competency-based training and supervision: development of the WHO-UNICEF Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) initiative

Globally, there has not been a standardised approach to ensure that the growing number of people who are not licensed clinicians but are delivering psychological interventions and mental health services have the competencies to deliver those interventions and services safely. Therefore, WHO and UNICEF developed Ensuring Quality in Psychosocial and Mental Health Care (EQUIP). EQUIP is a free resource with a digital platform that can be used to guide competency assessment. We describe EQUIP's 5-year development (2018-23) and the rationale supporting its contents and use. Development phases included establishing consensus for competency-based strategies; selecting foundational competencies; evaluating feasibility of assessments, role plays, and technology; piloting EQUIP when training non-specialists; and public dissemination and ongoing adaptations to increase scalability. From the public launch in March, 2022, through to March, 2024, EQUIP's digital platform has been used in 794 training programmes in 36 countries with 3760 trainees resulting in 10 001 competency assessments.

Applying systems theory to global mental health

In recent years the evidence base for psychological interventions in low- and -middle-income countries (LMIC) has rapidly accrued, demonstrating that task-shifting models result in desired outcomes. Next, it is important to look at how this evidence translates into practice. In doing so, this paper argues that the field of global mental health might benefit from applying a system theory or system science perspective. Systems thinking aims to understand how different components are connected and interdependent within a larger emergent entity. At present much of the research efforts into psychological interventions in LMIC are focusing on single interventions, with little focus on how these interventions sit in, or influence, a larger system. Adopting systems theory and system dynamics tools can help in; (i) better analyzing and understanding the key drivers of mental health problems and services, (ii) optimizing mental health services; and (iii) understanding the organization of people, institutions and resources required for rolling out and scaling-up mental health services. This paper reflects on some of these merits of a systems perspective, as well as provides some examples.

Data-driven supervision to optimize the effectiveness of proactive case detection for mental health care among children: a proof-of-concept study

This proof-of-concept study evaluated an optimization strategy for the Community Case Detection Tool (CCDT) aimed at improving community-level mental health detection and help-seeking among children aged 6-18 years. The optimization strategy, CCDT+, combined data-driven supervision with motivational interviewing techniques and behavioural nudges for community gatekeepers using the CCDT. This mixed-methods study was conducted from January to May 2023 in Palorinya refugee settlement in Uganda. We evaluated (1) the added value of the CCDT+ in improving the accuracy of detection and mental health service utilization compared to standard CCDT, and (2) implementation outcomes of the CCDT+. Of the 1026 children detected, 801 (78%) sought help, with 656 needing mental health care (PPV = 0.82; 95% CI: 0.79, 0.84). The CCDT+ significantly increased detection accuracy, with 2.34 times higher odds compared to standard CCDT (95% CI: 1.41, 3.83). Additionally, areas using the CCDT+ had a 2.05-fold increase in mental health service utilization (95% CI: 1.09, 3.83). The CCDT+ shows promise as an embedded quality-optimization process for the detection of mental health problems among children and enhance help-seeking, potentially leading to more efficient use of mental health care resources.

War exposure, daily stressors, and mental health 15 years on: implications of an ecological framework for addressing the mental health of conflict-affected populations

AIMS

Fifteen years ago, we published an article in Social Science and Medicine seeking to resolve the contentious debate between advocates of two very different frameworks for understanding and addressing the mental health needs of conflict-affected populations. The two approaches, which we labelled trauma-focused and psychosocial, reflect deeply held beliefs about the causes and nature of distress in war-affected communities. Drawing on the burgeoning literature on armed conflict and mental health, the reports of mental health and psychosocial support (MHPSS) staff in the field, and on research on the psychology and psychophysiology of stress, we proposed an integrative model that drew on the strengths of both frameworks and underscored their essential complementarity. Our model includes two primary pathways by which armed conflict impacts mental health: directly, through exposure to war-related violence and loss, and indirectly, through the harsh conditions of everyday life caused or exacerbated by armed conflict. The mediated model we proposed draws attention to the effects of stressors both past (prior exposure to war-related violence and loss) and present (ongoing conflict, daily stressors), at all levels of the social ecology; for that reason, we have termed it an ecological model for understanding the mental health needs of conflict-affected populations.

