Changes in attitudes toward persons with mental disorders after attendance of a psychiatric curriculum among medical students in Vietnam: A cross-sectional study

This study aimed to determine the influence of psychiatric training and hands-on learning with individuals with mental illness on increasing medical students' benevolent attitudes towards psychiatry and psychiatric patients. The cross-sectional study compares medical students' attitudes before and after a compulsory psychiatry curriculum and psychiatric bedside training at Hanoi Medical University with those of non-medical students who have yet to undergo similar training. Two validated scales regarding the attitudes toward psychiatry and psychiatric patients were evaluated. Analysis of the Medical Conditions Regard Scale[1] revealed a significant difference, indicating that medical students displayed more accepting and benevolent attitudes towards psychiatry and psychiatric patients after completing the curriculum and bedside training than medical students before participation. Most stigmatising and rejecting attitudes were found among non-medical students. This study is the first to examine medical students' attitudes toward psychiatry and psychiatric patients compared to non-medical students in Vietnam. It can guide the development of the medical curriculum to increase benevolence towards psychiatric patients and interest in the psychiatric field of work in Vietnam and Southeast Asia, aiming to improve the mental health care sector.

Testing pathways to scale: study protocol for a three-arm randomized controlled trial of a centralized and a decentralized ("Train the Trainers") dissemination of a mental health program for Kenyan adolescents

BACKGROUND

Providing care in Kenya to all youth in need is difficult because of a shortage of professional providers and societal stigma. Previous trials of the Anansi model, which involves delivering low-touch mental health interventions through a tiered caregiving model (including lay-providers, supervisors, and clinical experts), have shown its effectiveness for reducing depression and anxiety symptoms in school-going Kenyan adolescents. In this trial, we aim to assess two different scale-up strategies by comparing centralized implementation (i.e., by the organization that designed the Anansi model) against implementation through an implementing partner.

METHODS

In this three-arm trial, 1600 adolescents aged 13 to 20 years will be randomized to receive the Shamiri intervention from either the Shamiri Institute or an implementation partner or to be placed in the treatment as usual (TAU) control group. The implementation partner will be trained and supplied with protocols to ensure that the same procedures are followed by both implementors. Implementation activities will run concurrently for both implementors. The Shamiri intervention will be delivered by trained lay providers to groups of 10-15 adolescents over four weekly sessions which will take place in secondary schools in Machakos and Makueni counties in Kenya. The TAU group will receive the usual care offered by their respective schools. Outcomes will be assessed at baseline, midpoint (2 weeks), endpoint (4 weeks), and 1 month follow-up. The analysis will be based on an intent-to-treat approach. Mixed effects models will be used to assess trajectories over time of the primary outcomes (anxiety and depressive symptoms, mental well-being, perceived social support, and academic performance) and secondary outcomes for the intervention groups and the control group. Effect sizes will be computed for the mean differences of the intervention and control arms at midpoint, endpoint, and follow-up.

DISCUSSION

This trial will provide insight into the comparative effectiveness of different strategies for scaling a school-based mental health care model. Findings will also indicate areas for improved efficiency of the model to enhance its replicability by other implementors.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR) (ID: PACTR202305589854478, Approved: 02/05/2023).

Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems

In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.

