Mental health literacy: focus on developing countries

Psychiatric emergencies during pregnancy and puerperium in low - And middle-income countries

Pregnancy and puerperium are critical points in women's health, and various psychiatric emergencies may worsen or manifest (for the first time) during this period. In the presence of a psychiatric emergency, the pregnancy and puerperium outcomes may be compromised. In addition to the mother being at risk, the health of the fetus and the newborn may also be compromised if the psychiatric emergency is not managed appropriately. Early detection and collaborative approaches between mental health practitioners and obstetricians are of utmost importance in women who are at risk and those living with psychiatric illnesses during pregnancy and puerperium. Practitioners should also ensure that women with impaired capacity due to psychiatric disease are treated in a non-judgmental and respectful manner, even if their autonomies have been overridden.

"Trust in God, but tie your donkey": Holy water priest healers' views on collaboration with biomedical mental health services in Addis Ababa, Ethiopia

This exploratory qualitative study examines holy water priest healers' explanatory models and general treatment approaches toward mental illness, and their views and reflections on a collaborative project between them and biomedical practitioners. The study took place at two holy water treatment sites in Addis Ababa, Ethiopia. Twelve semi-structured interviews with holy water priest healers found eight notable themes: they held multiple explanatory models of illness, dominated by religious and spiritual understanding; they emphasized spiritual healing and empathic understanding in treatment, and also embraced biomedicine as part of an eclectic healing model; they perceived biomedical practitioners' humility and respect as key to their positive views on the collaboration; they valued recognition of their current role and contribution in providing mental healthcare; they recognized and appreciated the biomedical clinic's effectiveness in treating violent and aggressive patients; they endorsed the collaboration and helped to overcome patient and family reluctance to the use of biomedicine; they lamented the lack of spiritual healing in biomedical treatment; and they had a number of dissatisfactions and concerns, particularly the one-way referral from religious healers to the biomedical clinic. The study results show diversity in the religious healers' etiological understanding, treatment approaches and generally positive attitude and views on the collaboration. We present insights and explorations of factors affecting this rare, but much needed collaboration between traditional healers and biomedical services, and potential ways to improve it are discussed.

Can polygenic risk scores help explain disease prevalence differences around the world? A worldwide investigation

Complex disorders are caused by a combination of genetic, environmental and lifestyle factors, and their prevalence can vary greatly across different populations. The extent to which genetic risk, as identified by Genome Wide Association Study (GWAS), correlates to disease prevalence in different populations has not been investigated systematically. Here, we studied 14 different complex disorders and explored whether polygenic risk scores (PRS) based on current GWAS correlate to disease prevalence within Europe and around the world. A clear variation in GWAS-based genetic risk was observed based on ancestry and we identified populations that have a higher genetic liability for developing certain disorders. We found that for four out of the 14 studied disorders, PRS significantly correlates to disease prevalence within Europe. We also found significant correlations between worldwide disease prevalence and PRS for eight of the studied disorders with Multiple Sclerosis genetic risk having the highest correlation to disease prevalence. Based on current GWAS results, the across population differences in genetic risk for certain disorders can potentially be used to understand differences in disease prevalence and identify populations with the highest genetic liability. The study highlights both the limitations of PRS based on current GWAS but also the fact that in some cases, PRS may already have high predictive power. This could be due to the genetic architecture of specific disorders or increased GWAS power in some cases.

Tracking demands for seeking psychological help before and during the COVID-19 pandemic: a quanti-qualitative study

The COVID-19 pandemic has placed unprecedented burdens on individuals and communities around the world. The isolation, fear, and uncertainty caused by the virus has led to increased rates of anxiety, depression, and other mental health issues. The pandemic has also had a disproportionate impact on individuals and communities with low income and socioeconomic status.ObjectiveTo shed light on the consequences of the pandemic on individuals from minorities and low-income areas, we investigate the main reasons that led patients who were referred to a social clinic of a private university in Rio de Janeiro to seek psychological treatment before (2019) and during the pandemic (2020 and 2021).MethodsWe conducted a quanti-qualitative study with a lexical analysis that evaluated 549 complaint forms of patients seeking treatment in these two distinct periods. Our analyses included descending hierarchical analysis (DHA) and correspondence factor analysis (CFA).ResultsFamily dynamics and communication factors play a dominant role in the reason for seeking therapy and psychological treatment. Additionally, our study suggested an increase in anxiety and panic attacks among other mental health issues associated with grief and losses during the pandemic years.ConclusionBased on these analyses, we can begin to identify a few changes in the main demand and redirection of complaints of patients during the period of COVID-19.

Cultural adaptation of the mental health first aid guidelines for depression in Brazil: a Delphi expert consensus study

BACKGROUND

Depression is a significant contributor to disability in Brazil, with most Brazilians affected by depression receiving no treatment. As the community, including family and friends, plays a crucial role in providing support for someone with depression, it is important that evidence-based resources are available to support people who wish to help. The aim of this study was to culturally adapt the English-language mental health first aid guidelines for assisting a person with depression for the Brazilian culture.

METHODS

A Delphi expert consensus study was conducted, with two expert panels; health professionals (n = 29) and people with lived experience of depression (n = 28). One hundred and seventy-four statements from the English-language guidelines were translated into Brazilian Portuguese and administered as a survey. Participants were asked to rate statements based on how appropriate those statements were for the Brazilian culture and to suggest new statements if appropriate.

RESULTS

Data were collected over two survey rounds. Consensus was achieved on 143 statements. A total of 133 statements were adopted from the English-language guidelines, whereas 10 new endorsed statements were generated from suggestions of the two expert panels.

CONCLUSIONS

There were similarities between the English-language and Brazilian guidelines, mainly related to family involvement and the value of empathy. More research on dissemination and incorporation of the guidelines into the Mental Health First Aid (MHFA) training course for Brazil is required.

Agents of Change for Mental Health: A Survey of Young People's Aspirations for Participation Across Five Low- and Middle-Income Countries

PURPOSE

Effective intervention, policy, and research in mental health and well-being (MHWB) require young people to be understood not only as beneficiaries, but also as active agents in codesigning and implementing initiatives. To identify pathways for young people's participation in promoting MHWB in low- and middle-income countries (LMICs), this study surveyed young people's aspirations for engagement, their spheres of influence, capacity building needs, and key barriers to participation.

METHODS

Using U-Report, United Nations Children's Emergency Fund's social messaging tool and data collection platform, we distributed a short quantitative survey to a nonrepresentative, but large sample of young people aged 15-29 across five LMICs: Nigeria, Brazil, Jamaica, South Africa, and Burundi.

RESULTS

A total of 42,689 young people responded, with representation from most or all provinces within each country. Participants' average age was 23.8 years (SD = 3.77). Young people's core aspirations were to join a mental health awareness project and to support their peers. Participants considered schools and community settings to be the most important spheres for engagement. Lack of information about mental health was the main perceived barrier to participation, and mental health classes the main training need.

DISCUSSION

In many countries, MHWB is not taught or discussed in schools and youth-led mental health interventions are rare. Findings from this study reveal clear aspirations for participatory engagement to promote MHWB among young people in LMICs. To support meaningful participation, policymakers and youth service providers must ensure that young people have access to mental health literacy training and opportunities to raise awareness in schools or community settings.

Barriers to treatment and care for depression among the youth in Uganda: The role of mental health literacy

Background

Depression represents a significant mental health problem (MHP) in low- and middle-income countries (LMICs), especially among early adults. Nevertheless, most early adults with depression do not seek treatment. Failure to recognize depression and knowledge about mental health literacy (MHL) may contribute to poor help-seeking behavior. This study assessed MHL, access and barriers to mental health care for depression among early adults in Uganda.

