Effectiveness of combining prevention psychological interventions with interventions that address the social determinants of mental health in low and middle-income countries: protocol of a systematic review and meta-analysis.

INTRODUCTION: Common mental health conditions (CMHCs), including depression, anxiety and post-traumatic stress disorder (PTSD), are highly prevalent in low and middle-income countries (LMICs). Preventive strategies combining psychological interventions with interventions addressing the social determinants of mental health may represent a key strategy for effectively preventing CMHCs. However, no systematic reviews have evaluated the effectiveness of these combined intervention strategies for preventing CMHCs. METHODS AND ANALYSIS: This systematic review will include randomised controlled trials (RCTs) focused on the effectiveness of interventions that combine preventive psychological interventions with interventions that address the social determinants of mental health in LMICs. Primary outcome is the frequency of depression, anxiety or PTSD at postintervention as determined by a formal diagnostic tool or any other standardised criteria. We will search Epistemonikos, Cochrane Controlled Trials Register (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Global Index Medicus, ClinicalTrials.gov (Ctgov), International Clinical Trials Registry Platform (ICTRP). Two reviewers will independently extract the data and evaluate the risk of bias of included studies using the Cochrane risk of bias tool 2. Random-effects meta-analyses will be performed, and certainty of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: This study uses data from published studies; therefore, ethical review is not required. Findings will be presented in a published manuscript. TRIAL REGISTRATION NUMBER: CRD42023451072.

Strengthening self-regulation and reducing poverty to prevent adolescent depression and anxiety: Rationale, approach and methods of the ALIVE interdisciplinary research collaboration in Colombia, Nepal and South Africa.

AIMS: Depression and anxiety are the leading contributors to the global burden of disease among young people, accounting for over a third (34.8%) of years lived with disability. Yet there is limited evidence for interventions that prevent adolescent depression and anxiety in low- and middle-income countries (LMICs), where 90% of adolescents live. This article introduces the 'Improving Adolescent mentaL health by reducing the Impact of poVErty (ALIVE)' study, its conceptual framework, objectives, methods and expected outcomes. The aim of the ALIVE study is to develop and pilot-test an intervention that combines poverty reduction with strengthening self-regulation to prevent depression and anxiety among adolescents living in urban poverty in Colombia, Nepal and South Africa. METHODS: This aim will be achieved by addressing four objectives: (1) develop a conceptual framework that identifies the causal mechanisms linking poverty, self-regulation and depression and anxiety; (2) develop a multi-component selective prevention intervention targeting self-regulation and poverty among adolescents at high risk of developing depression or anxiety; (3) adapt and validate instruments to measure incidence of depression and anxiety, mediators and implementation parameters of the prevention intervention; and (4) undertake a four-arm pilot cluster randomised controlled trial to assess the feasibility, acceptability and cost of the selective prevention intervention in the three study sites. RESULTS: The contributions of this study include the active engagement and participation of adolescents in the research process; a focus on the causal mechanisms of the intervention; building an evidence base for prevention interventions in LMICs; and the use of an interdisciplinary approach. CONCLUSIONS: By developing and evaluating an intervention that addresses multidimensional poverty and self-regulation, ALIVE can make contributions to evidence on the integration of mental health into broader development policy and practice.

Potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people: A conceptual framework and lines of enquiry for research and policy.

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

Recommended updates to the USEPA Framework for Metals Risk Assessment: Aquatic ecosystems.

In 2007, the USEPA issued its "Framework for Metals Risk Assessment." The framework provides technical guidance to risk assessors and regulators when performing human health and environmental risk assessments of metals. This article focuses on advances in the science including assessing bioavailability in aquatic ecosystems, short- and long-term fate of metals in aquatic ecosystems, and advances in risk assessment of metals in sediments. Notable advances have occurred in the development of bioavailability models for assessing toxicity as a function of water chemistry in freshwater ecosystems. The biotic ligand model (BLM), the multiple linear regression model, and multimetal BLM now exist for most of the common mono- and divalent metals. Species sensitivity distributions for many metals exist, making it possible for many jurisdictions to develop or update their water quality criteria or guidelines. The understanding of the fate of metals in the environment has undergone significant scrutiny over the past 20 years. Transport and toxicity models have evolved including the Unit World Model allowing for estimation of concentrations of metals in various compartments as a function of loading and time. There has been significant focus on the transformation of metals in sediments into forms that are less bioavailable and on understanding conditions that result in resolubilization or redistribution of metals in and from sediments. Methods for spiking sediments have advanced such that the resulting chemistry in the laboratory mimics that in natural systems. Sediment bioavailability models are emerging including models that allow for prediction of toxicity in sediments for copper and nickel. Biodynamic models have been developed for several organisms and many metals. The models allow for estimates of transport of metals from sediments to organisms via their diet as well as their water exposure. All these advances expand the tool set available to risk assessors. Integr Environ Assess Manag 2023;00:1-28. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Validation of Nickel Bioavailability Models for Algae, Invertebrates, and Fish in Chinese Surface Waters.