The Challenge of Indigenous Healing for Global Mental Health

Psychiatry and anthropology have a long relationship, and it is worth examining aspects of how that relation is carried over into the developing field of Global Mental Health (GMH). One place at which the two disciplines overlap significantly is in addressing religious phenomena and ritual performance in relation to mental health, and one of the greatest challenges for GMH is how productively to take into account forms of indigenous healing based on religion and ritual. In this paper I compare recent texts in GMH written from the standpoint of psychiatry and anthropology, observing that the psychiatric texts emphasize evidence-based determination of treatment efficacy, while the anthropological texts emphasize ethnographic understanding of treatment experience. Reconciling these two emphases constitutes a challenge to the field, attending to contextual variations in treatment events, illness episodes, phenomenological factors both endogenous and intersubjective, and sociopolitical factors both interpersonal and structural. In addressing this challenge, I propose an approach to therapeutic process that on the empirical level can facilitate comparison across the diversity of healing forms, and on the conceptual level can constitute a bridge between efficacy and experience. This approach is predicated on a rhetorical model of therapeutic process including components of disposition, experience of the sacred, elaboration of alternatives, and actualization of change that highlights experiential specificity and incremental change. Deploying this model can help meet the challenge of understanding efficacy and experience in indigenous healing, and prepare the ground for the further challenge of how practitioners of GMH relate to and interact with such forms of healing.

Critical reflections on the concept and impact of "scaling up" in Global Mental Health

The field of Global Mental Health (GMH) aims to address the global burden of mental illness by focusing on closing the "treatment gap" faced by many low- and middle-income countries (LMICs). To increase access to services, GMH prioritizes "scaling up" mental health services, primarily advocating for the export of Western centred and developed biomedical and psychosocial "evidence-based" approaches to the Global South. While this emphasis on scalability has resulted in the increased availability of mental health services in some LMICs, there have been few critical discussions of this strategy. This commentary critically appraises the scalability of GMH by questioning the validity and sustainability of its approach. We argue that the current approach emphasizes the development of mental health services and interventions in "silos," focusing on the treatment of mental illnesses at the exclusion of a holistic and contextualized approach to people's needs. We also question the opportunities that the current approach to GMH offers for the growth of mental health programmes of local NGOs and investigate the potential pitfalls that scalability may have on NGOs' impact and ability to innovate. This commentary argues that any "scaling up" of mental health services must place sustainability at the core of its mission by favouring the growth and development of local solutions and wider forms of support that prioritize social inclusion and long-lasting mental health recovery.

Reprioritising global mental health: psychoses in sub-Saharan Africa

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Cracks that Let the Light in: Collective Reflections on Integrating Lived Experience of Psychosis in Research and Policy in the Context of a Global Commission

Within psychiatric research fields, there has been a marked uptick of interest in service user involvement in recent years. Nevertheless, it is often unclear how robust or impactful common forms of inclusion are, and the extent to which they have included individuals with psychosis. Using collective auto-ethnography, this paper describes the experiences of 8 academic and non-academic members of the 'lived experience' and participatory research workgroup of a global psychosis Commission and our navigation of power and power hierarchies, differences in background and training, and multiple vectors of identity, diversity, and privilege. We conclude that the realities of "involvement" are much messier, more fraught, and less intrinsically empowering than often signaled in calls for involvement and co-production. We nevertheless stress the power of collective dialogue and support-between and among a pluralistic group-and of honesty and transparency about challenges, barriers, and the colonial underpinnings and geopolitics of global mental health.

Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review

BACKGROUND

The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted.

AIMS

We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation.

METHODS

Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health.

RESULTS

Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers.

CONCLUSIONS

Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.

Global child and adolescent mental health perspectives: bringing change locally, while thinking globally

Child and adolescent mental health (CAMH) are a global priority. Different countries across the globe face unique challenges in CAMH services that are specific to them. However, there are multiple issues that are also similar across countries. These issues have been presented in this commentary from the lens of early career CAMH professionals who are alumni of the Donald J Cohen Fellowship program of the IACAPAP. We also present recommendations that can be implemented locally, namely, how promoting mental health and development of children and adolescents can result in better awareness and interventions, the need to improve quality of care and access to care, use of technology to advance research and practices in CAMH, and how investing in research can secure and support CAMH professionals and benefit children and adolescents across the globe. As we continue to navigate significant uncertainty due to dynamic circumstances globally, bolstering collaborations by "bringing change locally, while thinking globally" are invaluable to advancing global CAMH research, clinical service provision, and advancement of the field.

