Prevalence of psychological distress among parents of children with intellectual disabilities in Malawi.

BACKGROUND: Children with intellectual disabilities are common and are increasing in number as more children survive globally. In stark contrast to the 1-3% prevalence of intellectual disability in children globally (reported by WHO), studies from Malawi provide alarmingly high rates (26%). We know that the prevalence of psychological distress is as high as 50% in parents of children with intellectual disabilities in Europe and the US. No such studies have yet been conducted in Africa. This study is aimed at determining the prevalence and risk factors for psychological distress among parents of intellectually disabled children in Malawi. METHODS: This quantitative cross-sectional study was conducted in January and February 2015. One hundred and seventy mothers and fathers of children with intellectual disabilities as diagnosed by psychiatric clinical officers were randomly sampled from two selected child disability clinics. The Self-Reporting Questionnaire (SRQ) was used "as measure for psychological distress and questions on socio-demographic variables were administered to all consenting participants." Data was coded, cleaned and analyzed using STATA. RESULTS: 70/170 (41.2%) of parents of children with intellectual disabilities reported psychological distress. Univariate and multivariate analysis showed that area of residence (P < 0.05), low socio-economic status (P < 0.05), knowledge of the disability of one's child (P < 0.05), low confidence in managing the disabled child (P < 0.05), increased perceived burden of care (P = 0.05), and having no sources for psychological support (P < 0.05) significantly predicted psychological distress among the parents for children with disabilities. CONCLUSION: There is huge burden of psychological distress among parents of intellectually disabled children in Malawi. Psychosocial interventions are urgently needed to support parents of children with intellectual disability in Malawi.

Developmental outcomes in Malawian children with retinopathy-positive cerebral malaria.

OBJECTIVE: To assess children with retinopathy-positive cerebral malaria (CM) for neurocognitive sequelae. METHODS: Participants were selected from an ongoing exposure-control study. Eighty-three Malawian children averaging 4.4 years of age and diagnosed with retinopathy-positive CM were compared to 95 controls. Each child was classified as delayed or not using age-based norms for the Malawi Developmental Assessment Tool (MDAT) for developmental delay on the total scale and for the domains of gross motor, fine motor, language and social skills. Groups were also compared on the Achenbach Child Behaviour Checklist (CBCL) (1.5-5 years). RESULTS: Children with retinopathy-positive CM were delayed, relative to the comparison group, on MDAT total development (P = 0.028; odds ratio or OR = 2.13), with the greatest effects on language development (P = 0.003; OR = 4.93). The two groups did not differ significantly on the Achenbach CBCL internalizing and externalizing symptoms total scores. Stepwise regression demonstrated that coma duration, seizures while in hospital, platelet count and lactate level on admission were predictive of assessment outcomes for the children with retinopathy-positive CM. CONCLUSIONS: Children who suffer retinopathy-positive CM at preschool age are at greater risk of developmental delay, particularly with respect to language development. This confirms previous retrospective study findings with school-age children evaluated years after acute illness. The MDAT and the Achenbach CBCL proved sensitive to clinical indicators of severity of malarial illness.

Common mental disorder and associated factors amongst women with young infants in rural Malawi.

BACKGROUND: Common mental disorder (CMD) affecting women during the childbearing years is an important health problem in low and middle income countries. This study investigates CMD and associated factors amongst women with young infants in rural Malawi. METHODS: In this cross-sectional study, mothers of infants due for measles vaccination were recruited from a district hospital child health clinic. Maternal CMD was measured using a Chichewa version of the Self-Reporting Questionnaire (SRQ). DSM-IV diagnoses of major and minor depressive disorder were made using the structured clinical interview for DSM-IV (SCID). Socio-demographic, maternal and infant variables were measured and associations with CMD were determined. RESULTS: Of 519 eligible women, 501 were included in the analysis. Mean age was 24.4 years and median infant age was 9.9 months. The weighted prevalence of any current depressive episode (minor or major) was 30.4% (95% CI 22.8-38.1%). The weighted prevalence of current major depressive episode was 13.9% (95% CI 8.2-19.5%). Mean SRQ score for the total sample was 5.71 (SD 4.42). On multivariate analysis, SRQ score was significantly associated with lower socioeconomic status, lack of a confiding relationship with partner or relative, and recent infant illness. Amongst the women who knew their HIV status (n = 314), SRQ score was also associated with HIV infection. CONCLUSIONS: This study demonstrates that CMD is a significant health burden among women with infants in rural Malawi, and is associated with poverty, relationship difficulties, HIV infection and infant health problems.

