Mental health-related structural stigma and discrimination in health and social policies in Nepal: A scoping review and synthesis.

AIMS: National policies can be used to reveal structural stigma and discrimination in relation to mental health. This review assesses how structural stigma and discrimination are manifested in the policies and legislations of Government of Nepal. METHODS: Scoping review methodology was followed to review policy documents (acts of parliament, legislation, policies, strategies, guidelines and official directives) drafted or amended after 2010. RESULTS: Eighty-nine policies were identified related to health, social welfare, development and regulations which were relevant to people with psychosocial and mental disabilities or have addressed the mental health agendas. Several critical policy failings and gaps are revealed, such as the use of stigmatizing language (e.g., 'insane' or 'lunatic'), inconsistencies within and between policies, deviation from international protocols defining legal capacity and consent, lack of inclusion of the mental health agenda in larger development policies and lack of cost-effective interventions and identification of financing mechanisms. Provisions for people living with mental health conditions included adequate standard of living; attaining standard mental health; the right to exercise legal capacity, liberty and security; freedom from torture or discrimination; and right to live independently. However, other policies contradicted these rights, such as prohibiting marriage, candidacy for and retention of positions of authority and vulnerability to imprisonment. CONCLUSION: Mental health-related structural stigma and discrimination in Nepal can be identified through the use of discriminator language and provisions in the policies. The structural stigma and discrimination may be addressed through revision of the discriminating policies, integrating the mental health agenda into larger national and provincial policies, and streamlining policies to comply with national and international protocols.

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

AIMS: The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon. METHODS: In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely. RESULTS: CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F(1, 22) = 6.49, p < 0.018) and on the GroupACT (Mann-Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours. CONCLUSIONS: This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.

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

BACKGROUND: There is a scarcity of evaluated tools to assess whether non-specialist providers achieve minimum levels of competency to effectively and safely deliver psychological interventions in low- and middle-income countries. The objective of this study was to evaluate the reliability and utility of the newly developed Working with children - Assessment of Competencies Tool (WeACT) to assess service providers' competencies in Gaza, Palestine. METHODS: The study evaluated; (1) psychometric properties of the WeACT based on observed role-plays by trainers/supervisors (N = 8); (2) sensitivity to change among service provider competencies (N = 25) using pre-and-post training WeACT scores on standardized role-plays; (3) in-service competencies among experienced service providers (N = 64) using standardized role-plays. RESULTS: We demonstrated moderate interrater reliability [intraclass correlation coefficient, single measures, ICC = 0.68 (95% CI 0.48-0.86)] after practice, with high internal consistency (α = 0.94). WeACT assessments provided clinically relevant information on achieved levels of competencies (55% of the competencies were scored as adequate pre-training; 71% post-training; 62% in-service). Pre-post training assessment saw significant improvement in competencies (W = -3.64; p < 0.001). CONCLUSION: This study demonstrated positive results on the reliability and utility of the WeACT, with sufficient inter-rater agreement, excellent internal consistency, sensitivity to assess change, and providing insight needs for remedial training. The WeACT holds promise as a tool for monitoring quality of care when implementing evidence-based care at scale.

Perception of healthcare workers on mobile app-based clinical guideline for the detection and treatment of mental health problems in primary care: a qualitative study in Nepal.

BACKGROUND: In recent years, a significant change has taken place in the health care delivery systems due to the availability of smartphones and mobile software applications. The use of mobile technology can help to reduce a number of barriers for mental health care such as providers' workload, lack of qualified personnel, geographical and attitudinal barriers to seek treatment. This study assessed the perception of Nepali primary healthcare workers about the feasibility, acceptability, and benefits of using a mobile app-based clinical guideline for mental health care. METHOD: A qualitative study was conducted in two districts Chitwan and Ramechhap of Nepal with purposively selected medical officers (n = 8) and prescribing primary healthcare workers (n = 35) who were trained in the World Health Organization mental health Gap Action Program Intervention Guide. Semi-structured interviews and focus group discussions were conducted in Nepali, audio recorded, transcribed and translated into English for data analysis. Data were analysed manually using a thematic analysis approach. RESULTS: The majority of the healthcare workers and medical officers reported a high level of interest, motivation and positive attitudes towards the mobile app-based clinical guidelines for detection and treatment of people with mental disorders in primary care. They respondents suggested that several features and functions should be included in the app: suggestive diagnosis and treatment options; clinical data recording system; sending messages to patients to promote follow-up visits; allow offline functions; minimal typing options and content to be available in Nepali language. The study participants reported that the app could help in bringing uniformity in diagnosis and management of mental disorders across all health facilities, enabling remote supervision, helping verification of health workers' diagnosis and treatment; and increasing patients' trust in the treatment. Lack of reliable internet connection in health facilities, possibility of distracting interaction between patient and provider, and confidentiality were the key factors potentially hindering the use of the app. CONCLUSION: The suggested functions and features as well as the potential risk factors highlighted by the health workers, will be considered when further developing the mobile app-based clinical guidelines, training modality and materials, and the supervision system.