Communalistic use of psychoactive plants as a bridge between traditional healing practices and Western medicine: A new path for the Global Mental Health movement

The Global Mental Health (GMH) movement aims to provide urgently needed treatment to those with mental illness, especially in low- and middle-income countries. Due to the complexity of providing mental health services to people from various cultures, there is much debate among GMH advocates regarding the best way to proceed. While biomedical interventions offer some degree of help, complementary approaches should focus on the social/community aspects. Many cultures conduct traditional rituals involving the communal use of psychoactive plants. We propose that these practices should be respected, protected, and promoted as valuable tools with regard to mental health care at the community level. The traditional use of psychoactive plants promotes community engagement and participation, and they are relatively affordable. Furthermore, the worldviews and meaning-making systems of local population are respected. The medical systems surrounding the use of psychoactive plants can be explained in biomedical terms, and many recently published clinical trials have demonstrated their therapeutic potential. Psychoactive plants and associated rituals offer potential benefits as complementary aspects of mental health services. They should be considered as such by international practitioners and advocates of the GMH movement.

Long-term health outcomes of adolescent character strength interventions: 3- to 4-year outcomes of three randomized controlled trials of the Shamiri program

BACKGROUND

Adolescents in low- and middle-income countries in need of mental health care often do not receive it due to stigma, cost, and lack of mental health professionals. Culturally appropriate, brief, and low-cost interventions delivered by lay-providers can help overcome these barriers and appear effective at reducing symptoms of depression and anxiety until several months post-intervention. However, little is known about whether these interventions may have long-term effects on health, mental health, social, or academic outcomes.

METHODS

Three previous randomized controlled trials of the Shamiri intervention, a 4-week, group-delivered, lay-provider-led intervention, have been conducted in Kenyan high schools. Shamiri teaches positively focused intervention elements (i.e., growth mindset and strategies for growth, gratitude, and value affirmation) to target symptoms of depression and anxiety and to improve academic performance and social relationships, by fostering character strengths. In this long-term follow-up study, we will test whether these mental health, academic, social, and character-strength outcomes, along with related health outcomes (e.g., sleep quality, heart-rate variability and activity level measured via wearables, HIV risk behaviors, alcohol and substance use), differ between the intervention and control group at 3-4-year follow-up. For primary analyses (Nanticipated = 432), youths who participated in the three previous trials will be contacted again to assess whether outcomes at 3-4-year-follow-up differ for those in the Shamiri Intervention group compared to those in the study-skills active control group. Multi-level models will be used to model trajectories over time of primary outcomes and secondary outcomes that were collected in previous trials. For outcomes only collected at 3-4-year follow-up, tests of location difference (e.g., t-tests) will be used to assess group differences in metric outcomes and difference tests (e.g., odds ratios) will be used to assess differences in categorical outcomes. Finally, standardized effect sizes will be used to compare groups on all measures.

DISCUSSION

This follow-up study of participants from three randomized controlled trials of the Shamiri intervention will provide evidence bearing on the long-term and health and mental health effects of brief, lay-provider-delivered character strength interventions for youth in low- and middle-income countries.

TRIAL REGISTRATION

PACTR Trial ID: PACTR202201600200783 . Approved on January 21, 2022.

Loneliness in Myanmar's older population: A mixed-methods investigation

OBJECTIVES

Little is known about loneliness in lower- and middle-income countries. This study investigates loneliness in the older population of Myanmar using a mixed-methods approach.

METHODS

To identify predictors of loneliness, hierarchical regression models were used to analyze data from the Myanmar Aging Survey 2012 (N = 3,618, 57% women). In a mixed-methods sequential explanatory design, quantitative data were integrated with qualitative data from semi-structured interviews with older adults in Myanmar in 2019.