Nickel (Ni) is used primarily in the production of alloys like stainless steel and is increasingly being used in the production of batteries for the electric vehicle market. Exposure of Ni to ecosystems is of concern because Ni can be toxic to aquatic organisms. The influence of water chemistry constituents (e.g., hardness, pH, dissolved organic carbon) on the toxicity of Ni has prompted the development and use of bioavailability models, such as biotic ligand models (BLMs), which have been demonstrated to accurately predict Ni toxicity in broadly different ecosystems, including Europe, North America, and Australia. China, a leading producer of Ni, is considering bioavailability-based approaches for regulating Ni emissions. Adoption of bioavailability-based approaches in China requires information to demonstrate the validity of bioavailability models for the local water chemistry conditions. The present study investigates the toxicity of Ni to three standard test species (Daphnia magna, Pseudokirchneriella subcapitata, and Danio rerio) in field-collected natural waters that are broadly representative of the range of water chemistries and bioavailabilities encountered in Chinese lakes and rivers. All experimental data are within a factor of 3 of the BLM predicted values for all tests with all species. For D. magna, six of seven waters were predicted within a factor of 2 of the experimental result. Comparison of experimental data against BLM predictions shows that the existing Ni bioavailability models are able to explain the differences in toxicity that result from water chemistry conditions in China. Validation of bioavailability models to water chemistries and bioavailability ranges within China provides technical support for the derivation of site-specific Ni water quality criteria in China. Environ Toxicol Chem 2023;42:1257-1265. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Updating the Chronic Freshwater Ecotoxicity Database and Biotic Ligand Model for Nickel for Regulatory Applications in Europe.

Bioavailability has been taken into account in the regulation of nickel in freshwater ecosystems in Europe for over a decade; during that time a significant amount of new information has become available covering both the sensitivity of aquatic organisms to nickel toxicity and bioavailability normalization. The ecotoxicity database for chronic nickel toxicity to freshwater organisms has been updated and now includes 358 individual data points covering a total of 53 different species, all of which are suitable for bioavailability normalization to different water chemistry conditions. The bioavailability normalization procedure has also been updated to include updates to the bioavailability models that enable more sensitive water chemistry conditions to be covered by the model predictions. The updated database and bioavailability normalization procedure are applicable to more than 95% of regulated European surface water conditions and have been used to calculate site-specific criteria for a variety of different water chemistry scenarios, to provide an indication of how the sensitivity to nickel varies between different water types. The hazardous concentration for 5% of a species (HC5) values for this diverse selection of water types range from 1.6 to 36 µg L-1 , clearly demonstrating the importance of accounting for nickel bioavailability in freshwaters. This updated database and bioavailability normalization procedure provide a robust basis for the derivation of regulatory thresholds for chronic nickel toxicity in freshwaters such as predicted no-effect concentrations and Environmental Quality Standards and are protective of the results of several mesocosm studies. Environ Toxicol Chem 2023;42:566-580. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Healthcare use and costs among individuals receiving mental health services for depression within primary care in Nepal.

BACKGROUND: Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources. METHODS: Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference. RESULTS: The study included 192 primary care service users (TG = 60, TG + P = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (- 11%, p = 0.51) among TG + P and lower (- 35%, p = 0.01) among UC compared to TG. Visits increased 2.30 times (p < 0.001) at 3 months among TG, with a 50% greater increase (p = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (- 1%, p = 0.97) and cost changes did not significantly differ at three (- 16%, p = 0.67) or 12 months (- 45%, p = 0.13). Costs among UC were 54% lower than TG at baseline (p = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare. CONCLUSION: Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

Assessing the Extent of Environmental Risks From Nickel in European Freshwaters: A Critical Reflection of the European Commission's Current Approach.