METHODS

In the ensuing 15 years, the model has been rigorously tested in diverse populations and has found robust support. In this paper, we first summarize the development and key tenets of the model and briefly review recent empirical support for it. We then discuss the implications of an ecological framework for interventions aimed at strengthening mental health in conflict-affected populations.

RESULTS

We present preliminary evidence suggesting there has been a gradual shift towards more ecological (i.e., multilevel, multimodal) programming in MHPSS interventions, along the lines suggested by our model as well as other conceptually related frameworks, particularly public health.

CONCLUSIONS

We reflect on several gaps in the model, most notably the absence of adverse childhood experiences. We suggest the importance of examining early adversity as both a direct influence on mental health and as a potential moderator of the impact of potentially traumatic war-related experiences of violence and loss.

Cultural Adaptation and User Satisfaction of an Internet-Delivered Cognitive Behavioral Program for Depression and Anxiety Among College Students in Two Latin American Countries: Focus Group Study With Potential Users and a Cross-Sectional Questionnaire Study With Actual Users

BACKGROUND

To scale up mental health care in low-resource settings, digital interventions must consider cultural fit. Despite the findings that culturally adapted digital interventions have greater effectiveness, there is a lack of empirical evidence of interventions that have been culturally adapted or their adaptation documented.

OBJECTIVE

This study aimed to document the cultural adaptation of the SilverCloud Health Space from Depression and Anxiety program for university students in Colombia and Mexico and evaluate user satisfaction with the adapted program.

METHODS

A mixed methods process was based on Cultural Sensitivity and Ecological Validity frameworks. In phase 1, the research team added culturally relevant content (eg, expressions, personal stories, photos) for the target population to the intervention. In phase 2, potential users (9 university students) first evaluated the vignettes and photos used throughout the program. We calculated median and modal responses. They then participated in focus groups to evaluate and assess the cultural appropriateness of the materials. Their comments were coded into the 8 dimensions of the Ecological Validity Framework. Phase 3 consisted of choosing the vignettes most highly rated by the potential users and making modifications to the materials based on the student feedback. In the final phase, 765 actual users then engaged with the culturally adapted program and rated their satisfaction with the program. We calculated the percentage of users who agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them attain their goals.

RESULTS

The potential users perceived the original vignettes as moderately genuine, or true, which were given median scores between 2.5 and 3 (out of a possible 4) and somewhat identified with the situations presented in the vignettes given median scores between 1.5 and 3. The majority of comments or suggestions for modification concerned language (126/218, 57.5%), followed by concepts (50/218, 22.8%). Much less concerned methods (22/218, 10%), persons (9/218, 4.1%), context (5/218, 2.3%), or content (2/218, 0.9%). There were no comments about metaphors or goals. Intervention materials were modified based on these results. Of the actual users who engaged with the adapted version of the program, 87.7%-96.2% of them agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them to attain their goals.

CONCLUSIONS

We conclude that the adapted version is satisfactory for this population based on the focus group discussions and the satisfaction scores. Conducting and documenting such cultural adaptations and involving the users in the cultural adaptation process will likely improve the effectiveness of digital mental health interventions in low- and middle-income countries and culturally diverse contexts.