RESULTS

The prevalence of loneliness varied by between-person characteristics. Health impairments, lower income, being widowed, not having children, and living with fewer household members were each associated with loneliness. Qualitative findings suggested that the physical presence of family members was especially protective against loneliness. Religion had mixed associations with loneliness, depending on the type of religious practice, demographic characteristics, health status, and community engagement.

DISCUSSION

The findings contribute to a better understanding of individuals' experiences of loneliness and may inform the design of interventions to prevent loneliness in Myanmar and globally.

Testing the effects of the Shamiri Intervention and its components on anxiety, depression, wellbeing, and academic functioning in Kenyan adolescents: study protocol for a five-arm randomized controlled trial

BACKGROUND

Treatments for youth mental disorders are a public health priority, especially in sub-Saharan Africa (SSA), where treatment options remain limited due to high cost, elevated stigma, and lack of trained mental health professionals. Brief, accessible, and non-stigmatizing community-based interventions delivered by lay providers may help address treatment needs in SSA. One such intervention, the Shamiri Intervention, consisting of three elements (growth mindset, gratitude, and value affirmation) has been tested in randomized controlled trials with school-going Kenyan adolescents. This three-element Shamiri Intervention has been shown to significantly reduce depression and anxiety symptoms and improve social support and academic performance relative to a control group. In this trial, we aim to investigate the effects of each element of the Shamiri Intervention.

METHODS

In this five-arm randomized controlled trial, we will test each of the intervention components (growth mindset, gratitude, and value affirmation) against the full Shamiri Intervention and against a study skills control intervention. Students (Nplanned = 1288) at participating secondary schools who are interested in participating in this universal intervention will be randomized in equal numbers into the five groups. The students will meet in groups of 8-15 students led by local high school graduate lay providers. These lay providers will receive a brief training, plus expert supervision once a week throughout the intervention delivery. Multi-level models will be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes in each intervention group to the control group. Multi-level models will also be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes of participants in the single-element interventions compared to the full Shamiri Intervention. Finally, effect sizes (calculated as mean gain scores) will be used to compare all groups on all measures.

DISCUSSION

This trial will shed light on the mechanisms and outcomes targeted by each individual intervention, helping prioritize which mental health interventions are most important to disseminate.

TRIAL REGISTRATION

PACTR Trial ID: PACTR202104716135752 . Approved on 4/19/2021.

Cross-cultural adaptation of motivational interviewing for use in rural Nepal

Background

Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person’s behaviors.

Methods

We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment.

Results

Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not “allow” it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone’s motivations and align those with the patient’s needs.

Conclusions

MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient’s autonomy and their role as a member of a complex social fabric to facilitate behavior change.

Owning our madness: Contributions of Jamaican psychiatry to decolonizing Global Mental Health

The contentious debate on evidence-based Global Mental Health care is challenged by the primary mental health program of Jamaica. Political independence in 1962 ushered in the postcolonial Jamaican Government and the deinstitutionalization of the country's only mental hospital along with a plethora of mental health public policy innovations. The training locally of mental health professionals catalyzed institutional change. The mental health challenge for descendants of African people enslaved in Jamaica is to reverse the psychological impact of 500 years of European racism and colonial oppression and create a blueprint for the decolonization of GMH. The core innovations were the gradual downsizing and dismantling of the colonial mental hospital and the establishment of a novel community mental health initiative. The successful management of acute psychosis in open medical wards of general hospitals and a Diversion at the Point of Arrest Programme (DAPA) resulted in the reduction of stigma and the assimilation of mental health care into medicine in Jamaica. Successful decentralization has led to unmasking underlying social psychopathology and the subsequent development of primary prevention therapeutic programs based on psychohistoriographic cultural therapy and the Dream-A-World Cultural Therapy interventions. The Jamaican experience suggests that diversity in GMH must be approached not simply as a demographic fact but with postcolonial strategies that counter the historical legacy of structural violence.