Nickel (Ni) has a been a Priority Substance under the European Water Framework Directive since 2008. As such it is deemed to present an European Union-wide risk to surface waters. Since 2013, the Ni Environmental Quality Standard (EQS) has been bioavailability-based, and new European Guidance supports accounting for bioavailability in assessing Ni compliance with the EQS. The European Commission has developed an approach to determine whether Priority Substances present a sufficient European Union-wide risk to justify an ongoing statutory monitoring programme, effectively to deselect a substance. This is a key step to ensure that finite monitoring resources are targeted at delivering environmental benefit, when there is an ever-growing burden of determinands to measure for all regulators. When the European Commission performed this exercise for Ni without accounting for bioavailability, they concluded that Ni should not be deselected, and Ni is an European Union-wide risk. Performing this same exercise with the same methodology, using regulatory monitoring data for over 300 000 samples, from more than 19 000 sites across Europe, and accounting for bioavailability, as detailed in the Directive, >99% of sites comply with the Ni EQS. Nickel shows very low risks for all of the criteria identified by the European Commission that need to be met for deselection. Accounting for bioavailability is key in the assessment of Ni risks in surface waters to deliver ecologically relevant outcomes. Environ Toxicol Chem 2022;41:1604-1612. © 2022 NiPERA. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Association of Task-Shared Psychological Interventions With Depression Outcomes in Low- and Middle-Income Countries: A Systematic Review and Individual Patient Data Meta-analysis.

Importance: Task sharing, the training of nonspecialist workers with no formal experience in counseling, is a promising strategy for addressing the large gap in treatment for depression in low- and middle-income countries (LMICs). Objective: To examine the outcomes and moderators of task-shared psychological interventions associated with depression severity, response, and remission. Data Sources: Systematic literature searches in PubMed, Embase, PsycINFO, and Cochrane Library up to January 1, 2021. Study Selection: Randomized clinical trials (RCTs) of task-shared psychological interventions compared with control conditions for adults with depressive symptoms in LMICs were included. Data Extraction and Synthesis: Two researchers independently reviewed the titles, abstracts, and full text of articles from an existing generic meta-analytic database that includes all RCTs on psychotherapy for depression. A systematic review and individual patient data (IPD) meta-analysis was used to estimate the outcomes of task-shared psychological interventions across patient characteristics using mixed-effects models. Procedures for abstracting data and assessing data quality and validity followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Main Outcomes and Measures: Primary outcome was reduction in depression symptom severity measured by the 9-item Patient Health Questionnaire (PHQ-9). Response and remission rates were also estimated. Results: Of 13 eligible trials, 11 (4145 participants) contributed IPD. Task-shared psychological interventions were associated with a greater decrease in depressive symptom severity than control conditions (Hedges g, 0.32; 95% CI, -0.26 to -0.38). Participants in the intervention groups had a higher chance of responding (odds ratio, 2.11; 95% CI, 1.60 to 2.80) and remitting (odds ratio, 1.87; 95% CI, 1.20 to 1.99). The presence of psychomotor symptoms was significantly associated with the outcomes of task-shared psychological interventions (ß [SE], -1.21 [0.39]; P = .002). No other significant associations were identified. Heterogeneity among the trials with IPD was 74% (95% CI, 53%-86%). Conclusions and Relevance: In this meta-analysis of IPD, task-shared psychological interventions were associated with a larger reduction in depressive symptom severity and a greater chance of response and remission than control conditions. These findings show potential for the use of task-sharing of psychological interventions across different groups of patients with depression. Further research would help identify which people are most likely to benefit and strengthen larger-scale implementation of this strategy to address the burden of depression in LMICs.

Variation in chronic nickel toxicity to Daphnia magna among Japanese river waters and performance evaluation of bioavailability models in predicting the toxicity.