Review of the forensic psychiatry service at Zomba Mental Hospital and a comparison of forensic psychiatry services in Malawi and Scotland.

This retrospective case-note study describes the demographic details, offences and diagnostic characteristics of 283 patients admitted to Zomba Mental Hospital, Malawi, after early diversion from the Criminal Justice System between May 1997 and February 2007. Given the historical links between Malawi and Scotland and the ongoing involvement of Scottish psychiatrists in the development of psychiatry in Malawi, a comparison is drawn between the provision of secure psychiatric treatment in these low- and high-income countries. Consistent with Scottish prison mental health team referrals and Scottish high secure psychiatric patients, the Malawian patients were predominantly men, poorly educated and drug misusing, but alcohol was less often a problem. Affective disorders were rarely diagnosed, as is also the case in the equivalent Scottish populations. In Malawi, there appears to be a problem with aftercare because many of the patients had been detained before. The length of detention was very short, other than an exceptional finding for substance misuse--a mental disorder with no Mental Health Act equivalence in the UK. Absconding was the commonest outcome. Malawian patients diverted from the Criminal Justice System are treated on general adult psychiatry wards where few secure measures can be offered. Further, there is little capacity for follow-up, no community compulsion legislation exists and psychiatric expertise is limited to a few disparate sites. However, the service is developing and the data in this study represent a small part of that ongoing programme.

Validation of a Chichewa version of the self-reporting questionnaire (SRQ) as a brief screening measure for maternal depressive disorder in Malawi, Africa.

BACKGROUND: Depressive disorder affecting women during the perinatal period is common in low-income countries. The detection and study of maternal depression in a resource-poor setting requires a brief screening tool that is both accurate and practical to administer. METHOD: A Chichewa version of the Self Reporting Questionnaire (SRQ) was developed through a rigorous process of forward and back translation, focus-group discussion and piloting. Criterion validation was conducted as part of a larger study in a sample of women who had brought their infants to a child health clinic in rural Malawi, using DSM-IV major and minor depressive episode as the gold standard diagnoses. RESULTS: The criterion validation was conducted on 114 subjects who did not differ on health and sociodemographic characteristics from the total study sample (n=501). Test characteristics for each possible SRQ cut-off were calculated and Receiver Operator Characteristic (ROC) curves derived. Area under the ROC curve (AUROC) for detection of current major depressive disorder was 0.856 (95% CI 0.813 to 0.900), and for current major or minor depressive disorder was 0.826 (95% CI 0.783 to 0.869). Internal consistency of the SRQ was high (Cronbach's alpha 0.85). LIMITATION: Inter-rater reliability testing was not conducted. CONCLUSION: This Chichewa version of the SRQ shows utility as a brief screening measure for detection of probable maternal depression in rural Malawi.

Development of a psycho-social intervention for reducing psychological distress among parents of children with intellectual disabilities in Malawi.