Global Mental Health: Interdisciplinary challenges for a field in motion

In recent years, efforts in Global Mental Health (GMH) have evolved alongside critical engagement with the field's claims and interventions. GMH has shifted its agenda and epistemological underpinnings, increased its evidence base, and joined other global policy platforms such as the Sustainable Development Goals. This editorial introduction to a thematic issue traces the recent shifts in the GMH agenda and discusses the changing construct of "mental health" as GMH moves away from a categorical biomedical model toward dimensional and transdiagnostic approaches and embraces digital technologies. We highlight persistent and emerging lines of inquiry and advocate for meaningful interdisciplinary engagement. Taken together, the articles in this special issue of Transcultural Psychiatry provide a snapshot of current interdisciplinary work in GMH that considers the socio-cultural and historical dimensions of mental health important and proposes reflexive development of interventions and implementation strategies.

Finding "What Works": Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health

Global Mental Health has developed interventions that strive to work across great difference-variously conceptualized as cultural, socio-economic, geographic, or pertaining to the characteristics of health systems. This article discusses how the evaluation framework Theory of Change (ToC) facilitates the production of 'global' knowledge across such differences. Drawing on 14 months of multi-sited fieldwork among Global Mental Health actors in Europe, North America and South Africa, it traces the differential use of ToC in GMH interventions. While much critical scholarship of Global Health metrics holds that techniques of quantification rely on universals that necessarily betray the "real world", ToC unsettles these critiques. It comes into view as an epistemic and relational device that produces 'contingent universals'-concepts that are true and measurable until they stop working in the field, or until the parameters of 'what works' shift to a new iteration. As such, Theory of Change produces actionable-rather than true-knowledge attuned to open-ended change, both desirable (impact) and unforeseen (adaptation). Its effects, however, are ambiguous. ToC presents us with a horizoning technique that enables what I call "virtuous failure" within the evidence-based paradigm. It may equally harbor the potential to disrupt distinctions such as bricolage (tinkering) and design (planning) and their respective politics, as it may tie neatly into audit cultures, depending on its use. The article analyzes the novel stakes of reflexive evaluation techniques and calls on anthropology and critical Global Health for renewed empirical engagement.

Multiculturalism and Compassion: Responding to Mental Health Needs Among Refugees and Asylum Seekers Comment on "A Crisis of Humanitarianism: Refugees at the Gates of Europe"

As Fotaki (2019) argues, the current political climate in Europe is threatening principles of humanitarianism, particularly among refugees and asylum seekers. This commentary builds on that argument, with a spotlight on mental health and culturally relevant service design. By addressing some of the barriers faced by refugees and asylum seekers in accessing mental healthcare, we can address inequalities and develop compassionate societies.

Considering culture, context and community in mhGAP implementation and training: challenges and recommendations from the field

BACKGROUND

Major efforts are underway to improve access to mental health care in low- and middle-income countries (LMIC) including systematic training of non-specialized health professionals and other care providers to identify and help individuals with mental disorders. In many LMIC, this effort is guided by the mental health Gap Action Programme (mhGAP) established by the World Health Organization, and commonly centres around one tool in this program: the mhGAP-Intervention Guide.

OBJECTIVE

To identify cultural and contextual challenges in mhGAP training and implementation and potential strategies for mitigation.

METHOD

An informal consultative approach was used to analyze the authors' combined field experience in the practice of mhGAP implementation and training. We employed iterative thematic analysis to consolidate and refine lessons, challenges and recommendations through multiple drafts. Findings were organized into categories according to specific challenges, lessons learned and recommendations for future practice. We aimed to identify cross-cutting and recurrent issues.

RESULTS

Based on intensive fieldwork experience with a focus on capacity building, we identify six major sets of challenges: (i) cultural differences in explanations of and attitudes toward mental disorder; (ii) the structure of the local health-care system; (iii) the level of supervision and support available post-training; (iv) the level of previous education, knowledge and skills of trainees; (v) the process of recruitment of trainees; and (vi) the larger socio-political context. Approaches to addressing these problems include: (1) cultural and contextual adaptation of training activities, (2) meaningful stakeholder and community engagement, and (3) processes that provide support to trainees, such as ongoing supervision and Communities of Practice.