Nickel (Ni) ecotoxicity is dictated by water chemistry characteristics such as pH, water hardness, and amount of dissolved organic carbon. Bioavailability models have been developed to predict Ni toxicity and validated for European, Australian, and US natural waters. In this study, chronic toxicity tests in Ni-spiked Japanese river waters were conducted on a strain of Daphnia magna to test whether the chronic toxicity differs among Japanese natural waters with different water chemistries. Based on the results of chronic Ni toxicity tests, we assessed the performance of existing D. magna bioavailability models, which were developed in artificial waters (Model 1) and calibrated in European natural waters (Model 2), in terms of the accuracy and the bias of model predictions. Furthermore, we also calibrated the two models by using toxicity test results to develop a bioavailability model for Ni chronic toxicity to the strain of D. magna in Japanese river waters. The 10%, 20%, and 50% effect concentrations (EC10, EC20, and EC50) of dissolved Ni on reproduction of the D. magna strain were within ranges from 8.1 to 44.9 µg/L, 9.0 to 57.1 µg/L, and 10.9 to 86.1 µg/L, respectively. Results indicate that differences in water chemistry among Japanese river waters influenced chronic Ni toxicity to the model organism. Model 1predicted 43% of the observed EC10, EC20, and EC50 values within a factor of 2 and 100%, 100%, and 43% within a factor of 3, respectively. Model 2 predicted 14%, 14%, and 29% of the observed EC10, EC20, and EC50 values within a factor of 2 and 43% within a factor of 3. The values of model bias based on the geometric mean of ratios of EC10, EC20 and EC50 values predicted by each of the two models and observed EC10, EC20, and EC50 values were 0.71, 0.65, and 0.62 for Model 1 and 0.27, 0.26, and 0.29 for Model 2, respectively. After calibrating two models using the results of toxicity tests, refined Model 1 predicted 71%, 57%, and 57% of observed EC10, EC20, and EC50 values within a factor of 2 and 100%, 86%, and 100% within a factor of 3; refined Model 2 predicted 71% of observed EC10, EC20, and EC50 values within a factor 2 and 100%, 86%, and 86% within a factor of 3, respectively. Our results indicate that calibrating the Ni bioavailability models in Japanese natural waters increased their predictive capacity by a factor of up to approximately five.

The relationship between multidimensional poverty, income poverty and youth depressive symptoms: cross-sectional evidence from Mexico, South Africa and Colombia.

Whereas monetary poverty is associated with increased risk of depressive symptoms in young people, poverty is increasingly understood as a multidimensional problem. However, it is yet to be understood how the associations between different dimensions of poverty and youth mental health differ across countries. We examine the relationship between multidimensional, as well as income poverty, and depressive symptoms in young people (age 11-25 years) across three middle-income countries. Based on harmonised data from surveys in Colombia, Mexico and South Africa (N=16 173) we constructed a multidimensional poverty index that comprised five deprivations We used Poisson regression to examine relationships between different forms of poverty with depressive symptoms across the countries. Multidimensional poverty was associated with higher rates of depressive symptoms in the harmonised dataset (IRR (incidence rate ratio)=1.25, 95% CI 1.10 to 1.42), in Mexico (IRR=1.34, 95% CI 1.11 to 1.64) and Colombia (IRR=2.01, 95% CI 1.30 to 3.10) but not in South Africa, a finding driven by a lack of associations between child labour and health insurance coverage with depressive symptoms. There was only an association with income poverty and depressive symptoms in South Africa, not in Colombia or Mexico. Depressive symptoms were associated with individual deprivations such as school lag, child labour and lack of access to health services in the harmonised dataset, but not with household deprivations, such as parental unemployment and housing conditions, though the opposite pattern was observed in South Africa. Our findings suggest that the importance of specific dimensions of poverty for mental health varies across countries, and a multidimensional approach is needed to gain insights into the relationship between youth depression and poverty.

Communication about Sexual Consent and Refusal: A Learning Tool and Qualitative Study of Adolescents' Comments on a Sexual Health Website.