Enhancing Teacher Gatekeeper Skills for Suicide: A Cluster-Randomized Controlled Trial Among School-Based Lay People in China

Gatekeeper training equips individuals with the skills to identify those exhibiting warning signs of suicide risk and refer them to appropriate services. However, enhancing gatekeepers' knowledge, efficacy, subsequent behaviors, and the broader implications of such interventions in school settings remain pressing concerns. To address these challenges, the Life Gatekeeper Training Program (LGTP) was developed. This 8-session program is designed to train school teachers in essential gatekeeper skills through case demonstrations, role-plays, and group discussions, by using a train-the-trainer model. A cluster randomized controlled trial, which randomly assigned 84 schools (including 223 trainers and 4,140 trainees) to intervention and waitlist control groups, was conducted from December 2022 to March 2024 to evaluate the 6- and 12-month outcomes of the LGTP in Yunfu, China. The primary outcomes were teachers' stigmatization, suicide literacy, perceived competence, and willingness to intervene. The secondary outcome measures were gatekeeper behaviors, including identifying students at risk, discussing potential suicide risk with them, or with their caregiver(s), and referring them to a mental health professional or a specialist clinic. The study was pre-registered with the Chinese Clinical Trial Registry, with a registration number of ChiCTR2200066142. Following the principle of intention to treat (ITT), the results of the generalized estimating equations showed LGTP intervention led to significant decreases in stigmatization (b = - 0.80, SE=0.04, P FDR 0.001), increases in suicide literacy (b = 0.98, SE=0.04, P FDR<0.001), perceived competence (b = 1.03, SE=0.04, P FDR<0.001), and willingness to intervene (b = 0.76, SE=0.04, P FDR<0.001) compared to the control group at post-intervention, and these effects were moderately maintained at the 6 and 12 months follow up. In addition, gatekeeper behavior outcomes (i.e., Identify risk students, Talk to the students, Talk to the parents, Refer to professional help) in the intervention group were significantly higher than those in the control group. The LGTP, a standardized program with a brief training format, demonstrated efficacy in increasing actual gatekeeper behaviors among school teachers in China. The delivery strategies of this program enabled rapid scalability to reach a large population within a short time frame, thereby offering opportunities to expand early intervention and prevention efforts.

Psychological distress in the neonatal intensive care unit: a meta-review

INTRODUCTION

Parental psychological distress (PD) (anxiety, depression, stress and post-traumatic stress syndrome) can adversely affect parents' own physical and mental health as well as their children's long-term health and development. Numerous studies have addressed PD in mothers of infants admitted to NICU, with interventions proposed, but few have addressed the impact on fathers or other family members. The present review examined systematic reviews that addressed PD in NICU and potential interventions.

METHODS

A meta-review was performed by searching various databases between 2000 and May 2024.

RESULTS

Fifty-four studies were included. The incidence of maternal PD varied depending on the screening tool used (13-93%), as did paternal PD (0.08-46%). The incidence of PD in sexual, racial and gender minorities, siblings, grandparents and those in lower-middle income countries is not known. Numerous screening tools were used with a wide variety of cut-off values. Various intervention programmes were evaluated and showed contradictory evidence regarding their effect on PD.

DISCUSSION

Routine screening should be implemented together with a combination of interventional programmes, specifically family-centred interventions. More research is required for PD in siblings, sexual and gender minority parents as well as parents living in low middle income countries.

IMPACT STATEMENT

Psychological distress is high in NICU, affecting parents and siblings. Maternal psychological distress may have long lasting effects on infant health and differs from that of fathers, who require as much attention as mothers Little is known about emotional stress in siblings and sex and gender minority group peoples Few interventions showed conclusive effectiveness in reducing psychological distress with combination interventions showing more effectiveness than single interventions.