Impact of integrated district level mental health care on clinical and functioning outcomes of people with depression and alcohol use disorder in Nepal: a non-randomised controlled study.

BACKGROUND: Integration of mental health services into primary healthcare is proliferating in low-resource countries. We aimed to evaluate the impact of different compositions of primary care mental health services for depression and alcohol use disorder (AUD), when compared to usual primary care services. METHODS: We conducted a non-randomized controlled study in rural Nepal. We compared treatment outcomes among patients screening positive and receiving: (a) primary care mental health services without a psychological treatment component (TG); (b) the same services including a psychological treatment (TG + P); and (c) primary care treatment as usual (TAU). Primary outcomes included change in depression and AUD symptoms, as well as disability. Disability was measured using the 12-item WHO Disability Assessment Schedule. Symptom severity was assessed using the 9-item Patient Health Questionnaire for depression, the 10-item Alcohol Use Disorders Identification Test for AUD. We used negative binomial regression models for the analysis. RESULTS: For depression, when combining both treatment groups (TG, n = 77 and TG + P, n = 60) compared to TAU (n = 72), there were no significant improvements. When only comparing the psychological treatment group (TG + P) with TAU, there were significant improvements for symptoms and disability (aß = - 2.64; 95%CI - 4.55 to - 0.74, p = 0.007; aß = - 12.20; 95%CI - 19.79 to - 4.62; p = 0.002, respectively). For AUD, when combining both treatment groups (TG, n = 92 and TG + P, n = 80) compared to TAU (n = 57), there were significant improvements in AUD symptoms and disability (aß = - 15.13; 95%CI - 18.63 to - 11.63, p < 0.001; aß = - 9.26; 95%CI - 16.41 to - 2.12, p = 0.011; respectively). For AUD, there were no differences between TG and TG + P. Patients' perceptions of health workers' skills in common psychological factors were associated with improvement in depression patient outcomes (ß = - 0.36; 95%CI - 0.55 to - 0.18; p < 0.001) but not for AUD patients. CONCLUSION: Primary care mental health services for depression may only be effective when psychological treatments are included. Health workers' competencies as perceived by patients may be an important indicator for treatment effect. AUD treatment in primary care appears to be beneficial even without additional psychological services.

Feasibility of Group Problem Management Plus (PM+) to improve mental health and functioning of adults in earthquake-affected communities in Nepal.