CONCLUSION

Contextual and cultural factors present major barriers to mhGAP implementation and sustainability of improved services. To enable trainees to effectively apply their local cultural knowledge, mhGAP training needs to: (1) address assumptions, biases and stigma associated with mental health symptoms and problems; (2) provide an explicit framework to guide the integration of cultural knowledge into assessment, treatment negotiation, and delivery; and (3) address the specific kinds of problems, modes of clinical presentations and social predicaments seen in the local population. Continued research is needed to assess the effectiveness these strategies.

Sustainable financing options for mental health care in South Africa: findings from a situation analysis and key informant interviews

BACKGROUND

With the implicit neglect for the integration of mental health services into general health service development in South Africa, there is an urgent need for an understanding of the ways in which existing reforms may be leveraged to incorporate the objectives of the National Mental Health Policy Framework and Strategic Plan (MHPF) and the mechanisms by which these reforms can be structured and financed in the context of fiscal constraint.

METHODS

A situational analysis guided by a newly developed analytical framework for sustainable mental health financing was conducted. The review was followed by qualitative, indepth interviews with a range of expert national stakeholders.

RESULTS

Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing include: increased decentralization of resources to primary and community mental health services; active integration of mental health into ongoing NHI implementation including expanding the mandate of District hospitals and drawing on the private sector; submission of costed budget bids to support a mental health conditional grant and ensuring that explicit outcomes and deliverables are in place to monitor Provincial implementation.

CONCLUSION

This paper has suggested several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, revealing critical opportunities for mental health service scale-up to be embedded in South Africa's future health delivery strategy. The realization of a conditional grant for mental health will require technical expertise to cost existing services towards the development of an investment case for mental health service scale-up nationally, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, the NHI benefit package must be expanded to include comprehensive mental health services at all levels. Explicit results-based financing mechanisms within the NHI Fund must also be incorporated for mental health to incentivise quality of care. Private providers engaged by the NHI must commit to make use of evidence-based mental health interventions.

The application of mindfulness for individuals living with HIV in South Africa: A hybrid effectiveness-implementation pilot study

Despite the recent growth of mindfulness research worldwide, there remains little research examining the application of mindfulness-based interventions in resource-limited, international settings. This study examined the application of Mindfulness Based Stress Reduction (MBSR) for HIV-infected individuals in South Africa, where rates of HIV are highest in the world. Mixed methods were used to examine the following over a three-month follow up: (1) feasibility, acceptability, and preliminary adaptation of MBSR for this new context; and (2) effects of MBSR on immune functioning, self-reported mindfulness (MAAS, FFMQ), depression, anxiety, and stress (DASS-21). Ten individuals initiated MBSR, and seven completed all eight sessions. Results indicated medium effect size improvements in immune functioning (CD4 count and t-cell count; d = .5) through the three-month follow up, though the small sample size limited power to detect a statistically significant effect. From baseline to post-treatment, improvements in "Observing" and "Non-reactivity" (FFMQ) approached statistical significance with large effect sizes (observing: d = 1.5; p = .08; non-reactivity: d = .7; p = .07). There were no statistically significant changes in depression, anxiety, or stress throughout the study period. Primary areas for adaptation of MBSR included emphasis on informal practice, ways to create "space" without much privacy, and ways to concretize the concepts and definitions of mindfulness. Feedback from participants can shape future adaptations to MBSR for this and similar populations. Findings provide preliminary evidence regarding the implementation of MBSR for individuals living with HIV in South Africa. A future randomized clinical trial with a larger sample size is warranted.