The Effectiveness and Implementation of Psychological First Aid as a Therapeutic Intervention After Trauma: An Integrative Review

Psychological First Aid (PFA) is known to be an initial early intervention following traumatic exposure, yet little is known about its optimal implementation and effectiveness. This review aims to examine the evidence for the effectiveness of PFA interventions and how PFA interventions have been designed, implemented, and experienced. MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsychINFO, Embase, Web of Science, PILOTS, and China National Knowledge Infrastructure (in Chinese) databases were searched. Twenty studies from 4,735 records were included and quality rated, followed by an integrative synthesis of quantitative and qualitative evidence. PFA intervention following trauma exposure shows a positive effect for reducing anxiety and facilitating adaptive functioning in the immediate and intermediate term, yet the evidence for reducing Post-traumatic stress disorder/depressive symptoms is less compelling. Furthermore, commonalities in the components and techniques across different PFA approaches identified tend to align with four of Hobfoll's five essential elements: safety, calm, efficacy, and connectedness (as reflected among 7/11 PFA protocols), whereas the "hope" element was less developed. These commonalities include active listening, relaxation/stabilization, problem-solving/practical assistance, and social connection/referral. Intensive techniques such as cognitive reconstruction have also been incorporated, intensifying PFA delivery. The substantial variation observed in PFA format, timing, and duration, coupled with inadequate documentation of fidelity of implementation and adaptation, further constrains the ability to inform best practices for PFA. This is concerning for lay frontline providers, vital in early trauma response, who report implementation challenges despite valuing PFA as a time-sensitive, supportive, and practical approach.

Enhancing mental health and well-being in adults from lower-resource settings: A mixed-method evaluation of the impact of problem management plus

Mental health conditions, recognised as a global crisis, were further exacerbated by the COVID-19 pandemic. Access to mental health services remains limited, particularly in low-income regions. Task-sharing interventions, exemplified by Problem Management Plus (PM+), have emerged as potential solutions to bridge this treatment gap. This study presents an evaluation of the PM+ scale-up in Sub-Saharan Africa (Ethiopia and Benin) and Eastern Europe (Croatia and Bosnia and Herzegovina) as part of a mental health and psychosocial support programming including 87 adult participants. A mixed-method approach assesses the impact of the intervention. Quantitative analyses reveal significant reductions in self-reported problems, depression, anxiety and improved functioning. Qualitative data highlight four main themes: general health, family relationships, psychosocial problems and daily activities. These thematic areas demonstrate consistent improvements across clients, irrespective of the region. The findings underscore the impact of PM+ in addressing a broad spectrum of client issues, demonstrating its potential as a valuable tool for mitigating mental health challenges in diverse settings. This study contributes to the burgeoning body of evidence supporting PM+ and highlights its promise in enhancing mental health outcomes on a global scale, particularly for vulnerable populations.

Evaluating a Movement-Based Mental Health Promotion Intervention for Refugee Children in Uganda: A Quasi-Experimental Study

OBJECTIVE

Mental health promotion interventions are widely implemented in humanitarian settings and low- and middle-income contexts (LMICs), yet evidence on effectiveness is scarce and mixed. This study evaluated the movement-based mental health promotion intervention "TeamUp" in Bidibidi refugee settlement, in Northern Uganda.

METHOD

A quasi-experimental study including four schools (two per arm) assessed the outcomes of 10- to 15-year-old South Sudanese and Ugandan children (n = 549). Randomly allocated, they either participated in up to 11 TeamUp sessions (n = 265) provided by trained facilitators; or belonged to a control group, which continued care as usual (n = 284). Primary outcomes measured psychosocial wellbeing, friendships and attitude to school; secondary outcomes included traumatic distress, depressive symptoms, quality of life, physical health, bullying, interoceptive awareness, and irritability. Data were collected at baseline and endline.

RESULTS

Children joining TeamUp, showed significantly more improvements on primary outcomes: emotional and psychosocial wellbeing (Mdiff = -1.49, SE = 0.6, p = .01), satisfaction with and attitude toward school (-0.57, SE = 0.2, p = .004); and secondary outcomes: traumatic stress (2.64, SE = 0.8, p < .001), health-related quality of life (-1.56, SE = 0.4, p = .001), physical health (-0.78, SE = 0.3, p = .014) and the TeamUp mechanisms of action scale (-3.34, SE = 0.9, p < .001), specifically the subscales social connectedness (-0.74, SE = 0.3, p = .007) and sense of agency (-0.91, SE = 0.3, p = .005), compared to the control group. No significant differences were found on bullying, interoceptive awareness, irritability and depressive symptoms.