Methods

Data were collected from students in two of the largest universities in Uganda. Participants completed questionnaires on depression, MHL, sources of barriers and opportunities for MH service. Regression analyses and parametric tests were used to assess depression, access, barriers and opportunities to promote MH.

Results

About 12 per cent (n = 56) of the respondents were at the level of moderately severe to severe depression. Mental health literacy (MHL) scores were generally low ranging from "Ability to recognize mental disorders" (mean = 19.32, SD 3.22, range 18-32), and "Knowledge of risk factors" (mean = 4.39, SD 1.17, range 2-8), and "Knowledge of available information" (mean = 9.59, SD 2.53, range 5-20). Respondents reported barriers such as "stigma/discrimination" (65.53%), "lack of knowledge of where to receive help" (65.15%), "lack of trust in health workers" (62.56%), and "distant health facilities" (19.70%) that impede access to treatment and care. MHL significantly predicted depression (based on a continuous scale) (β = 0.63, 95% confidence interval [CI]: [0.56, 0.70]) with the regression model yielding a significant fit [R ² = 0.40, F (2, 460) = 189.84, p < 0.001].

Conclusions

MHL is low among university students amidst several barriers such as stigma, fear, and lack of trust. To attenuate the negative effects of MHPs on wellbeing and lower the increased risk of psychopathology into adulthood, it is critical to prioritize MHL, address barriers to treatment and care, and develop the requisite infrastructure to tackle depression among early adults.

Mental health literacy among primary healthcare workers in South Africa and Zambia

BACKGROUND

In developing countries, mental health literacy (MHL) still needs to be improved due to the high prevalence of mental disorders. It is widely recognized that MHL can improve health outcomes for both individuals and populations. Healthcare professionals' development in MHL is crucial to the prevention of mental disorders. The aim of this study was to assess MHL of primary healthcare (PHC) workers in South Africa (SA) and Zambia and determinants thereof. Limited evidence is available on the levels of MHL among PHC workers in the sub-Saharan Africa region, which faces a large burden of mental disorders.

METHODS

The study population for this cross-sectional survey comprised PHC workers (n = 250) in five provinces of SA and Zambia. MHL was measured with the Mental Health Literacy Scale (MHLS). We conducted a multivariate analysis to explore determinants of MHL.

RESULTS

Results showed moderate MHL among PHC professionals, but with a wide range from low to high MHL. Knowledge-related items had a greater dispersion than other attributes of MHL. PHC workers with more education showed a greater ability to recognize mental health-related disorders. Those who had experience in the use of mental health-related assessment scales or screening tools reported a higher total MHL. The results confirmed strong internal consistency for the MHLS.

CONCLUSION

The results highlighted varying mental health perceptions and knowledge in PHC. Implementation of specifically developed formal training programs and interventions to improve MHL in PHC workers to strengthen their competence may help bridge the treatment gap.

Anxiety and school absenteeism without permission among adolescents in 69 low- and middle-income countries

Background

Anxiety disorders are common among adolescents. In high-income countries, anxiety is a known contributor to truancy and school refusal, but this association has been understudied in low- and middle-income countries (LMICs).

Methods

We used complex samples analysis to examine the association between self-reported worry-induced insomnia (an indicator of anxiety) and unauthorized school absenteeism among 268,142 adolescents from 69 LMICs that participated in the Global School-based Student Health Survey (GSHS).

Results

The median proportion of students who reported experiencing symptoms of anxiety most or all of the time during the previous year was 11.4% (range: 3.6%-28.2%); in 44 of the 69 countries, girls had a significantly higher prevalence of anxiety than boys. The percentage of students reporting school absence without permission during the past month was 30.2% (range: 14.7%-56.0%); in 40 countries, boys were significantly more likely than girls to report that they had missed school without permission. In 53 countries, adolescents who reported frequent anxiety were significantly more likely to miss school than adolescents reporting infrequent anxiety; in most of those countries, the association was significant for both girls and boys.

Conclusion

School-based interventions that help children and adolescents learn how to manage stress and refer students with symptoms of psychiatric disorders to healthcare services that can provide formal diagnosis and clinical treatment may be useful for improving both mental health and school attendance, thus contributing to achievement of Sustainable Development Goals related to both health (SDG 3.4) and education (SDG 4.1).

Mental health literacy of school-going adolescents in sub-Saharan Africa: a regional systematic review protocol

INTRODUCTION

Assessing mental health literacy has implications for the identification and treatment of mental health problems. Adolescents have been identified as a particularly important target group for initiating and improving mental health literacy. However, much of what we know about adolescent mental health literacy comes from high-income countries. This proposed review seeks to synthesise the available published primary evidence from sub-Saharan Africa on the status and measurement of mental health literacy among school-going adolescents.

METHODS AND ANALYSIS

We will perform a systematic review reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA-2020). We will systematically search selected global databases (EMBASE, PsycINFO, PubMed and MEDLINE) and regional electronic databases (African Index Medicus and African Journals OnLine) up to December 2021 for observational and qualitative studies published in English and French. The standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst criteria) will be used to appraise the methodological quality of the included studies. The Petticrew-Roberts 3-step approach to narrative synthesis will be applied to the included studies.

ETHICS AND DISSEMINATION

We will not seek ethical approval from an institutional review board, as this is a systematic review of available and accessible literature. When completed, the full report of this review will be submitted to a journal for peer-reviewed publication; the key findings will be presented at local and international conferences with-partial or full-focus on (adolescent) mental health (literacy).

PROSPERO REGISTRATION NUMBER

CRD42021229011.

Effectiveness and Implementation Outcome Measures of Mental Health Curriculum Intervention Using Social Media to Improve the Mental Health Literacy of Adolescents

Purpose

Globally, adolescent mental health problems reportedly manifest more severely in individuals with lower mental health literacy. Mental health curriculum interventions using social media have been associated with positive implementation outcomes. This study aimed to investigate whether such an intervention significantly improves adolescent mental health literacy and is associated with positive implementation outcome measures.

Methods

This study employed a quasi-experimental design, comparing the before-and-after difference between the intervention group (n₁=77) and the control group (n₁=76). A mental health literacy module was delivered using social media. Data were collected using validated questionnaires. Effect size and difference-in-differences model calculations (and associated 95% confidence intervals, CI) were conducted alongside other descriptive analyses.

Results

The estimated intervention effect size and difference-in-differences estimates were greater than zero. The effect was greater in the intervention than in the control group (p<0.05) despite sex and age differences. The effect size estimate provided by Cohen’s d and Hedges’ g values was medium-to-large (d/g=0.429–0.767, p<0.05). The difference-in-differences reflected a significant effect (DID=0.348, CI: 0.154–0.542, p<0.001) in increasing mental health literacy despite differences associated with sex, age, and school grade. The intervention program was acceptable, appropriate, feasible, and satisfactory, and more than 80% of participants said they agree to completely agree with these implementation outcomes. Resources and personal and family-related factors were among the perceived influencing factors determining the effectiveness and implementation outcome measures.

Conclusion

The intervention program effectively improved the mental health literacy of adolescents. It has been highlighted that social media interventions for mental health promotion could be practical and scalable; however, there is a need to take into account socio-demographic differences and barriers to inclusion/compliance.

Mental health literacy: A systematic review of knowledge and beliefs about mental disorders in Malaysia

BACKGROUND

Mental health problems in Malaysia are on a rise. This study aimed at performing a systematic review of mental health literacy (MHL) in Malaysia.

METHODS

Medline, Embase, ERIC/Proquest, ScienceDirect, Pubmed, PsycINFO, CINAHL, Scopus, EBM Reviews - Cochrane Central Register of Controlled Trials, Ovid Emcare and reference lists of included studies were searched in February 2020. Studies that evaluated at least one of the main components of MHL, including (1) knowledge related to mental health issues, and (2) stigma, were included irrespective of study design. As secondary findings, the review also synthesized results related to facilitators and barriers to seeking mental health services. Depending on the research design, the quality of each study was assessed through checklists.