BACKGROUND: The burden of intellectual disabilities in low and middle income countries (LMIC) is high and is associated with parental psychological distress. There are few services for children and parents in most developing countries and few interventions have been created that target the psychological issues among parents of such children. This study aimed to develop a contextualized intervention to provide psychological support for parents of children with intellectual disabilities in an African setting. METHODS: Six steps were adopted from the Medical Research Council framework for designing complex interventions. This include: literature review of similar interventions and models, qualitative studies to gain insights of lived experiences of parents of such children, a consensus process with an expert panel of professionals working with children with disabilities and piloting and pre-testing the draft intervention for its acceptability and practicability in this settings. RESULTS: 21 intervention modules were found from a systematic search of the literature which were listed for possible use in our intervention along with four themes from our qualitative studies. An expert panel formed consensus on the eight most pertinent and relevant modules for our setting. This formed the intervention; "Titukulane." This intervention was piloted and found to have high acceptability and practicability when contextualized in the field. CONCLUSION: The use of a systematic framework for designing a complex intervention for supporting the mental health of parents of children with disabilities enables good acceptability and practicability for future use in low resource settings.

Assessment of an undergraduate psychiatry course in an African setting.

BACKGROUND: International reports recommend the improvement in the amount and quality of training for mental health workers in low and middle income countries. The Scotland-Malawi Mental Health Education Project (SMMHEP) has been established to support the teaching of psychiatry to medical students in the University of Malawi. While anecdotally supportive medical educational initiatives appear of value, little quantitative evidence exists to demonstrate whether such initiatives can deliver comparable educational standards. This study aimed to assess the effectiveness of an undergraduate psychiatry course given by UK psychiatrists in Malawi by studying University of Malawi and Edinburgh University medical students' performance on an MCQ examination paper. METHODS: An undergraduate psychiatry course followed by an MCQ exam was delivered by the SMMHEP to 57 Malawi medical students. This same MCQ exam was given to 71 Edinburgh University medical students who subsequently sat their own Edinburgh University examination. RESULTS: There were no significant differences between Edinburgh students' performance on the Malawi exam and their own Edinburgh University exam. (p = 0.65). This would suggest that the Malawi exam is a comparable standard to the Edinburgh exam. Malawi students marks ranged from 52.4%-84.6%. Importantly 84.4% of Malawi students scored above 60% on their exam which would equate to a hypothetical pass by UK university standards. CONCLUSION: The support of an undergraduate course in an African setting by high income country specialists can attain a high percentage pass rate by UK standards. Although didactic teaching has been surpassed by more novel educational methods, in resource poor countries it remains an effective and cost effective method of gaining an important educational standard.

Maternal common mental disorder and infant growth--a cross-sectional study from Malawi.

The objective of the study was to investigate the association between maternal common mental disorder (CMD) and infant growth in rural Malawi. A cross-sectional study was conducted at a district hospital child health clinic. Participants were consecutive infants due for measles vaccination, and their mothers. Mean infant weight-for-age and length-for-age z-scores were compared between infants of mothers with and without CMD as measured using the self-reporting questionnaire (SRQ). Of 519 eligible infants/mothers, 501 were included in the analysis. Median infant age was 9.9 months. 29.9% of mothers scored 8 or above on the SRQ indicating CMD. Mean length-for-age z-score for infants of mothers with CMD (-1.50 SD 1.24) was significantly lower than for infants of mothers without CMD (-1.11 SD 1.12) Student's t-test: P = 0.001. This association was confirmed in multivariate analysis. Mean weight-for-age z-score for infants of mothers with CMD (-1.77 SD 1.16) was lower than for infants of mothers without CMD (-1.59 SD 1.09) but this difference was not significant on univariate (Student's t-test: P = 0.097) or multivariate analysis. The study demonstrates an association between maternal CMD and infant growth impairment in rural sub-Saharan Africa.

The effect of depression management on diabetes and hypertension outcomes in low- and middle-income countries: a systematic review protocol.