CONCLUSION

The results are promising for TeamUp as a mental health promotion intervention for children affected by armed-conflict, displacement and on-going adversity. Further research will need to assess the intervention's effectiveness.

Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Barriers and Facilitators to Implementing a Community-Based Psychosocial Support Intervention Conducted In-Person and Remotely: A Qualitative Study in Quibdó, Colombia

Community-based psychosocial support group (CB-PSS) interventions using task-shifting approaches are well suited to provide culturally appropriate services in low- and middle-income countries. However, contextual barriers and facilitators must be considered to tailor interventions effectively, particularly considering the challenges introduced by the COVID-19 pandemic. We explore the barriers, facilitators, and psychosocial changes associated with implementing a CB-PSS group intervention delivered by local lay providers to conflict-affected adults in Quibdó, Colombia, using both in-person and remote modalities. Data were analyzed from 25 individual interviews with participants and a focus group discussion involving staff members, including 7 community psychosocial agent facilitators and 2 mental health professional supervisors. The analysis used a thematic approach grounded in a descriptive phenomenology to explore the lived experiences of participants and staff members during implementation. Participant attendance in the in-person modality was compromised by factors such as competing work and family responsibilities and disruption caused by the COVID-19 pandemic. Participants in the remote modality faced challenges concerning unstable Internet connectivity, recurrent power outages caused by heavy rain, distractions, interruptions, and threats to confidentiality by family and coworkers. Despite these challenges, data revealed key contextual facilitators, including the community-based knowledge of facilitators and integration of traditional practices, such as the comadreo (informal talks and gatherings). Respondents shared that the CB-PSS groups promoted stronger community relationships and created opportunities for participants to exchange peer support, practice leadership skills, develop problem-solving skills based on peers' experiences, and enhance emotional regulation skills. Differences and similarities across in-person and remote modalities are discussed, as are key considerations for practitioners and policymakers.

Implementation outcomes in psychosocial intervention studies for children and adolescents living in low- and middle-income countries: A systematic review

Psychosocial interventions play a key role in addressing mental health and substance use needs for children and adolescents living in low- and middle-income countries (LMICs). While research efforts have primarily focused on their effectiveness, implementation outcomes also require examining. We conducted a systematic review of qualitative, quantitative, and mixed-methods studies (PROSPERO: CRD42022335997) to synthesize the literature on implementation outcomes for psychosocial interventions for children and adolescents in LMICs. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Web of Science, PsychINFO, and Global Health through April 2023. Data were extracted and quality appraised through the Mixed Methods Appraisal Tool (MMAT) independently by two reviewers. A total of 13,380 records were screened, and 87 studies met inclusion criteria. Feasibility was the most reported implementation outcome (69, 79%), followed by acceptability (60, 69%), and fidelity (32, 37%). Appropriateness was assessed in 11 studies (13%), implementation costs in 10 (11%), and sustainability in one (1%). None of the included studies reported on penetration or adoption. Despite a growing body of evidence for implementation research in child and adolescent global mental health, most research focused on earlier-stage implementation outcomes, assessing them in research-controlled settings. To overcome this, future efforts should focus on assessing interventions in routine care, assessing later-stage implementation outcomes through standardized tools.

Strategies to improve the quality and usefulness of mental health trials in humanitarian settings

A striking rise in the number of people affected by humanitarian crises has led to an increase in mental health and psychosocial support interventions to reduce the psychological effects of such crises. In a parallel trend, researchers have brought increased methodological rigour to their evaluation of these interventions. However, several methodological issues still constrain the quality and real-world relevance of the existing evidence base. We examine five core challenges in randomised controlled trials of mental health and psychosocial support interventions with conflict-affected and disaster-affected populations. These challenges are: translating intervention effects into metrics of real-world significance; giving adequate consideration to the selection and monitoring of control conditions; following rigorous processes to ensure outcome measures are culturally appropriate and psychometrically sound; ensuring and monitoring implementation variables, including fidelity, exposure, participant engagement, and the competence of implementation staff; and assessing mechanisms of change.