RESULTS

Forty six studies published between 1995 to 2019 were included. Most studies used cross-sectional designs to investigate MHL. Findings indicate that most Malaysians have stigmatizing attitudes towards mental health problems. Participants in the included studies endorsed multifactorial explanations of mental health issues with a dominance of supernatural and religious aetiologies. Likewise, the commonest barrier was considering sources other than professional sources of mental-health services. Presence of adequate knowledge and considering providers as competent facilitated help-seeking. Additionally, there was considerable heterogeneity in studies and a lack of standardized measures assessing MHL.

CONCLUSIONS

There is an increase in studies on MHL in Malaysia. A few of these studies, based on experimental design, have shown positive effects. Researchers, practitioners, and policymakers should develop standardized measures and interventional studies based on all the components of MHL.

Locus of Control and Self-Esteem as Predictors of Maternal and Child Healthcare Services Utilization in Nigeria

This study investigated the influence of locus of control and self-esteem on the utilization of maternal and child healthcare services in Nigeria. Specifically, it explored the differences in utilization of antenatal care, skilled birth care, postnatal care, and child vaccination by women having internal and external locus of control and women having high and low self-esteem. It also examined the association between utilization of maternal and child healthcare on other sociodemographic characteristics. We collected information on non-cognitive traits of 1,411 randomly selected women along with information on utilization of various indicators of maternal and child healthcare services. We estimated logistic regression models for various components of maternal and child healthcare services utilization and found that women's internal locus of control was a significant predictor of utilization of antenatal care, skilled birth care and completion of child vaccination. We also found that having a high self-esteem was a significant predictor of utilization of antenatal care, postnatal care and completion of child vaccination after adjusting for other control variables. By improving our understanding of non-cognitive traits as possible barriers to maternal and child healthcare utilization, our findings offer important insights for enhancing participants' engagement in intervention programs that are initiated to improve maternal and child health outcomes in lower-middle-income countries.

Construct validity and internal consistency of the revised Mental Health Literacy Scale in South African and Zambian contexts

AIM

The aim of this study was to evaluate the construct validity and internal consistency of the revised Mental Health Literacy Scale (MHLS) in South Africa (SA) and Zambia.

DESIGN

This cross-sectional study was conducted between October 2018 and December 2019.

METHODS

The study population comprised PHC workers (n = 454) in five districts in SA and Zambia. Principal component analysis (PCA) was used to explore the construct validity, and Cronbach's alpha was applied to measure the internal consistency of the MHLS.

RESULTS

Cronbach's alpha values for three attributes were below the appropriate level, but the value was strong (0.804) for the whole scale. The study found nine components explaining ~59% of the total variance of variables. All MHLS items loaded to main attributes based on the theory of MHL. The results stated that the revised version of the MHLS is a construct valid instrument with strong internal consistency.

Suicidal behavior sociocultural factors in developing countries during COVID-19

Objectives

Sociocultural factors in the aftermath of any pandemic can play a role in increasing suicidal behavior like suicidal ideation, suicidal attempts, or suicide. The authors discuss the risk and predisposing factors for suicidal ideation among mental health patients in four developing countries (Bangladesh, Colombia, India and Pakistan), this aims to grasp the heterogeneity of these motivators and to elaborate specific interventions regarding suicide in the COVID-19 pandemic.

Methods

We searched PubMed, Medline, and Google Scholar through March, 2021 for articles using a combination of the keywords and generic terms for suicide, suicide ideation, COVID-19, developing countries, low-middle-income countries, Sociocultural factors, Suicidal behavior, predisposing factors and predictive factors, for articles in English language only, and without publication time restriction.

Results

This narrative review summarizes the sociocultural risk and predisposing factors for suicidal behavior in developing countries during the COVID-19 pandemic. The findings reveal those factors such as fear of being infected, growing economic pressure, lack of resources due to lockdown are mostly responsible in the four countries for the current increase in suicides. There are a few cultural differences that are specified in the narrative.

Conclusion

The COVID-19 pandemic is a public health challenge, in which prevention and intervention of suicidal behavior have been suboptimal, especially in low-middle-income countries. Based on literature results, we provide practical suggestions (e.g., reducing infodemic, specialized helplines, improving mental health services availability) in order to tackle main challenges of suicide prevention, such as lack of adequate manpower, fragile health system and poverty.

The effectiveness of a psycho-education intervention on mental health literacy in communities affected by the COVID-19 pandemic-a cluster randomized trial of 24 villages in central Uganda-a research protocol

Background

Literature shows a high prevalence of psychological distress (PD) as well as common mental disorders (CMD) such as major depressive disorders (MDD), generalized anxiety disorders (GAD), post-traumatic stress disorders (PTSD), and substance misuse disorders (SUD) among people exposed to disasters and pandemics like the COVID-19. Moreover, CMD are associated with increased mortality (mainly through suicide) and morbidity (loss of productivity). A number of countries have made deliberate efforts to identify and manage CMD in light of COVID-19. However, low levels of mental health literacy (MHL) manifested by the individual’s unawareness of CMD symptoms, limited human and mental health infrastructure resources, and high levels of mental illness stigma (MIS) are barriers to integration of mental health care in general health care during pandemics and epidemics such as the COVID-19.

Objectives

For the proposed study, we will determine effectiveness of a psycho-education intervention delivered by village health team (VHT) members.

Methods

We will employ a cluster randomized trial design in 24 villages in central Uganda. We will collect baseline data to and document the prevalence of MHL, PD, MDD, PTSD, GAD, and SUD. We will distribute information education and communication materials (IEC) aimed at improving MHL to 420 adult individuals in the intervention arm (n = 12 villages). In the control arm (n = 12 villages), VHTs will distribute ministry of health COVID-19 information leaflets to 420 participants. Within 7 days of distributing the materials, research assistants will conduct a follow-up interview and assess for the same parameters (MHL, PD, MDD, PTSD, GAD, and SUD). We will use an intention to treat analysis to estimate the effectiveness of the psycho-education intervention.

Discussion

Findings from this research will guide policy and practice regarding the integration of mental health services in the community in the context of epidemic preparedness and response.

Trial registration

ClinicalTrials.govNCT04616989. Registered on 05 November 2020

Risk and protective factors of relapse in patients with first-episode schizophrenia from perspectives of health professionals: a qualitative study in northeastern Thailand

Background:  Schizophrenia is a serious mental illness that can relapse after treatments. Risk and protective factors for relapse are dependent on multicultural contexts.

Objective: To identify risk and protective factors related to relapse in first-episode schizophrenia (FES) in northeastern Thailand from perspectives of health professionals.

Methods: This qualitative research collected data from 21 health professional staff members (psychiatric nurses, psychiatrists, psychologists, social workers, occupational therapists and nutritionist) of a tertiary psychiatric hospital of northeastern Thailand who had been involved in mental health care for schizophrenia for at least 5 years by in-depth interviews and group interview using semi-structured interview schedule. Content analyses was used to identify staff perception of factors that put patients at risk of relapse.

Results: Data analyses demonstrated that factors related to relapse in FES patients were drug adherence (drug discontinuation, limited access to new generation drugs, self-dose reduction and skipping medication, and poor insight), family factors (stressful circumstances and family supports), substance abuses (narcotics, addictive substances, caffeinated drinks), concurrent medical illness (insomnia, thyroid diseases, and pregnancy-related hormonal changes), and natural course of disease. 

Conclusion: Factors affecting relapse in FES was not only drug adherence. Family factors, drug abuses, and concurrent health status should be also taken into account. A comprehensive mental health care program should be developed for FES patients in the region.