BACKGROUND: Depression and non-communicable diseases (NCDs) account for a growing burden on health systems in low- and middle-income countries (LMICs). Depression is generally associated with the outcomes of NCDs and is an important barrier to consistent NCD care management. There is great need to understand the efficacy of interventions to treat depression for people with NCDs, but there is a paucity of evidence of the efficacy of the interventions in LMICs. Therefore, the broad objective of this review is to systematically review the literature on the effectiveness of depression management among patients with diabetes and hypertension to improve outcomes. METHODS: This is a systematic review to assess the evidence of the effect of depression management in diabetic and hypertensive patients on diabetes and hypertension outcomes in LMICs. Two independent reviewers will search articles on PubMed, EMBASE, PsycINFO, and Global Index Medicus. Two reviewers will then screen the articles independently based on predefined criteria. We will use standard methods as recommended by the Cochrane Collaboration of assessing quality of evidence and publish our report using the PRISMA guidelines. DISCUSSION: The findings from this review will provide evidence to be used in guiding practice and policy on how to integrate depression management in diabetes and hypertension clinics. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017068257.

Study protocol for evaluating the effectiveness of depression management on gylcaemic control in non-communicable diseases clinics in Malawi.

INTRODUCTION: Depression is associated with negative patient outcomes for chronic diseases and likely affects consistent physical non-communicable diseases (NCDs) care management in relation to clinic attendance and medication adherence. We found no published studies on the integration of depression management in physical NCD clinics in Malawi and assessing its effects on patient and service outcomes. Therefore, the aim of this study is to evaluate the effectiveness of integrating depression screening and management in physical NCD routine care on patient and service outcomes in Malawi. We will also determine the sensitivity and specificity of the Patient Health Questionnaire-9 (PHQ-9) in the detection of depression in NCD clinics. METHODS AND ANALYSIS: The study will have two phases. Phase I will involve the validation of the PHQ-9 screening tool for depression, using a cross-sectional study design involving 323 participants, in two specialised physical NCD clinics in one of the 28 districts of Malawi. Using a quasi-experimental study design in four districts of Malawi not involved in the phase I study, the phase II study will evaluate the effectiveness of integrating depression screening (using PHQ-9) and management (based on a specially designed toolkit). Outcomes will be measured at 3 months and 6 months among patients with comorbid diabetes (poorly controlled) and depression attending physical NCD clinics in Malawi. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee (COMREC) on 31 August 2017 (reference P.07/17/2218). The findings will be disseminated through presentations at journal clubs, senior management of the Ministry of Health, national and international conferences as well as submission to peer-reviewed publications. Policy briefs will also be created. TRIAL REGISTRATION NUMBER: PACTR201807135104799.

Prevalence and correlates of probable depression diagnosis and suicidal ideation among patients receiving HIV care in Lilongwe, Malawi.

BACKGROUND: Depression and suicide ideation among people living with HIV (PLHIV) can threaten the success of HIV care and treatment programs, particularly within high HIV prevalence settings. We describe the prevalence and correlates associated with depression and suicidal ideation among PLHIV receiving HIV care in Lilongwe, Malawi. METHODS: From July to September 2013, 206 HIV clinic patients, who were ≥18 years of age and either pre-antiretroviral therapy (ART) or established on ART for ≥6 months prior to study, participated in a survey to assess the prevalence of a likely depressive disorder and suicidal ideation using the Patient Health Questionnaire-9. We explored factors associated with depression using bivariable linear regression and suicidal ideation using bivariable log-binomial regression. RESULTS: The prevalence of a likely depressive disorder and suicidal ideation was 12% (95% CI: 8%, 17%) and 16% (95% CI: 11%, 21%), respectively. Pre-ART patients (ß=1.17, 95% CI: 0.03, 2.30, p-value=0.04) and those with problematic alcohol use (ß=0.49, 95% CI: 0.07, 0.92, p-value=0.02) were associated with a higher depression severity. Suicidal ideation was relatively common (8%, 95% CI: 5%, 13%) among those without a likely depressive disorder and significantly correlated with having no primary, secondary, or tertiary education (ß=-1.52, 95% CI: -2.46, -0.59, p-value<0.01). CONCLUSIONS: Interventions that enhance identification and management of depressive disorders and suicidal ideation should be integrated within HIV care clinics in Malawi.