Youth Mental Health Screening and Linkage to Care

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

Identifying Core Competencies for Remote Delivery of Psychological Interventions: A Rapid Review

OBJECTIVE

The COVID-19 pandemic led to a rapid shift toward remote delivery of psychological interventions and transition to voice-only and video communication platforms. However, agreement is lacking on key competencies that are aligned with equitable approaches for standardized training and supervision of remote psychological intervention delivery. A rapid review was conducted to identify and describe competencies that could inform best practices of remote services delivery during and after the COVID-19 pandemic.

METHODS

Scopus, MEDLINE, and PsycINFO were searched for literature published in English (2015-2021) on competencies for synchronous, remote psychological interventions that can be measured through observation.

RESULTS

Of 135 articles identified, 12 met inclusion criteria. Studies targeted populations in high-income countries (11 in the United States and Canada, one in Saudi Arabia) and focused on specialist practitioners, professionals, or trainees in professional or prelicensure programs working with adult populations. Ten skill categories were identified: emergency and safety protocols for remote services, facilitating communication over remote platforms, remote consent procedures, technological literacy, practitioner-client identification for remote services, confidentiality during remote services, communication skills during remote services, engagement and interpersonal skills for remote services, establishing professional boundaries during remote services, and encouraging continuity of care during remote services.

CONCLUSIONS

These 10 skills domains can offer a foundation for refinement of discrete, individual-level competencies that can be aligned with global initiatives promoting use of observational competency assessment during training and supervision programs for psychological interventions. More research is needed on identification of and agreement on remote competencies and on their evaluation.

Adverse childhood experiences and global mental health: avenues to reduce the burden of child and adolescent mental disorders

Mental disorders are one of the largest contributors to the burden of disease globally, this holds also for children and adolescents, especially in low- and middle-income countries. The prevalence and severity of these disorders are influenced by social determinants, including exposure to adversity. When occurring early in life, these latter events are referred to as adverse childhood experiences (ACEs).In this editorial, we provide an overview of the literature on the role of ACEs as social determinants of mental health through the lenses of global mental health. While the relation between ACEs and mental health has been extensively explored, most research was centred in higher income contexts. We argue that findings from the realm of global mental health should be integrated into that of ACEs, e.g. through preventative and responsive psychosocial interventions for children, adolescents and their caregivers. The field of global mental health should also undertake active efforts to better address ACEs in its initiatives, all with the goal of reducing the burden of mental disorders among children and adolescents globally.

Decentralisation and community stakeholders’ engagement for better mental health services development in the conflict-affected regions of Ukraine

Purpose

The purpose of this paper is to explore how conflict-affected communities in Ukraine (the Lugansk region) can develop sustainable mental health services in decentralised settings. The main interest focuses on community stakeholders’ perception of their problems and solutions that communities can create to achieve better mental health coverage.

Design/methodology/approach

A series of roundtables (RTs) (4 RTs, 62 participants overall), accompanied by interactive brainstorming techniques, were conducted with communities’ representatives/stakeholders from the East of Ukraine (Lugansk region, a government-controlled area) during the year 2021. Participants (health, mental health, social care workers and administration representatives) were provided with the opportunity to discuss mental health services’ development challenges and create affordable solutions for their communities. Results of discussions were submitted to qualitative analysis and offered for review by participants.