AIMS: Psychological interventions that are brief, acceptable, effective and can be delivered by non-specialists are especially necessary in low- and middle-income countries, where mental health systems are unable to address the high level of psychosocial needs. Problem Management Plus (PM+) is a five-session intervention designed for those impaired by psychological distress while living in communities affected by adversity. Individual PM+ has demonstrated effectiveness in reducing distress in Kenya and Pakistan, and a group version of PM+ (Group PM+) was effective for conflict-affected women in Pakistan. This paper describes a feasibility and acceptability trial of locally adapted Group PM+ for women and men in an earthquake-affected region of rural Nepal. METHODS: In this feasibility cluster randomised controlled trial, participants in the experimental arm were offered five sessions of Group PM+ and participants in the control arm received enhanced usual care (EUC), which entailed brief psycho-education and providing referral options to primary care services with health workers trained in the mental health Gap Action Programme Intervention Guide (mhGAP-IG). A mixed-methods design was used to assess the feasibility and acceptability of Group PM+. Feasibility was assessed with criteria including fidelity and retention of participants. Acceptability was assessed through in-depth interviews with participants, family members, programme staff and other stakeholders. The primary clinical outcome was depression symptoms assessed using the Patient Health Questionnaire (PHQ-9) administered at baseline and 8-8.5 weeks post-baseline (i.e. after completion of Group PM+ or EUC). RESULTS: We recruited 121 participants (83% women and 17% men), with equal allocation to the Group PM+ and EUC arms (1:1). Group PM+ was delivered over five 2.5-3 hour sessions by trained and supervised gender-matched local non-specialists, with an average attendance of four out of five sessions. The quantitative and qualitative results demonstrated feasibility and acceptability for non-specialists to deliver Group PM+. Though the study was not powered to assess for effectiveness, for all five key outcome measures, including the primary clinical outcome, the estimated mean improvement was larger in the Group PM+ arm than the EUC arm. CONCLUSION: The intervention and trial procedures were acceptable to participants, family members, and programme staff. The communities and participants found the intervention to be beneficial. Because feasibility and acceptability were established in this trial, a fully powered randomised controlled trial will be conducted for larger scale implementation to determine the effectiveness of the intervention in Nepal.

Adapting culturally appropriate mental health screening tools for use among conflict-affected and other vulnerable adolescents in Nigeria.

BACKGROUND: The Boko Haram insurgency has brought turmoil and instability to Nigeria, generating a large number of internally displaced people and adding to the country's 17.5 million orphans and vulnerable children. Recently, steps have been taken to improve the mental healthcare infrastructure in Nigeria, including revamping national policies and initiating training of primary care providers in mental healthcare. In order for these efforts to succeed, they require means for community-based detection and linkage to care. A major gap preventing such efforts is the shortage of culturally appropriate, valid screening tools for identifying emotional and behavioral disorders among adolescents. In particular, studies have not conducted simultaneous validation of screening tools in multiple languages, to support screening and detection efforts in linguistically diverse populations. We aim to culturally adapt screening tools for emotional and behavioral disorders for use among adolescents in Nigeria, in order to facilitate future validation studies. METHODS: We used a rigorous mixed-method process to culturally adapt the Depression Self Rating Scale, Child PTSD Symptom Scale, and Disruptive Behavior Disorders Rating Scale. We employed expert translations, focus group discussions (N = 24), and piloting with cognitive interviewing (N = 24) to achieve semantic, content, technical, and criterion equivalence of screening tool items. RESULTS: We identified and adapted items that were conceptually difficult for adolescents to understand, conceptually non-equivalent across languages, considered unacceptable to discuss, or stigmatizing. Findings regarding problematic items largely align with existing literature regarding cross-cultural adaptation. CONCLUSIONS: Culturally adapting screening tools represents a vital first step toward improving community case detection.

Reducing mental health-related stigma among medical and nursing students in low- and middle-income countries: a systematic review.

AIMS: This systematic review compiled evidence on interventions to reduce mental health-related stigma among medical and nursing students in low- and middle-income countries (LMICs). Primary outcomes were stigmatising attitudes and discriminatory behaviours. METHODS: Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, professional students in medicine and nursing, and LMICs. A qualitative analysis of all included full texts was done with the software MAXQDA. Full texts were analysed with regard to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a methodological quality assessment was undertaken. RESULTS: A total of nine studies from six countries (Brazil, China, Malaysia, Nigeria, Somaliland and Turkey) were included. All studies reported significant results in at least one outcome measure. However, from the available literature, it is difficult to draw conclusions on the most effective interventions. No meta-analysis could be calculated due to the large heterogeneity of intervention content, evaluation design and outcome measures. Studies with contact interventions (either face-to-face or video) demonstrated attitudinal change. There was a clear lack of studies focusing on discriminatory behaviours. Accordingly, training of specific communication and clinical skills was lacking in most studies, with the exception of one study that showed a positive effect of training interview skills on attitudes. Methods for cultural adaptation of interventions were rarely documented. The methodological quality of most studies was relatively low, with the exception of two studies. CONCLUSIONS: There is an increase in studies on anti-stigma interventions among professional students in LMICs. Some of these studies used contact interventions and showed positive effects. A stronger focus on clinical and communication skills and behaviour-related outcomes is needed in future studies.