Pathway to care for psychiatric patients in a developing country: Malawi.

BACKGROUND: Paramedics dominate primary health care in Malawi where native healers also play a major role in the provision of health care and psychiatric nurses are the backbone of district mental health services. AIM: The aim is to improve understanding of prior care-seeking and treatment of new patients seen at mental health services in a developing country like Malawi. METHOD: For one calendar month, 128 newly referred patients to the mental health services in the three psychiatric units in Malawi were interviewed using an encounter form. RESULTS: Most of the patients went through a first carer before attending a psychiatric unit with only 11.7% going straight to a psychiatric unit. All patients who went straight to a psychiatric unit involved the private/Christian Health Association of Malawi (CHAM) unit in the northern region of Malawi. About 22.7% of the patients had a native healer as a first carer. Only 23% of all patients seen went through a second carer, with none going through a third carer. Over 8% of those who had a paramedic as their first carer had a native healer as their second carer. Duration of stay at different carers varied a lot with about half (48.2%) of all patients who saw a native healer as the first carer spending more than 2 weeks before referral while about 67.0% of those who saw convectional health workers spent 3 days or less before referral. CONCLUSION: The pathway to care for patients with psychological problems in Malawi is not very much different to pathways to care in other developing countries whereby native healers and paramedics play a significant role. With the high proportion of patients being seen by native healers and the fact that most patients stay longer at native healers before referral, there is need for official collaboration and training of native healers on mental health.

Integrating community mental health within primary care in southern Malawi: a pilot educational intervention to enhance the role of health surveillance assistants.

BACKGROUND: In response to the significant contribution of mental health problems to the global burden of disease, the World Health Organization (WHO, 2008) renewed its call for the integration of mental health services within primary care. The operationalization of this within resource-constrained settings such as rural Malawi, however, presents a challenge, not least the cultural acceptance of approaches to responding to psychological distress. AIM: This study reports on the development, implementation and evaluation of a mental health care training programme for 271 health surveillance assistants (HSAs) designed to overcome such challenges. METHOD: A structured evaluation of the impact of training on HSAs' provision of mental health care was undertaken. RESULTS: Result's demonstrated a statistically significant positive effect on HSAs' knowledge and confidence in providing care and analysis of patient records revealed considerable mental health care and health promotion activity wherein HSAs initiated a new dialogue with the community on mental health and human rights concerns. CONCLUSION: The HSAs' focus on the psychosocial concerns of individuals' 'distress' and 'risk' prepared the way for a practical set of culturally sensitive and therapeutic interventions and offers a potential path towards increasing the capacity of primary care mental health provision that is responsive to local understandings and experiences of distress.

Health service utilization by patients with common mental disorder identified by the Self-Reporting Questionnaire in a primary care setting in Zomba, Malawi: a descriptive study.

BACKGROUND: There has been no study carried out to assess health service utilization by people with common mental disorder (CMD) in Malawi. AIM: The aim of the study was to evaluate health service utilization patterns of patients with CMD in primary health care (PHC) clinics. METHODS: The study was conducted in two PHC clinics in one of the 28 districts in Malawi. Face-to-face interviews with the Self-Reporting Questionnaire (SRQ-20) were conducted in a sample of 323 PHC attendees aged 18 years and older who attended the PHC clinics for any reason. RESULTS: The prevalence of probable CMD in the sample was 20.1%. People with probable CMD had a higher mean number of health facility visits in the previous three months compared to those without probable CMD (1.6 vs 1.19, p = .02). CONCLUSION: The study reveals high utilization of health services for people with CMD in the PHC setting. There is a need for PHC workers to improve skills in diagnosing patients with CMD to make PHC services more effective by reducing re-attendance and improving patient outcomes.

Short structured general mental health in service training programme in Kenya improves patient health and social outcomes but not detection of mental health problems - a pragmatic cluster randomised controlled trial.