Assessing mental health literacy of primary health care workers in Kenya: a cross-sectional survey

AIM

To assess mental health literacy of health workers in primary health care services in Kenya.

BACKGROUND

Mental illness is common in Kenya, yet there are fewer than 500 specialist mental health workers to serve Kenya's population of over 50 million. The World Health Organization recommends the integration of mental health care into primary health care services to improve access to and equity of this care, especially in low and middle-income countries. An important step to integrating mental health care into primary health care services is to determine mental health literacy levels of the primary health care workforce.

METHOD

A cross-sectional survey using Jorm's Mental Health Literacy Instrument (adapted for the Kenyan context) was administered to 310 primary health care workers in four counties of Kenya.

RESULTS

Of the 310 questionnaires distributed, 212 (68.3%) were returned. Of the respondents, 13% had a formal mental health qualification, while only 8.7% had received relevant continuing professional development in the five years preceding the survey. Just over one third (35.6%) of primary health care workers could correctly identify depression, with even fewer recognising schizophrenia (15.7%).

CONCLUSIONS

This study provides preliminary information about mental health literacy among primary health care workers in Kenya. The majority of respondents had low mental health literacy as indicated by their inability to identify common mental disorders. While identifying gaps in primary health care workers' mental health knowledge, these data highlight opportunities for capacity building that can enhance mental health care in Kenya and similar low and middle-income countries.

Mental illness attitudes and knowledge in non-specialist medical doctors working in state and private sectors

BACKGROUND

An increasing number of South Africans utilise primary healthcare services (either in the state or private sector) for mental health concerns; hence, there is a need to objectively assess these doctors' attitudes and knowledge of mental illness.

AIM

To investigate aspects of knowledge and attitudes towards mental illness of a group of private and state-employed non-specialist medical doctors.

METHOD

Doctors in the state sector who were working at a primary healthcare level and who were not working towards, or did not hold, a specialist qualification were considered eligible for the study. Doctors in the private sector who were working as general practitioners and who did not hold a specialist qualification were considered eligible for the study. Data were collected by means of a self-administered questionnaire. A link to the study questionnaire, information about the study, details of the researcher and matters pertaining to informed consent were emailed to potential participants.

RESULTS

Of the 140 practitioners who responded to the survey, 51.4% (n = 72) worked in the state sector, 41.4% (n = 58) worked in the private sector and 7.1% (n = 10) worked in both the state and private sectors (χ2 1 = 45.31, p < 0.010). The majority (> 50%) of participants in all three groups had a positive attitude towards mental illness (χ2 2 = 1.52, p = 0.468). Although there were no significant associations between attitude and socio-demographic characteristics (p > 0.05), male SS doctors reported feeling less comfortable when dealing with mentally ill patients (p = 0.015); SS doctors who did not have family contact with mental illness were less likely to feel that mentally ill patients did not pose a risk to others (p = 0.007), and PS doctors under the age of 35 years were more likely to feel adequately trained to treat mental illness (p = 0.026). The majority (> 50%) of participants in all three groups had an adequate level of knowledge of mental illness (modal scores = 10). There were no significant associations between knowledge and socio-demographic characteristics (p > 0.05).

CONCLUSION

Despite the findings of a positive attitude and adequate knowledge of mental illness amongst the participants of this study, it is recommended that more targeted interventions are established to further improve mental health awareness and knowledge of doctors at both undergraduate and postgraduate levels of study.

Mental health capacity building in Mali by training rural general practitioners and raising community awareness

Introduction

despite the high prevalence and significant burden of mental disorders, they remain grossly under-diagnosed and undertreated. In low-income countries, such as Mali, integrating mental health services into primary care is the most viable way of closing the treatment gap. This program aimed to provide a mental health training intervention to rural general practitioners (GPs), to organize community awareness activities, and to evaluate the impact on mental health knowledge and through the number of new patients diagnosed with mental disorders and managed by these general practitioners.

Methods

a pre-test/post-test design and the monthly monitoring of the number of new patients diagnosed with mental disorders by the trained GPs were used to evaluate the effect of the training interventions (two face-to-face group training workshops followed by individual follow-up supervisions) and of the community awareness activities.

Results

the mean knowledge score of the 19 GPs who completed the initial 12-day group training raised from 24.6/100 at baseline, to 61.5/100 after training (p<0.001), a 150% increase. Among them, sixteen completed the second 6-day group training with a mean score increasing from 50.2/100 to 70.1/100 (p<0.001), a 39.6% improvement. Between July 2018 and June 2020, 2,396 new patients were diagnosed with a mental disorder by the 19 GPs who took part in the program.

Conclusion

despite limited data regarding the effect of the community awareness component at this stage, the findings from this study suggest that the training intervention improved GPs' knowledge and skills, resulting in a significant number of new patients being identified and managed.

The Effectiveness of the Pilot Implementation of Iran's Comprehensive Mental and Social Health Services (the SERAJ Program): A Controlled Community Trial

Objective: A national program on providing comprehensive social and mental health services, entitled "SERAJ" was developed and piloted in three districts of Iran. The present study aimed to evaluate the effectiveness of SERAJ by conducting assessments before and after the implementation in the intervention and the control areas. Method : This was a controlled community trial that was assessed by conducting repeated surveys in the intervention and the control areas. In total, 2952 and 2874 individuals were assessed in the intervention and the control areas, respectively. The change in prevalence of mental disorders (using the Composite International Diagnostic Interview; CIDI), service utilization, mental health literacy, happiness, and perceived social support were measured over 18 months in three districts of Osko, Bardsir, and Quchan as the intervention areas, which were compared with three matched districts as the control areas. Results: No significant difference was found in the mean score of happiness between the intervention and the control areas throughout the study period. Most aspects of mental health literacy were improved in the intervention areas after implementing the intervention. The mean score of social support decreased after implementing the intervention in all areas. The prevalence of mental disorders in the intervention districts was significantly reduced after 18 months. The rate of using any mental health services after the intervention was not statistically different between the intervention and the control areas. Conclusion: There was no significant change in some indicators in the intervention compared with the control areas. We suggest evaluating SERAJ's achievements and challenges in the three intervention districts before expanding the implementation of this pilot experience into other districts.

Trends in Psychotropic Medication Prescriptions in Urban China From 2013 to 2017: National Population-Based Study

Purpose: Psychotropic medications are commonly used for treating mental disorders; however, there is currently no study on how commonly they are used in China. This study reported the trends in psychotropic medications prescriptions in urban China. Methods: A national population-based study was conducted using the China Health Insurance Research Association database to estimate the period prescription prevalence of 11 major classes of psychotropic medications annually during 2013-2017. The World Health Organization Anatomical Therapeutic Chemical (ATC) classification codes were used to identify psychotropic medications. Results: The prescription prevalence of any psychotropic medication increased from 8.110% (8.106-8.114%) in 2013 to 11.362% (11.357-11.366%) in 2017. The prescription prevalence of six classes increased significantly during 2013-2017, including sedatives-hypnotics (from 3.177 to 5.388%), anxiolytics (from 1.436 to 2.200%), antiepileptic drugs (from 1.416 to 2.140%), antipsychotics (from 0.809 to 1.156%), antidepressants (from 0.891 to 1.045%), and psycholeptic polypills (from 0.682 to 0.866%). The prescription prevalence of antidementia drugs increased from 0.069 to 0.122%, and mood stabilizers increased from 0.029 to 0.037%, although not statistically significant. The prescription prevalence of nootropic drugs, attention deficit hyperactivity disorder (ADHD) medications and drugs used in the treatment of addictive disorders was largely stable. Psychotropic medication prescription increased with age for all classes except for ADHD medications and mood stabilizers. Conclusion: Increasing trends in prescription prevalence were observed for most classes of psychotropic medications in urban China, although the prevalence was still lower than that in most developed countries. Further research is warranted to explore the potential treatment gap between China and most developed countries.