Sexual communication skills are needed to create healthy romantic relationships. Arguably, these skills also can be used to prevent some instances of unwanted sex. This study presents a qualitative analysis of adolescents' comments after reading a teen-friendly article on sexual consent as part of a web-based sexual health promotion intervention. The sample was comprised predominantly of female adolescents recruited from a Midwest urban region in the United States. Adolescents varied with respect to self-efficacy to request, provide, and deny consent, as well as the perceived need to ask for consent in the context of established relationships. Many adolescents perceived that nonverbal methods of communication were sufficient to request, provide, or deny sexual consent. Factors that make it difficult to discuss sexual boundaries and say "no" to unwanted sex included low self-efficacy and an underlying desire to nurture or preserve a relationship. Cultural norms must be changed to support verbal, affirmative sexual consent. In addition, adolescents must be aided in the development of skills to request sexual consent, say "yes" to specific activities, and say "no" to others. Without supportive norms and skills to enhance self-efficacy, adolescents may be unwilling to engage in verbal communication about sexual consent and boundaries.

Costs of common perinatal mental health problems in South Africa.

Background: Perinatal mental health problems, defined as mental health problems occurring from the start of pregnancy to one year after birth, substantially affect women's and children's quality of life in low- and middle-income countries. In South Africa, despite high prevalence and documented negative impacts, most women do not receive any care. Methods: A modelling study examined the costs of perinatal mental health problems, namely depression and anxiety, for a hypothetical cohort of women and their children in South Africa over part of their life course (10 years for women, 40 years for children). In sensitivity analysis, additional impacts of post-traumatic stress disorder (PTSD) and completed suicide were included. Data sources were published findings from cohort studies, as well as epidemiological and economic data from South Africa. Data from international studies were considered where no data from South Africa were available. Results: Lifetime costs of perinatal depression and anxiety in South Africa amount to USD 2.8 billion per annual cohort of births. If the impacts of PTSD and suicide are included, costs increase to USD 2.9 billion. This includes costs linked to losses in quality of life (USD 1.8 billion), losses in income (USD 1.1 billion) and public sector costs (USD 3.5 million). Conclusions: Whilst important progress has been made in South Africa with regards to mental health policies and interventions that include assessment and management of perinatal mental health problems, substantial underinvestment prevents progress. Findings from this study strengthen the economic case for investing in perinatal mental health care.

Conditional cash transfers and adolescent mental health in Brazil: Evidence from the 2004 Pelotas Birth Cohort.

BACKGROUND: Young people living in poverty are at higher risk of mental disorders, but whether interventions aimed to reduce poverty have lasting effects on mental health has not been well established. We examined whether exposure to Brazil's conditional cash transfers programme (CCT), Bolsa Família (BFP), during childhood reduces the risk of mental health problems in early adolescence. METHODS: We used data from 2063 participants in the 2004 Pelotas Birth Cohort study. Propensity score matching (PSM) estimated the association between BFP participation at age 6 and externalising problems (Strengths and Difficulties Questionnaire - SDQ and violent behaviour) and socio-emotional competencies (Development and Well-Being Assessment questionnaire, and the Nowick-Strickland Internal-External Scale) at age 11. RESULTS: PSM results suggest that programme participation at age of six was not significantly associated with externalising problems (P = 0.433), prosocial behaviour (P = 0.654), violent behaviour (P = 0.342), social aptitudes (P = 0.281), positive attributes (P = 0.439), or locus of control (P = 0.148) at the age of 11 years. CONCLUSIONS: Participation in BFP during childhood was not associated with improved or worsened mental health in early adolescence. While we cannot fully discard that findings may be due to adverse selection, results suggest that CCTs alone may not be sufficient to improve mental health outcomes and would be prudent to assess whether mental health interventions as an addition to CCTs may be helpful.

Environmental risk of nickel in aquatic Arctic ecosystems.

The Arctic faces many environmental challenges, including the continued exploitation of its mineral resources such as nickel (Ni). The responsible development of Ni mining in the Arctic requires establishing a risk assessment framework that accounts for the specificities of this unique region. We set out to conduct preliminary assessments of Ni exposure and effects in aquatic Arctic ecosystems. Our analysis of Ni source and transport processes in the Arctic suggests that fresh, estuarine, coastal, and marine waters are potential Ni-receiving environments, with both pelagic and benthic communities being at risk of exposure. Environmental concentrations of Ni show that sites with elevated Ni concentrations are located near Ni mining operations in freshwater environments, but there is a lack of data for coastal and estuarine environments near such operations. Nickel bioavailability in Arctic freshwaters seems to be mainly driven by dissolved organic carbon (DOC) concentrations with bioavailability being the highest in the High Arctic, where DOC levels are the lowest. However, this assessment is based on bioavailability models developed from non-Arctic species. At present, the lack of chronic Ni toxicity data on Arctic species constitutes the greatest hurdle toward the development of Ni quality standards in this region. Although there are some indications that polar organisms may not be more sensitive to contaminants than non-Arctic species, biological adaptations necessary for life in polar environments may have led to differences in species sensitivities, and this must be addressed in risk assessment frameworks. Finally, Ni polar risk assessment is further complicated by climate change, which affects the Arctic at a faster rate than the rest of the world. Herein we discuss the source, fate, and toxicity of Ni in Arctic aquatic environments, and discuss how climate change effects (e.g., permafrost thawing, increased precipitation, and warming) will influence risk assessments of Ni in the Arctic.