Reducing mental health-related stigma in primary health care settings in low- and middle-income countries: a systematic review.

AIMS: This systematic review compiled evidence on interventions to reduce mental health-related stigma in primary health care (PHC) in low- and middle-income countries (LMICs). Studies targeting PHC staff (including non-professionals) were included. Primary outcomes were stigmatising attitudes and discriminatory behaviours. METHODS: Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, PHC staff and LMICs. A qualitative analysis of all included full-texts was done with software MAXQDA. Full-texts were analysed with regards to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a risk of bias assessment was undertaken. RESULTS: A total of 18 studies were included. Risk of bias was rated as high in most included studies. Only six studies had tested their intervention against a control condition, two of which had used random allocation. Most frequently used interventions were lectures providing theoretical information. Many studies also used interactive methods (N = 9), discussed case studies (N = 8) or used role plays (N = 5). Three studies reported that they had used clinical practice and supervision. Results of these studies were mixed. No or little effects were found for brief training interventions (e.g. 1 h to 1 day). Longer training interventions with more sophisticated didactic methods produced statistically significant changes in validated stigma questionnaires. These results have to be interpreted with caution due to risk of bias. Methods for cultural adaptation of interventions were rarely documented. CONCLUSIONS: More rigorous trials are needed in LMICs to test interventions that target discriminatory behaviours in relationship with patients. Cultural adaptation of stigma interventions and structural/institutional factors should be more explicitly addressed in such trials.

Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: findings from a representative cluster sample survey.

AIMS: Two large earthquakes in 2015 caused widespread destruction in Nepal. This study aimed to examine frequency of common mental health and psychosocial problems and their correlates following the earthquakes. METHODS: A stratified multi-stage cluster sampling design was employed to randomly select 513 participants (aged 16 and above) from three earthquake-affected districts in Nepal: Kathmandu, Gorkha and Sindhupalchowk, 4 months after the second earthquake. Outcomes were selected based on qualitative preparatory research and included symptoms of depression and anxiety (Hopkins Symptom Checklist-25); post-traumatic stress disorder (PTSD Checklist-Civilian); hazardous alcohol use (AUDIT-C); symptoms indicating severe psychological distress (WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS)); suicidal ideation (Composite International Diagnostic Interview); perceived needs (Humanitarian Emergency Settings Perceived Needs Scale (HESPER)); and functional impairment (locally developed scale). RESULTS: A substantial percentage of participants scored above validated cut-off scores for depression (34.3%, 95% CI 28.4-40.4) and anxiety (33.8%, 95% CI 27.6-40.6). Hazardous alcohol use was reported by 20.4% (95% CI 17.1-24.3) and 10.9% (95% CI 8.8-13.5) reported suicidal ideation. Forty-two percent reported that 'distress' was a serious problem in their community. Anger that was out of control (symptom from the WASSS) was reported by 33.7% (95% CI 29.5-38.2). Fewer people had elevated rates of PTSD symptoms above a validated cut-off score (5.2%, 95% CI 3.9-6.8), and levels of functional impairment were also relatively low. Correlates of elevated symptom scores were female gender, lower caste and greater number of perceived needs. Residing in Gorkha and Sindhupalchowk districts and lower caste were also associated with greater perceived needs. Higher levels of impaired functioning were associated with greater odds of depression and anxiety symptoms; impaired functioning was less strongly associated with PTSD symptoms. CONCLUSIONS: Four months after the earthquakes in Nepal, one out of three adults experienced symptoms of depression and distressing levels of anger, one out of five engaged in hazardous drinking, and one out of ten had suicidal thoughts. However, posttraumatic stress symptoms and functional impairment were comparatively less frequent. Taken together, the findings suggest that there were significant levels of psychological distress but likely low levels of disorder. The findings highlight the importance of indicated prevention strategies to reduce the risk of distress progressing to disorder within post-disaster mental health systems of care.

Evaluation of outcomes for psychosis and epilepsy treatment delivered by primary health care workers in Nepal: a cohort study.