Stakeholder perspectives of Community Mental Health Forums: a qualitative study in Sierra Leone

Background

Mental health is the leading cause of disability worldwide. In the wake of both a civil war and an Ebola outbreak, Sierra Leone ranks as one of the lowest ranked countries on the Human Development Index (UNDP. Human Development Report 2015, Work for Human Development. The United Nations Development Programme; 2015). The WHO identified Sierra Leone among its priority countries for the piloting of its Mental Health Gap Action Programme (mhGAP). Aligned to these efforts, CBM and their affiliated partners employed the use of Community Mental Health Forums (CMHFs), facilitated by Mental Health Nurses (MHNs), as a sensitive and practical way of engaging key community stakeholders to discuss and address issues of mental health. This study sought firstly, to identify factors that affect the successful implementation of CMHFs, as identified by programme participants. Second, the study sought to identify what changes participants perceived as having taken place as a result of their participation in CMHFs.

Methods

10 MHNs and 52 forum participants were purposely selected to take part in key informant interviews and focus group discussions, conducted across eight districts in Sierra Leone. Interview transcripts were analysed across four rounds of coding, using a mixture of deductive and inductive approaches.

Results

Results identified three themes, Traditional Beliefs and Culture; Health System; and Inclusive Approaches as affecting the implementation of CMHFs in their districts. Participants further perceived that their participation in the Community Mental Health Forums resulted in changes taking place across the themes of Awareness and beliefs, Behaviours towards people experiencing psychological distress, and as leading to greater Collaboration and cooperation between formal and informal mental health practitioners.

Conclusions

Results are discussed in the context of the extant literature and a novel framework, that incorporates multiple best practice recommendations and factors which influence the successful implementation of CMHFs is put forward.

A Conceptual Framework for Understanding the Cultural and Contextual Factors on Autism Across the Globe

Autism research is heavily skewed toward western high-income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low- and middle-income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with autism spectrum disorders (ASD) is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross-cultural psychology, and intellectual disability research. The resulting conceptual framework considers the identification, help-seeking, and diagnostic process at four interrelated levels: (a) the expression; (b) recognition; (c) interpretation; and (d) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behavior, culture-specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility, and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification, help-seeking, and diagnosis of ASD may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross-cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide. Autism Res 2020, 13: 1029-1050. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The vast majority of autism research is conducted in western high-income settings. We therefore know relatively little of how culture and context can affect the identification, help-seeking, and diagnosis of autism across the globe. This study synthesizes what is known from the autism research literature and a broader literature and maps out how culture and context may affect (a) the expression, (b) recognition, (c) interpretation, and (d) reporting of autism symptoms.

The development and tailoring of a peer support program for patients with diabetes mellitus and depression in a primary health care setting in Central Uganda

BACKGROUND

About 20-40% of patients with diabetes mellitus (DM) suffer from depressive disorders (DD) during the course of their illness. Despite the high burden of DD among patients with DM, it is rarely identified and adequately treated at the majority of primary health care clinics in sub-Saharan Africa (SSA). The use of peer support to deliver components of mental health care have been suggested in resource constrained SSA, even though its acceptability have not been fully examined.

METHODS

We conducted qualitative interviews (QI) to assess the perceptions of DM patients with an experience of suffering from a DD about the acceptability of delivering peer support to patients with comorbid DM and DD. We then trained them to deliver peer support to DM patients who were newly diagnosed with DD. We identified challenges and potential barriers to a successful implementation of peer support, and generated solutions to these barriers.

RESULTS

Participants reported that for one to be a peer, they need to be mature in age, consistently attend the clinics/keep appointments, and not to be suffering from any active physical or co-morbid mental or substance abuse disorder. Participants anticipated that the major barrier to the delivery of peer support would be high attrition rates as a result of the difficulty by DM patients in accessing the health care facility due to financial constraints. A potential solution to this barrier was having peer support sessions coinciding with the return date to hospital. Peers reported that the content of the intervention should mainly be about the fact that DM was a chronic medical condition for which there was need to adhere to lifelong treatment. There was consensus that peer support would be acceptable to the patients.

CONCLUSION

Our study indicates that a peer support program is an acceptable means of delivering adjunct care to support treatment adherence and management, especially in settings where there are severe staff shortages and psycho-education may not be routinely delivered.

The role of patient-provider communication: a qualitative study of patient attitudes regarding co-occurring depression and chronic diseases in Malawi

BACKGROUND

Globally, depression is a leading cause of morbidity and mortality particularly in Low and Middle-Income Countries (LMICs). The burden of non-communicable diseases (NCDs) are also increasing in LMICs, the conditions frequently co-occur and exacerbate NCD outcomes. Depression interventions alone are not effective at improving NCD outcomes, resulting in wide-reaching calls for integrated services. Integrated services are in a nascent phase in LMICs in general and in Malawi in particular. This manuscript serves to clarify Malawian patients' attitudes and perceptions towards depression integration into routine NCD services.

METHODS

Ten District Hospitals were selected for data collection and 2 participants were interviewed from each site (N = 20). An iterative approach to concept-driven coding was applied to facilitate the formation of similarities, differences, and connections between codes.

RESULTS

While patients infrequently described moderate depression as a medical condition, and held various attitudes regarding treatments, they agreed on the appropriateness of integrated services. Patients' respect for their providers led them to support integration. Patients discussed how medical knowledge is highly regarded, revealing a power dynamic with their providers. Patients further acknowledged the importance of a provider's communication in shaping a patient's feelings about depression.

CONCLUSIONS

Training and interventions that facilitate providers' abilities to transfer their medical knowledge, use strategies to channel their power, and engage patients in a meaningful and collaborative relationship will be key to successfully integrating depression treatment into Malawian NCD clinics.

TRIAL REGISTRATION

This work served as part of formative data collection for National Institute of Mental Health (NIMH) Trail NCT03711786 registered on 10th October, 2018.

Involving End Users in Adapting a Spanish Version of a Web-Based Mental Health Clinic for Young People in Colombia: Exploratory Study Using Participatory Design Methodologies

BACKGROUND

Health information technologies (HITs) hold enormous promise for improving access to and providing better quality of mental health care. However, despite the spread of such technologies in high-income countries, these technologies have not yet been commonly adopted in low- and middle-income countries. People living in these parts of the world are at risk of experiencing physical, technological, and social health inequalities. A possible solution is to utilize the currently available HITs developed in other counties.

OBJECTIVE

Using participatory design methodologies with Colombian end users (young people, their supportive others, and health professionals), this study aimed to conduct co-design workshops to culturally adapt a Web-based Mental Health eClinic (MHeC) for young people, perform one-on-one user-testing sessions to evaluate an alpha prototype of a Spanish version of the MHeC and adapt it to the Colombian context, and inform the development of a skeletal framework and alpha prototype for a Colombian version of the MHeC (MHeC-C).

METHODS

This study involved the utilization of a research and development (R&D) cycle including 4 iterative phases: co-design workshops; knowledge translation; tailoring to language, culture, and place (or context); and one-on-one user-testing sessions.