TRIAL DESIGN: A pragmatic cluster randomised controlled trial. PARTICIPANTS: Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over. INTERVENTIONS: Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers. OBJECTIVE: To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes. OUTCOMES: The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment. RESULTS: Numbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively. OUTCOME: At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis). HARMS: None identified. CONCLUSION: The training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register ISRCTN53515024.

Increasing the capacity of health surveillance assistants in community mental health care in a developing country, Malawi.

Mental health services in Malawi are centralized in the three tertiary units which are located one in each of the three regions of Malawi and this means that most people with mental health problems do not get help. With severe shortages of mental health professionals in the country, integration of mental health into existing primary and community health services is the most feasible way of increasing access to services for people with mental health problems. This paper discusses a pilot program of integrating mental health in the activities of Health Surveillance Assistants (HSAs) who are community health workers in Malawi.

Mental health and the development agenda in Sub-Saharan Africa.

This article synthesizes the views of participants in two roundtables that were convened in Nairobi (March 2007) and London (July 2008) to identify key challenges to the prioritization of mental health in Africa and possible solutions. Participants included leading development experts and policy makers from head and country offices of international donors, national directors of mental health for several African countries, key mental health and public health professionals, epidemiologists, and an international nongovernmental organization. The challenges they identified to mainstreaming mental health include lack of understanding of the contribution of mental disorders to morbidity and mortality, competition for limited resources within health reform efforts, poor distribution of interventions and lack of inclusion of mental health among core generic health indicators, lack of economic research evidence, lack of a strategic approach to human resources planning, lack of partnerships with the social development sector, and mental health professionals' need for public health skills to effectively conduct national advocacy. Potential solutions include further investment in economic research, better strategic identification of the levers and entry points for integrating mental health into health sector reform plans, more vigorous engagement of mental health professionals in general health sector reforms, strengthening the linkage between mental health and social development, and intensive resource mobilization. In summary, partnerships, underpinned by collaborative training, research, and mutual dialogue with other health and nonhealth sectors, are needed.

Management of mental health services in Malawi.

Malawi is a country in sub-Saharan Africa bordering Mozambique, Tanzania and Zambia. It has an area of approximately 118 000 km2 and is divided into northern, central and southern regions. It has an estimated population of 13 million, 47% of whom are under 15 years of age and just 5% over 60 years. Its economy is largely based on agriculture, with tobacco being the main export. The projected growth in gross domestic product (GDP) for 2007 was 8.8%; GDP per capita was $284 per annum.

The practice of electroconvulsive therapy in Malawi.

OBJECTIVES: To describe the practice of electroconvulsive therapy (ECT), including indications, efficacy, and side effects, in patients treated with unmodified ECT at Zomba Mental Hospital (ZMH) in Malawi. METHODS: A naturalistic, descriptive cohort study that includes all patients receiving ECT in March and April 2006. Efficacy of ECT treatment was assessed with the "Clinical Global Impression" of change scale, and side effects and complications were systematically assessed with a checklist. RESULTS: The circumstances and procedure of ECT at ZMH are described. Forty-seven patients underwent unmodified ECT for various affective and psychotic disorders. Depending on the indication, improvement was reported in 71% to 90%. Cognitive side effects (confusion and amnesia), muscle aches, headache, and lesions of the oral cavity were the most prevalent side effects. Serious complications were not encountered. CONCLUSIONS: Unmodified ECT in Malawi is an effective treatment with less severe side effects than commonly thought. Efforts to improve treatment standards are undertaken.

Malawi.

Malawi is a country with an approximate area of 118 000 km2. Its population is estimated at 13 million and the gender ratio (men per hundred women) is 98. The proportion of the population under the age of 15 years is 47% and the proportion above the age of 60 years is 5%. The literacy rate is 75.5% for men and 48.7% for women (World Health Organization, 2005).