BACKGROUND: Most evaluations of task-shifting have focused on common mental disorders. Much less work has been done on severe mental neurological and substance use (MNS) disorders, such as chronic psychosis and epilepsy. Given the high burden associated with severe MNS and the lack of mental health professionals in low and middle income countries, evaluations on the impact of task-shifting for these disorders are important. METHODS: In a rural district of Nepal, a community mental health program, based on World Health Organization's Mental Health Gap Action Programme guidelines, was evaluated using a cohort study design. People with epilepsy and psychotic disorders were interviewed at treatment initiation and at 12-month follow-up. We also compared a group that was offered a comprehensive package of care (medication combined with psychosocial interventions, such as counselling and peer support groups) to a group that received medication only. RESULTS: One-hundred nineteen persons were enrolled in the epilepsy cohort (EC) and 85 in the psychosis cohort (PC). The patients were enrolled in either the comprehensive package (n = 157) or medication only (n = 47). There was significant improvement (P < 0.0001) in psychosis symptoms (PC: Z = 6.78, r = 0.80) and depressive symptoms (EC: Z = 7.43, r = 0.73; PC: Z = 6.02, r = 0.70), seizures (EC: Z = 6.78), functional disability (EC: Z = 6.38, r = 0.67; PC: Z = 4.60, r = 0.57), family and caregiver burden (EC: Z = 8.09, r = 0.85; PC: Z = 6.81, r = 0.84), and social behaviour (PC: Z = 5.94, r = 0.84). There was greater risk reduction for recent seizures among people with epilepsy in the comprehensive treatment package vs. medication only (risk ratio = 0.52, 95% CI 0.29-0.95; P = 0.03); no other significant differences were observed between treatment arms. CONCLUSIONS: A community mental health program in Nepal, implemented by non-specialists, resulted in moderate to large effects among people with epilepsy or psychosis. A comprehensive package of care, including counselling and patient support groups, appears to offer added clinical benefits for patients with epilepsy. For people with psychosis, the basic package of care (i.e., psychotropic medications) performed similar to the comprehensive package, suggesting a less resource-intensive package may offer comparable results.

How is depression experienced around the world? A systematic review of qualitative literature.

To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fisher's exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.

Alternative approaches for studying humanitarian interventions: propensity score methods to evaluate reintegration packages impact on depression, PTSD, and function impairment among child soldiers in Nepal.

BACKGROUND: Ethical, logistical, and funding approaches preclude conducting randomized control trials (RCTs) in some humanitarian crises. A lack of RCTs and other intervention research has contributed to a limited evidence-base for mental health and psychosocial support (MHPS) programs after disasters, war, and disease outbreaks. Propensity score methods (PSMs) are an alternative analysis technique with potential application for evaluating MHPS programs in humanitarian emergencies. METHODS: PSMs were used to evaluate impacts of education reintegration packages (ERPs) and other (vocational or economic) reintegration packages (ORPs) v. no reintegration programs on mental health of child soldiers. Propensity scores were used to determine weighting of child soldiers in each of the three treatment arms. Multiple linear regression was used to estimate adjusted changes in symptom score severity on culturally validated measures of depression, post-traumatic stress disorder (PTSD), and functional impairment from baseline to 1-year follow-up. RESULTS: Among 258 Nepali child soldiers participating in reintegration programs, 54.7% completed ERP and 22.9% completed ORP. There was a non-significant reduction in depression by 0.59 (95% CI -1.97 to 0.70) for ERP and by 0.60 (95% CI -2.16 to 0.96) for ORP compared with no treatment. There were non-significant increases in PTSD (1.15, 95% CI -1.55 to 3.86) and functional impairment (0.91, 95% CI -0.31 to 2.14) associated with ERP and similar findings for ORP (PTSD: 0.66, 95% CI -2.24 to 3.57; functional impairment (1.05, 95% CI -0.71 to 2.80). CONCLUSION: In a humanitarian crisis in which a non-randomized intervention assignment protocol was employed, the statistical technique of PSMs addressed differences in covariate distribution between child soldiers who received different integration packages. Our analysis did not demonstrate significant changes in psychosocial outcomes for ERPs and ORPs. We suggest the use of PSMs in evaluating non-randomized interventions in humanitarian crises when non-randomized conditions are not utilized.