RESULTS

A total of 2 co-design workshops were held with 18 users-young people (n=7) and health professionals (n=11). Moreover, 10 users participated in one-on-one user-testing sessions-young people (n=5), supportive others (n=2), and health professionals (n=3). A total of 204 source documents were collected and 605 annotations were coded. A thematic analysis resulted in 6 themes (ie, opinions about the MHeC-C, Colombian context, functionality, content, user interface, and technology platforms). Participants liked the idea of having an MHeC designed and adapted for Colombian young people, and its 5 key elements were acceptable in this context (home page and triage system, self-report assessment, dashboard of results, booking and video-visit system, and personalized well-being plan). However, to be relevant in Colombia, participants stressed the need to develop additional functionality (eg, phone network backup; chat; geolocation; and integration with electronic medical records, apps, or electronic tools) as well as an adaptation of the self-report assessment. Importantly, the latter not only included language but also culture and context.

CONCLUSIONS

The application of an R&D cycle that also included processes for adaptation to Colombia (language, culture, and context) resulted in the development of an evidence-based, language-appropriate, culturally sensitive, and context-adapted HIT that is relevant, applicable, engaging, and usable in both the short and long term. The resultant R&D cycle allowed for the adaptation of an already available HIT (ie, MHeC) to the MHeC-C-a low-cost and scalable technology solution for low- and middle-income countries like Colombia, which has the potential to provide young people with accessible, available, affordable, and integrated mental health care at the right time.

Design and Development Process of a Youth Depression Screening m-Health Application for Primary Health Care Workers in South Africa and Zambia: An Overview of the MEGA Project

Literature indicates a high prevalence and burden of mental illness in youths world-wide, which may be even higher in low- and middle-income countries (LMIC), such as South Africa and Zambia. Additionally, there is a lack of knowledge regarding youth depression amongst many primary health care (PHC) practitioners. The principal goal of the MEGA project is to provide youth with better access to mental health services and appropriate care, by developing a mental health screening mobile application tool to be used in PHC settings in South Africa and Zambia. In this study, we will use a mixed methods multi-center study design. In phase one, we will investigate the mental health literacy of PHC practitioners to identify areas in need of development. Based on the needs identified, we will develop and test a mobile health application to screen for common youth mental health problems in phase two. In phase three, we will implement and evaluate a tiered education and training program in the use of the m-health application. In the final phase, we will evaluate the acceptability and feasibility of the m-health application in PHC centres across South Africa and Zambia. Evidence suggests that PHC practitioners should routinely consider mental illness when assessing youth. However, common psychiatric disorders remain largely undetected and untreated in PHC settings. By identifying limitations in PHC workers knowledge with regard to youth mental health, we aspire to improve the depression care provided to youth in Southern Africa and Zambia by developing and implementing a locally relevant m-health application.

Content validation of Mental Health Literacy Scale (MHLS) for primary health care workers in South Africa and Zambia ─ a heterogeneous expert panel method

Background: The lack of public knowledge and the burden caused by mental-health issues’ effect on developing and implementing adequate mental-health care for young and adolescent in low- and middle-income countries (LMIC). Primary health care could be the key in facing the challenge, but it suffers from insufficient resources and poor mental health literacy. This study’s aim was to adapt the content validity of the Mental Health Literacy Scale (MHLS) developed by O’Connor & Casey (2015) with researchers and primary health-care workers in low- and middle-income contexts in South Africa (SA) and in Zambia.

Objectives: The study population comprised two expert panels (N = 21); Clinical Experts (CE) (n = 10) from Lusaka, Zambia and Professional Research Experts (PE) (n = 11) from the MEGA project management team were recruited to the study.

Methods: MHLS was validated in a South African and a Zambian context using a heterogeneous expert-panel method. Participants were asked to rate the 35 MHLS items on a 4-point scale with 1 as not relevant and 4 as very relevant After the rating, all 35 MHLS items were carefully discussed by the expert panel and evaluated according their relevance. The data were analyzed using an item-level content validity index (I-CVI) and narrative and thematic analyses.

Results: All 35 items ranked by the PREs met the cutoff criteria (≥0.8), and ten (n = 10) items were seen as relevant by CE when calculating I-CVIs. Based on the results of ratings and discussion, a group of sixteen (n = 16) of all items (n = 35) were retained as original without reviewing. A total of nineteen (n = 19) items were reviewed.

Conclusion: This study found the MHLS to have sufficient validity in LMICs’ context but also recognized a gap between professional researchers’ and clinical workers’ knowledge and attitudes related to mental health.

Changing patterns of mental health knowledge in rural Kenya after intervention using the WHO mhGAP-Intervention Guide

BACKGROUND

Despite the high prevalence of mental disorders, mental health literacy has been comparatively neglected. People's symptom-management strategies will be influenced by their mental health literacy. This study sought to determine the feasibility of using the World Health Organization mhGAP-Intervention Guide (IG) as an educational tool for one-on-one contact in a clinical setting to increase literacy on the specified mental disorders.

METHODS

This study was conducted in 20 health facilities in Makueni County, southeast Kenya which has one of the poorest economies in Kenya. It has no psychiatrist or clinical psychologist. We recruited 3267 participants from a community that had already been exposed to community mental health services. We used Mental Health Knowledge Schedule to measure the changing patterns of mental health knowledge after a period of 3 months, following a training intervention using the WHO mhGAP-IG.

RESULTS

Overall, there was a significant increase in mental health related knowledge [mean range 22.4-23.5 for both post-test and pre-test scores (p < 0.001)]. This increase varied with various socio-demographic characteristics such as sex, marital status, level of education, employment status and wealth index.

CONCLUSIONS

mhGAP-IG is a feasible tool to increase mental health literacy in low-resource settings where there are no mental health specialists. Our study lends evidence that the WHO Mental Health Action Plan 2013-2020 and reduction of the treatment gap may be accelerated by the use of mhGAP-IG through improving knowledge about mental illness and potentially subsequent help seeking for early diagnosis and treatment.

Stakeholders' Views Regarding Their Role as Support System for People with Mental Illness and Their Families in Rural South Africa

The diverse needs associated with mental illness warrant for the provision of mental health care by various sources. The South African government recognises the involvement of stakeholders as a potential means of narrowing the gaps in mental health service delivery. This study explored the views of different stakeholders about their roles as support systems for people with mental illness and their families at Mashashane, a rural setting in Limpopo Province, South Africa. Seven focus group discussions were conducted with various stakeholders. This qualitative study employed content analysis to allow for comparison of stakeholders' views. Stakeholders understanding of mental illness was based on reaction towards people with mental illness, causes of mental illness and the behaviour displayed by the ill individual. The identified formal and informal systems were seen as ineffective with regards to provision of support. Collaboration was recommended as a mechanism to improve mental health services. The findings contributed in the formulation of guidelines to improve support.

A cross-sectional study of psychiatric morbidity and quality of life among participants utilizing the preventive health-care services of a tertiary hospital

BACKGROUND

The burden of mental disorders has been increasingly recognized and 450 million people globally are suffering from mental illness. Mental-physical comorbidity has adverse effects on the overall outcome. Research is scarce with regard to mental health screening in the context of "preventive health care" in India. Thus, the study aimed to identify the prevalence of mental illness and the effect on quality of life (QOL) among participants attending preventive health-care unit (PHCU).

SETTINGS AND DESIGN

This was a cross-sectional study conducted in PHCU of a tertiary hospital in Puducherry.

MATERIALS AND METHODS

All consecutive participants (>18 years) attending PHCU were included in the study. The Standard for Clinicians' Interview in Psychiatry (SCIP) screening module, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Level 1 Cross-Cutting Symptom Measure, Mini-Cog, and Quality of Life Enjoyment and Satisfaction Questionnaire were administered. Relevant diagnostic modules of SCIP were applied to participants who screened positive on SCIP. Data analysis was performed using SPSS (version 17.0).

RESULTS

The mean age of participants was 43.38 ± 13.99 years. Of 203 participants enrolled, 28.1% screened positive and 26.1% were confirmed to have psychiatric disorder. About 4% screened positive for cognitive impairment. Most commonly diagnosed disorders were alcohol use disorder and major depressive disorder. The prevalence of depressive disorder was higher in patients with physical disorder. Participants with psychiatric disorder alone or with both psychiatric and physical disorders had significantly poorer QOL (F = 27.13; P < 0.001).