Group problem solving therapy for perinatal depression in primary health care settings in rural Uganda: an intervention cohort study.

BACKGROUND: Perinatal depression is of substantial public health importance in low and middle income countries. The study aimed to evaluate the impact of a mental health intervention delivered by non-specialist health workers on symptom severity and disability in women with perinatal depression in Uganda. METHODS: Pregnant women in the second and third trimester were consecutively screened using the Luganda version of the 9-item Patient Health Questionnaire (PHQ-9). Women who scored ≥5 on the PHQ-9 and who were confirmed to have depression by a midwife were recruited into a treatment cohort and offered a psychological intervention in a stepped care fashion. Women were assessed with PHQ-9 and WHODAS-2.0 at baseline and again at 3 and 6 months after the intervention. Negative regression analysis was done to examine change in PHQ-9 and WHODAS-2.0 scores from baseline to end line. Data were analysed using STATA version 14. RESULTS: A total of 2652 pregnant women (98.3%) consented to participate in the study and 153 (5.8%) were diagnosed as depressed. Over a quarter (28.8%) reported having experienced physical interpersonal violence (IPV) while (25.5%) reported sexual IPV in the past year. A third (34.7%) of women diagnosed with depression received 4 or more group PST sessions. There was a mean reduction in PHQ-9 score of 5.13 (95%CI - 6.79 to - 3.47, p < 0.001) and 7.13 (95%CI - 8.68 to - 5.59, p < 0.001) at midline and endline, respectively. WHODAS scores reduced significantly by - 11.78 points (CI 17.64 to - 5.92, p < 0.001) at midline and - 22.92 points (CI 17.64 to - 5.92, p < 0.001) at endline. Clinical response was noted among 69.1% (95%CI 60.4-76.6%) and 93.7% (95%CI 87.8-96.8%) of respondents at midline and endline, respectively. CONCLUSION: An evidence based psychological intervention implemented in primary antenatal care by trained and supervised midwives in a real-world setting may lead to improved outcomes for women with perinatal depression. Future randomised studies are needed to confirm the efficacy of this intervention and possibility for scale up.

Examining the dynamics between young people's mental health, poverty and life chances in six low- and middle-income countries: protocol for the CHANCES-6 study.

PURPOSE: Poverty and poor mental health are closely related and may need to be addressed together to improve the life chances of young people. There is currently little evidence about the impact of poverty-reduction interventions, such as cash transfer programmes, on improved youth mental health and life chances. The aim of the study (CHANCES-6) is to understand the impact and mechanisms of such programmes. METHODS: CHANCES-6 will employ a combination of quantitative, qualitative and economic analyses. Secondary analyses of longitudinal datasets will be conducted in six low- and middle-income countries (Brazil, Colombia, Liberia, Malawi, Mexico and South Africa) to examine the impact of cash transfer programmes on mental health, and the mechanisms leading to improved life chances for young people living in poverty. Qualitative interviews and focus groups (conducted among a subset of three countries) will explore the views and experiences of young people, families and professionals with regard to poverty, mental health, life chances, and cash transfer programmes. Decision-analytic modelling will examine the potential economic case and return-on-investment from programmes. We will involve stakeholders and young people to increase the relevance of findings to national policies and practice. RESULTS: Knowledge will be generated on the potential role of cash transfer programmes in breaking the cycle between poor mental health and poverty for young people, to improve their life chances. CONCLUSION: CHANCES-6 seeks to inform decisions regarding the future design and the merits of investing in poverty-reduction interventions alongside investments into the mental health of young people.