Findings

Decentralisation in Ukraine led to allocating funds alongside responsibilities for developing the services to communities. Most of the communities appear not to be ready to acknowledge the role of mental health services, entirely relying on the existing weak psychiatric hospital-based system. Awareness-raising interactive capacity-building activities for the community leaders and decision-makers effectively promote community-based mental health services development. Five clusters of challenges were identified: leadership, coordination and collaboration problems; infrastructure, physical accessibility and financial problems; mental health and primary health-care workforce shortage and lack of competencies; low awareness of mental health and available services and high stigma; war, crises and pandemic-related problems. Communities stakeholders foresaw seven domains of action: increasing the role of communities and service users in the initiatives of governmental bodies; establishing in the communities local coordination/working groups dedicated to mental health service development; developing the community-based spaces (hubs) for integrated services provision; embedding the mental health services in the existing services (social, administrative and health care); mental health advocacy and lobbying led by local leaders and service users; increasing capacity of communities in financial management, fundraising; developing services by combining efforts and budgets of neighbouring communities.

Research limitations/implications

The study has potential limitations. Participants of the roundtables were mostly appointed by local authorities, so some of them didn`t have a motivation for mental health services development. Service users were involved only from the facilitators` side, not from the side of communities; therefore, it was impossible to include their view of problems and solutions. Obtained data were limited to the opinion of local professionals, administration workers and other local stakeholders. The human rights aspect was not clearly articulated in the tasks of the roundtables.

Originality/value

To the best of the authors’ knowledge, the paper is original in terms of its topic (connecting decentralisation and local stakeholders’ engagement for understanding the challenges of mental health services development) and research strategy (engagement of Ukrainian communities, qualitative analysis of the discussion results and applying the best practices and international recommendations to the local context).

Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC.

METHODS

Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers.

RESULTS

From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish.

CONCLUSIONS

Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO [CRD42021271404].

Evaluation of competency-driven training for facilitators delivering a psychological intervention for children in Lebanon: a proof-of-concept study

AIMS

The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon.

METHODS

In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely.

RESULTS

CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F_{(1, 22)} = 6.49, p < 0.018) and on the GroupACT (Mann-Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours.

CONCLUSIONS

This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

The Costs and Health Benefits of Expanded Access to MDMA-assisted Therapy for Chronic and Severe PTSD in the USA: A Modeling Study

Background and Objective

Intensive psychotherapy assisted with 3,4-methylenedioxymethamphetamine (MDMA-AT) was shown in Phase 3 clinical trials to substantially reduce post-traumatic stress disorder (PTSD) symptoms compared to psychotherapy with placebo. This study estimates potential costs, health benefits, and net savings of expanding access to MDMA-AT to eligible US patients with chronic and severe PTSD.

Methods

Using a decision-analytic model, we compared the costs, deaths averted, and quality-adjusted life years (QALYs) gained of three, 10-year MDMA-AT coverage targets (25%, 50%, and 75%) compared to providing standard of care to the same number of eligible patients with chronic and severe PTSD. We used a payer perspective and discounted costs (in US$) and QALYs to 2020. We conducted one-way, scenario, and probabilistic sensitivity analyses and calculated the net monetary value of MDMA-AT using a cost-effectiveness threshold of $100,000 per QALY gained.

Results

Expanding access to MDMA-AT to 25–75% of eligible patients is projected to avert 43,618–106,932 deaths and gain 3.3–8.2 million QALYs. All three treatment targets are dominant or cost-saving compared to standard of care. Our sensitivity analyses found that accounting for parameter uncertainty and changes in various assumptions did not alter the main finding—MDMA-AT is dominant compared to standard of care.

Conclusion

Expanding access to MDMA-AT to patients with chronic and severe PTSD will provide substantial health and financial benefits. The precise magnitude is uncertain and will depend on the number of eligible patients and other inputs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40261-022-01122-0.

Reporting Cultural Adaptation in Psychological Trials - The RECAPT criteria

Background

There is a lack of empirical evidence on the level of cultural adaptation required for psychological interventions developed in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups. This lack of evidence is partly due to insufficient documentation of cultural adaptation in psychological trials. Standardised documentation is needed in order to enhance empirical and meta-analytic evidence.