CONCLUSION

One-fourth of the participants attending preventive health-care services were found to have psychiatric disorders. The presence of psychiatric disorder was associated with significantly poorer QOL. This highlights the importance of routine mental health screening in this setting.

The therapeutic value of trauma stabilisation in the treatment of post-traumatic stress disorder - A Southeast Asian Study

OBJECTIVE

Southeast Asia suffers from various forms of natural disasters and interpersonal violence. This creates a large trauma population, while at the same time mental health services in this area are limited. The humanitarian organisation Trauma Aid Germany established trauma capacity building by training 37 local therapists in psycho-traumatology, including trauma stabilisation, in Cambodia, Indonesia and Thailand. This analysis examines the impact of trauma stabilisation as a sole treatment for traumatized clients.

METHOD

Clients were screened for PTSD using the Harvard Trauma Questionnaire pre- and post-treatment. Analysis only included clients who had received trauma stabilisation, including psychoeducation, but no confrontation with the traumatic event.

RESULTS

Trauma stabilisation was highly effective in reducing PTSD symptoms, with high remission from PTSD post-treatment. Trauma stabilisation affected all subscales of PTSD and was effective in clinical as well as subclinical traumatized clients.

CONCLUSION

The research supports the notion that trauma stabilisation is a treatment effect for PTSD. It was highly effective in its own in reducing PTSD symptoms. Based on the analysis, trauma stabilisation was a safe, language independent treatment for PTSD sufficiently flexible to be sensitive to the client's context. Therapists can adapt the techniques to the individual client and his cultural, spiritual, developmental, cognitive and situational background. Trauma stabilisation is suitable for implementation in crisis areas. The research has also implications to the potential utilisation of para-professionals.

Pluralism and practicality: village health workers' responses to contested meanings of mental illness in Southern Malawi

The individual and social construction of psychological distress is fundamental to help-seeking and the extent to which interventions are seen as credible. Where pluralistic attributions for mental health problems predominate, the development of global mental health (GMH) interventions in the form of task-shifting approaches create increased access to new ways of understanding and responding to distress. However, little is known about how participants in these initiatives manage these encounters. This qualitative study in Malawi explored village-based health workers' (HSAs) and patients' and carers' views of the causes of distress and how these beliefs influenced help-seeking and the health workers' response.Eight HSAs and nine paired patients/carers were interviewed separately to enable each of nine experiences of distress to be explored. Findings revealed a complex set of personal, social and cultural influences that informed causative attributions and help-seeking decisions. Patients/carers viewed psychosocial stresses as compelling explanations and readily reported others attributing their distress to supernatural causes (bewitchment). Yet attributional beliefs alone were not the only influence over help-seeking, which evolved pragmatically in response to the impact of treatments and social pressure for conformity. In turn HSAs navigated the interactions with patients/carers by emphasising the biomedical approach and discrediting bewitchment attributions. This caused tensions when biomedical interventions were unhelpful or the traditional healers' approach proved beneficial.Conclusions add to the call for such task-shifting approaches to work with communities to discern authentic and practical responses to mental distress that mirror the 'pluralism and pragmatism' found in the communities they serve.

Depression, anxiety, and post-traumatic stress disorder among youth in low and middle income countries: A review of prevalence and treatment interventions

BACKGROUND

Low and middle income countries (LMICs) not only have the majority of the world's population but also the largest proportion of youth. Poverty, civil conflict and environmental stressors tend to be endemic in these countries and contribute to significant psychiatric morbidity, including depression, anxiety and post-traumatic stress disorder (PTSD). However, mental health data from LMICs is scarce, particularly data on youth. Evaluation of such information is crucial for planning services and reducing the burden of disability. This paper reviews the published data on the prevalence and randomized trials of interventions for depression, anxiety and PTSD in youth in LMICs.

METHODS

PubMed and Google Scholar were searched for articles published in English up to January 2017, using the keywords: Low/middle income country, depression, anxiety, post-traumatic stress disorder, child, youth, adolescent, prevalence, treatment, intervention, and outcomes.

RESULTS

The few prevalence studies in LMICs reported rates of up to 28% for significant symptoms of depression or anxiety among youth, and up to 87% for symptoms of PTSD among youth exposed to traumatic experienences, though these rates varied widely depending on several factors, including the assessments tools used. Most rigorous interventions employed some form or variation of CBT, with mixed results. Studies using other forms of psychosocial interventions appear to be heterogeneous and less rigorous.

CONCLUSIONS

The mental health burden due to depression and anxiety disorders in youth is substantial in LMICs, with high needs but inadequate services. Youth specific services for early detection and cost-effective interventions are needed.

The validation of the visual screening tool for anxiety disorders and depression in hypertension and/or diabetes

Background

Depression and anxiety disorders remain poorly detected at primary health care, particularly in patients with hypertension and/or diabetes. A visual screening tool for anxiety disorders and depression (VISTAD) has been developed, but not validated.

Aim

To validate the VISTAD in primary health care participants diagnosed with hypertension and/or diabetes.

Setting

Participants were recruited from five primary health care centres in the Eastern Cape, South Africa (urban, peri-urban and rural).

Methods

The study used a cross-sectional study design to validate the VISTAD. The VISTAD was validated against the International Neuropsychiatric Interview (M.I.N.I) using field testing. A demographic questionnaire was used to collect data on socio-economic variables.

Results

Sixty-nine (87%) females and 10 (13%) males with a mean age of 49 (SD 8.6844) participated in the study. Fifty black people (63%), 16 mixed race people (20%) and 13 white people (16%) participated in the study. The majority of the participants (77%) did not complete high school. The area under curve score (AUC) for the VISTAD in screening for depression was 0.91, and for anxiety disorders, 0.87 post-traumatic stress disorder, 0.87 panic disorder, 0.85 social phobia, 0.88 agoraphobia, and 0.83 generalised anxiety disorder revealing acceptable psychometric properties.

Conclusion

The use of the VISTAD as a screening tool at primary health care in people living with hypertension and/or diabetes is recommended. The VISTAD could, therefore, play a key role in the prevention and early treatment of individuals diagnosed with hypertension and/or diabetes across cultures and levels of education. The VISTAD needs to be validated in a large population representative of primary care patients diagnosed with hypertension and/or diabetes.

A review of mental health literacy in Singapore

Mental health is a major concern throughout the world. The lifetime prevalence of mental health problems in Singapore for those aged 18 years and above was reported to be 12%. However, studies on mental health literacy are relatively scarce in Singapore. The aim of this paper is to provide a topical review of local studies on mental health literacy, people's knowledge of, and attitude toward mental illness, and beliefs about mental health treatment. A narrative review of studies on mental health literacy in Singapore covering the period from 1995 to 2016 highlights the findings from various local studies about attitudes toward mental illness, belief about the causes, and help-seeking behavior. Findings revealed that many lay people are unable to recognize different types of mental disorders. Negative attitudes toward mental illness that hinders individuals from seeking professional treatment, and help-seeking, are the common themes that emerge from the findings. Health professionals have differing views about the causes and treatment of mental disorders. Findings also revealed that treatment seeking and attitudes and beliefs toward mental illness are related to mental health literacy. Implications for promoting mental health literacy are provided.

Evaluating the benefits of a youth mental health curriculum for students in Nicaragua: a parallel-group, controlled pilot investigation

BACKGROUND

High rates of mental illness and addictions are well documented among youth in Nicaragua. Limited mental health services, poor mental health knowledge and stigma reduce help-seeking. The Mental Health Curriculum (MHC) is a Canadian school-based program that has shown a positive impact on such contributing factors. This pilot project evaluated the impact of the MHC on mental wellness and functioning among youth in Leon, Nicaragua.