Global Mental Health: A Call for Increased Awareness and Action for Family Therapists

Global mental health (GMH) is an emerging field that focuses on the need for culturally sensitive mental health services in low- and middle-income countries (LMICs). While many new initiatives have been established worldwide to understand GMH needs and to provide care in LMICs, family therapists have primarily worked with families in high-income countries. The few existing family-based initiatives in GMH focus on psychoeducation and are typically not based on general systems theory. However, emerging trends in family therapy may enable family therapists to impact mental health issues in LMICs. These trends, which are shared interests of both family therapy and GMH, include collaborative care, a growing emphasis on the importance of culture in understanding and treating mental health issues, recognition of the ability of families to support or impede recovery from mental illness, and the use of strength-based and evidence-based treatments. This paper describes ways for family therapists to become active in the GMH community.

Building Resilience in Families, Communities, and Organizations: A Training Program in Global Mental Health and Psychosocial Support

This article describes the Summer Institute in Global Mental Health and Psychosocial Support, a brief immersion training program for mental health, health, and allied professionals who work with populations that have endured severe adversities and trauma, such as domestic and political violence, extreme poverty, armed conflict, epidemics, and natural disasters. The course taught participants to apply collaborative and contextually sensitive approaches to enhance social connectedness and resilience in families, communities, and organizations. This article presents core training principles and vignettes which illustrate how those engaging in such interventions must: (1) work in the context of a strong and supportive organization; (2) appreciate the complexity of the systems with which they are engaging; and (3) be open to the possibilities for healing and transformation. The program utilized a combination of didactic presentations, hands-on interactive exercises, case studies, and experiential approaches to organizational team building and staff stress management.

The Mental Health Education Gap among Primary Care Providers in Rural Nepal

OBJECTIVE

In low- and middle-income countries, the majority of individuals with mental illness go untreated largely because of a severe shortage of mental health professionals. Global initiatives to close the mental health treatment gap focus on primary care providers delivering this care. For this to be effective, primary care providers require the skills to assess, diagnose, and treat patients with mental illness.

METHODS

To assess primary care providers' training and experience in caring for mental health patients, the authors conducted five focus groups at three isolated district hospitals in rural Nepal where there was no access to mental health professionals.

RESULTS

Primary care providers reported limited training, lack of knowledge and skills, and discomfort in delivering mental health care.

CONCLUSION

To address the mental health education gap, primary care providers in Nepal, and perhaps other low- and middle-income countries, require more training during both undergraduate and graduate medical education.

Global Mental Health: concepts, conflicts and controversies

This paper introduces, describes and analyses the emerging concept of Global Mental Health (GMH). The birth of GMH can be traced to London, 2007, with the publication of a series of high-profile papers in The Lancet. Since then, GMH has developed into a movement with proponents, adherents, opponents, an ideology and core activities. The stated aims of the Movement for GMH are 'to improve services for people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income countries where effective services are often scarce'. GMH could be considered an attempt to right a historic wrong. During the colonial and post-colonial eras, the mental health of subject populations was accorded a very low priority. This was fuelled by scientific racism, which alleged that mental illness was uncommon in places such as Africa. As developing nations have made the epidemiological transition, the burden of mental illness has proportionately increased, with research suggesting a massive 'treatment gap' between those in need and those actually receiving formal mental health care. As such, much GMH research and action has been devoted to: (i) the identification and scale-up of cost-effective evidence-supported interventions that could be made more widely available; (ii) task-shifting of such intervention delivery to mental-health trained non-specialist Lay Health Workers. GMH has come under sustained critique. Critics suggest that GMH is colonial medicine come full circle, involving the top-down imposition of Western psychiatric models and solutions by Western-educated elites. These critiques suggest that GMH ignores the various indigenous modalities of healing present in non-Western cultures, which may be psychologically adaptive and curative. Relatedly, critics argue that GMH could be an unwitting Trojan horse for the mass medicalisation of people in developing countries, paving the way for exploitation by Big Pharma, while ignoring social determinants of health.