Process

A "Task force for cultural adaptation of mental health interventions for refugees" was established to harmonise and document the cultural adaptation process across several randomised controlled trials testing psychological interventions for mental health among refugee populations in Germany. Based on the collected experiences, a sub-group of the task force developed the reporting criteria presented in this paper. Thereafter, an online survey with international experts in cultural adaptation of psychological interventions was conducted, including two rounds of feedback.

Results

The consolidation process resulted in eleven reporting criteria to guide and document the process of cultural adaptation of psychological interventions in clinical trials. A template for documenting this process is provided. The eleven criteria are structured along A) Set-up; B) Formative research methods; C) Intervention adaptation; D) Measuring outcomes and implementation.

Conclusions

Reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability.

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

BACKGROUND

Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting.

METHODS AND FINDINGS

We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, "heart-mind" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have "heart-mind" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information.

CONCLUSIONS

In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03747055.

Development of the mental health cultural adaptation and contextualization for implementation (mhCACI) procedure: a systematic framework to prepare evidence-based psychological interventions for scaling

BACKGROUND

Because of the high burden of untreated mental illness in humanitarian settings and low- and middle-income countries, scaling-up effective psychological interventions require a cultural adaptation process that is feasible and acceptable. Our adaptation process incorporates changes into both content and implementation strategies, with a focus on local understandings of distress and treatment mechanisms of action.

METHODS

Building upon the ecological validity model, we developed a 10-step process, the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) procedure, and piloted this approach in Nepal for Group Problem Management Plus (PM+), a task-sharing intervention, proven effective for adults with psychological distress in low-resource settings. Detailed documentation tools were used to ensure rigor and transparency during the adaptation process.

FINDINGS

The mhCACI is a 10-step process: (1) identify mechanisms of action, (2) conduct a literature desk review for the culture and context, (3) conduct a training-of-trainers, (4) translate intervention materials, (5) conduct an expert read-through of the materials, (6) qualitative assessment of intervention population and site, (7) conduct practice rounds, (8) conduct an adaptation workshop with experts and implementers, (9) pilot test the training, supervision, and implementation, and (10) review through process evaluation. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of 'tension'; modification of recruitment procedures to assure fit; and development of a skills checklist.

CONCLUSION

A 10-step mhCACI process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation.

Assessment of service provider competency for child and adolescent psychological treatments and psychosocial services in global mental health: evaluation of feasibility and reliability of the WeACT tool in Gaza, Palestine

BACKGROUND

There is a scarcity of evaluated tools to assess whether non-specialist providers achieve minimum levels of competency to effectively and safely deliver psychological interventions in low- and middle-income countries. The objective of this study was to evaluate the reliability and utility of the newly developed Working with children - Assessment of Competencies Tool (WeACT) to assess service providers' competencies in Gaza, Palestine.

METHODS

The study evaluated; (1) psychometric properties of the WeACT based on observed role-plays by trainers/supervisors (N = 8); (2) sensitivity to change among service provider competencies (N = 25) using pre-and-post training WeACT scores on standardized role-plays; (3) in-service competencies among experienced service providers (N = 64) using standardized role-plays.

RESULTS

We demonstrated moderate interrater reliability [intraclass correlation coefficient, single measures, ICC = 0.68 (95% CI 0.48-0.86)] after practice, with high internal consistency (α = 0.94). WeACT assessments provided clinically relevant information on achieved levels of competencies (55% of the competencies were scored as adequate pre-training; 71% post-training; 62% in-service). Pre-post training assessment saw significant improvement in competencies (W = -3.64; p < 0.001).

CONCLUSION

This study demonstrated positive results on the reliability and utility of the WeACT, with sufficient inter-rater agreement, excellent internal consistency, sensitivity to assess change, and providing insight needs for remedial training. The WeACT holds promise as a tool for monitoring quality of care when implementing evidence-based care at scale.