METHODS

High school and university students (aged 14-25 years) were assigned to intervention (12-week MHC; n  =  567) and control (wait-list; n  =  346) groups in a non-randomized design. Both groups completed measures of mental health knowledge, stigma and function at baseline and 12 weeks. Multivariate analyses and repeated measures analyses were used to compare group outcomes.

RESULTS

At baseline, intervention students showed higher substance use (mean difference [MD]  =  0.24) and lower perceived stress (MD = -1.36) than controls (p  <  0.05); there were no other group differences in function. At 12 weeks, controlling for baseline differences, intervention students reported significantly higher mental health knowledge (MD  =  1.75), lower stigma (MD  =  1.78), more adaptive coping (MD  =  0.82), better lifestyle choices (MD  =  0.06) and lower perceived stress (MD = -1.63) (p  <  0.05) than controls. The clinical significance as measured by effect sizes was moderate for mental health knowledge, small to moderate for stigma and modest for the other variables. Substance use also decreased among intervention students to similar levels as controls (MD  =  0.03) (p > 0.05).

CONCLUSIONS

This pilot investigation demonstrates the benefits of the MHC in a low-and-middle-income youth population. The findings replicate results found in Canadian student populations and support its cross-cultural applicability.

Research on help-seeking for mental illness in Africa: Dominant approaches and possible alternatives

There is growing concern within the global mental health arena that interventions currently being executed to scale up mental health services in Africa will be ineffective unless simultaneous steps are taken to address people's help-seeking behaviour. Drawing upon two conceptual tools arising from science and technology studies (STS), those of a "classification system" and "the black box," this paper looks critically at discursive constructions of help-seeking in Africa within mental health research over the last decade. Research in this area can be divided into two dominant traditions: the knowledge-belief-practice survey and indigenous-knowledge-system approaches. Although the content and value-codes between these approaches differ, structurally they are very similar. Both are mediated by the same kind of system of classification, which demarcates the world into homogenous entities and binary oppositions. This system of ordering is one of the most stubborn and powerful forms of classification buried in the "black box" of the modernist/colonial knowledge archive and is fraught with many questionable Eurocentric epistemological assumptions. I consider whether there might be other ways of understanding help-seeking for mental illness in Africa and discuss two studies that illustrate such alternative approaches. In conclusion, I discuss some of the challenges this alternative kind of research faces in gaining more influence within contemporary global mental health discourse and practice.

Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs

BACKGROUND

Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda.

METHODS

Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach.

RESULTS

Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training.

CONCLUSION

This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.

Pharmacist-patient communication barriers in dispensing practice: a descriptive study in Adama Hospital Medical College, Adama City, Oromia regional state, Ethiopia

Objectives

Drug dispensers should provide appropriate, understandable and relevant information to patient about their medication. But poor communication between patient and pharmacist carries potential adverse clinical consequences. Patients with inadequate literacy and/or health literacy skills are the most likely to have difficulties in understanding proper drug use. Our study is intended to assess the extent of pharmacist–patient communication barriers in dispensing.

Methods

This study was conducted in Adama Hospital Medical College, Adama City, Ethiopia, from March 2014 to May 2014. The survey data were collected both from pharmacists and patients through questionnaire and interview, respectively, and analysed manually by a data master sheet.

Key findings

A total of 345 outpatients who were collecting their medication from the Outpatient Department pharmacy and nine pharmacists were included in the study. 11.11% pharmacists utilised pictorial aid to their oral counselling. 77.78% of pharmacists can communicate in three languages (Amharic, Oromiffa and English). 20.87% of patients were geriatrics, 30.73% were illiterate and 34.20% were in low literacy. Misunderstanding of drug dose and frequency among illiterate and low literacy geriatric patients was 46.88%. 22.22% of geriatrics revisited the hospital for re-treatment of the same condition.

Conclusions

Counselling on dispensing is a fundamental step to enhance the patients’ rational use of medicine. When patients’ health is concerned, pharmacists should try their best to enhance the patient's understanding about medication use.

Quantifying and predicting depression literacy of undergraduates: a cross sectional study in Sri Lanka

BACKGROUND

The high rates of depression and low rates of related help-seeking among undergraduates are matters for concern. In response to the need to examine their knowledge about depression and its management, and the dearth of such research from non-western developing countries, this study examined the depression literacy of undergraduates in Sri Lanka.

METHODS

A questionnaire was administered among 4671 undergraduates to examine their depression literacy relating to problem-recognition, measured using a vignette of a depressed undergraduate, and their treatment beliefs measured by assessing their perceptions about the helpfulness of various options of help for the presented problem. Responses for the latter aspect were quantified using a scale comprising the options of help endorsed by Sri Lankan mental health professionals. Regression analysis models were used to identify the correlates of these aspects of depression literacy.

RESULTS

Females, medical undergraduates and those in higher years of study (compared to first-years) were more likely to recognise the problem as depression. The undergraduates obtained a mean percentage score of 76% on the constructed Depression Treatment Beliefs Scale. Scores on this scale were higher among females, medical undergraduates, those who got help for the problem after trying to deal with it alone and those who recognised the problem as depression, as well as those who used other mental health-related labels for this purpose. Scores were lower among undergraduates in years 2-4 (compared to first-years), those with family or friends with the problem and those with higher stigma on a Social Distance Scale. However, the effect sizes of these relationships were small.

CONCLUSIONS

As factors such as gender, discipline, year of study, exposure to depression and stigma are associated with differences in the depression literacy of these undergraduates, concerning their ability to recognise the problem and their related treatment beliefs, these must be considered when designing related educational initiatives. Recognising the problem as depression or the use of other mental health-related labels is associated with better treatment beliefs as per expert consensus, indicating that such labelling could have value for appropriate help-seeking.

Depression literacy of undergraduates in a non-western developing context: the case of Sri Lanka

BACKGROUND

Research examining the depression literacy of undergraduates in non-western developing countries is limited. This study explores this among undergraduates in Sri Lanka.

METHODS

A total of 4671 undergraduates responded to a survey presenting a vignette of a depressed undergraduate. They were asked to identify the problem, describe their intended help-seeking actions if affected by it and rate the helpfulness of a range of help-providers and interventions for dealing with it. Mental health experts also rated these options, providing a benchmark for assessing the undergraduates' responses.

RESULTS

Only 17.4% of undergraduates recognised depression, but this was significantly lower among those responding in Sinhala compared to English (3.5 vs 36.8%). More undergraduates indicated intentions of seeking informal help, such as from friends and parents, than from professionals, such as psychiatrists and counsellors. However, a majority rated all these help-providers as 'helpful', aligning with expert opinion. Other options recommended by experts and rated as 'helpful' by a large proportion of undergraduates included counselling/psychological therapy and self-help strategies such as doing enjoyable activities and meditation/yoga/relaxation exercises. However, a low proportion of undergraduates rated "western medicine to improve mood" as 'helpful', deviating from expert opinion. Although not endorsed by experts, undergraduates indicated intentions of using religious strategies, highly endorsing these as 'helpful'. Labelling the problem as depression and using mental health-related labels were both associated with higher odds of endorsing professional help, with the label 'depression' associated with endorsing a wider range of professional options.

CONCLUSIONS

The recognition rate of depression might be associated with the language used to label it. These undergraduates' knowledge about the use of medication for depression needs improvement. Health promotion interventions for depressed undergraduates must be designed in light of the prevalent socio-cultural backdrop, such as the undergraduates' high endorsement of informal and culturally relevant help-seeking. Improving their ability to recognise the problem as being mental health-related might trigger their use of professional options of help.