Peer support for frequent users of inpatient mental health care in Uganda: protocol of a quasi-experimental study.

BACKGROUND: Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated. METHODS: This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral. DISCUSSION: To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.

Community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis.

BACKGROUND: There is consensus that the treatment of schizophrenia should combine anti-psychotic medication and psychosocial interventions in order to address complex social, economic and health needs. It is recommended that family therapy or support; community-based rehabilitation; and/or self-help and support groups should be provided for people with schizophrenia in low and middle-income countries. The effectiveness of community-based psychosocial interventions in these settings is unclear. METHODS: Studies evaluating community-based psychosocial interventions for people with schizophrenia were identified through database searching up to April 2016. Randomised controlled trials were included if they compared the intervention group with a control group receiving treatment as usual including medication. Only studies set in low and middle-income countries were included. Random effects meta-analyses were performed separately for each intervention type. RESULTS: Eleven randomised controlled trials in five middle-income countries were identified, with a total of 1580 participants. The content of included interventions varied from single-faceted psychoeducational interventions, to multi-component rehabilitation-focused interventions, to case management interventions. A third of the included studies did not incorporate any community involvement in the intervention. The quality of evidence was often low. Amongst the seven studies that reported on symptom severity up to 18 months post intervention, the pooled standardised mean difference (SMD) across all intervention types was 0.95 (95% CI 0.28, 1.61; P 0.005; I 2 = 95%; n = 862), representing a strong effect. A strong effect on symptom severity remained after excluding two studies with a high risk of bias (SMD 0.80; 95% CI 0.07, 1.53; P 0.03; I 2 = 94%; n = 676). Community-based psychosocial interventions may also have beneficial impacts on functioning (SMD 1.12; 95% CI 0.25, 2.00; P 0.01; I 2 = 94%; n = 511) and reducing hospital readmissions (SMD 0.68; 95% CI 0.27, 1.09; P 0.001; I2 = 33%; n = 167). CONCLUSION: The limited evidence from low and middle-income countries supports the feasibility and effectiveness of community-based psychosocial interventions for schizophrenia, even in the absence of community mobilisation. Community-based psychosocial interventions should therefore be provided in these settings as an adjuvant service in addition to facility-based care for people with schizophrenia.

Planning and evaluating mental health services in low- and middle-income countries using theory of change.

BACKGROUND: There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings. AIMS: To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME). METHOD: ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13-22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members. RESULTS: One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts. CONCLUSIONS: ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.

Evaluation of district mental healthcare plans: the PRIME consortium methodology.

BACKGROUND: Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings. AIMS: To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda. METHOD: Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change. RESULTS: The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation. CONCLUSIONS: To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.

Maternal obesity and Caesarean delivery in sub-Saharan Africa.

OBJECTIVES: To quantify maternal obesity as a risk factor for Caesarean delivery in sub-Saharan Africa. METHODS: Multivariable logistic regression analysis using 31 nationally representative cross-sectional data sets from the Demographic and Health Surveys (DHS). RESULTS: Maternal obesity was a risk factor for Caesarean delivery in sub-Saharan Africa; a clear dose-response relationship (where the magnitude of the association increased with increasing BMI) was observable. Compared to women of optimal weight, overweight women (BMI 25-29 kg/m(2) ) were significantly more likely to deliver by Caesarean (OR: 1.54; 95% CI: 1.33, 1.78), as were obese women (30-34.9 kg/m(2) (OR: 2.39; 95%CI: 1.96-2.90); 35-39.9 kg/m(2) (OR: 2.47 95%CI: 1.78-3.43)) and morbidly obese women (BMI ≥40 kg/m(2) OR: 3.85; 95% CI: 2.46-6.00). CONCLUSIONS: BMI is projected to rise substantially in sub-Saharan Africa over the next few decades and demand for Caesarean sections already exceeds available capacity. Overweight women should be advised to lose weight prior to pregnancy. Furthermore, culturally appropriate prevention strategies to discourage further population-level rises in BMI need to be designed and implemented.

Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis.

PURPOSE: To evaluate the effectiveness of peer-delivered interventions in improving clinical and psychosocial outcomes among individuals with severe mental illness (SMI) or depression. METHODS: Systematic review and meta-analysis of randomised controlled trials comparing a peer-delivered intervention to treatment as usual or treatment delivered by a health professional. Random effect meta-analyses were performed separately for SMI and depression interventions. RESULTS: Fourteen studies (10 SMI studies, 4 depression studies), all from high-income countries, met the inclusion criteria. For SMI, evidence from three high-quality superiority trials showed small positive effects favouring peer-delivered interventions for quality of life (SMD 0.24, 95 % CI 0.08-0.40, p = 0.003, I (2) = 0 %, n = 639) and hope (SMD 0.24, 95 % CI 0.02-0.46, p = 0.03, I (2) = 65 %, n = 967). Results of two SMI equivalence trials indicated that peers may be equivalent to health professionals in improving clinical symptoms (SMD -0.14, 95 % CI -0.57 to 0.29, p = 0.51, I (2) = 0 %, n = 84) and quality of life (SMD -0.11, 95 % CI -0.42 to 0.20, p = 0.56, I (2) = 0 %, n = 164). No effect of peer-delivered interventions for depression was observed on any outcome. CONCLUSIONS: The limited evidence base suggests that peers may have a small additional impact on patient's outcomes, in comparison to standard psychiatric care in high-income settings. Future research should explore the use and applicability of peer-delivered interventions in resource poor settings where standard care is likely to be of lower quality and coverage. The positive findings of equivalence trials demand further research in this area to consolidate the relative value of peer-delivered vs. professional-delivered interventions.

Effect of maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets.

BACKGROUND: Rates of obesity are increasing worldwide, including in sub-Saharan Africa. Neonates born to obese mothers in low-income settings are at increased risk of complications including admission to neonatal intensive care, macrosomia, low Apgar scores, and perinatal death. We investigated whether maternal obesity is a risk factor for neonatal death in sub-Saharan Africa and the effect on the detailed timing of death within the neonatal period. METHODS: Cross-sectional Demographic and Health Surveys from 27 sub-Saharan countries (2003-09) were pooled. We used multivariable logistic regression to assess the risk of neonatal death (in women's most recent singleton livebirth in the 5 years preceding the survey) by maternal body-mass index (BMI) category (measured during the survey). Timing of death was investigated with a discrete-time survival model. FINDINGS: 15,518 of 81,126 eligible women were overweight (4266 were obese), 52,006 had an optimum BMI, and 13,602 were underweight. Maternal obesity was associated with an increased odds of neonatal death after adjustment for confounding factors (adjusted odds ratio 1·46, 95% CI 1·11-1·91). Maternal obesity was a significant risk factor for neonatal deaths occurring during the first 2 days of life (1·62, 1·11-2·37). We noted no statistically significant relation later in the neonatal period (days 2-6 1·36, 0·84-2·21; days 7-27 1·19, 0·65-2·18), possibly because of low statistical power. INTERPRETATION: Maternal obesity in sub-Saharan Africa is associated with increased risk of early neonatal death. Potential mechanisms include prematurity, intrapartum events, or infections. Strategies to prevent and reduce obesity need to be considered; obese women should be advised to deliver in a health-care facility that can provide emergency obstetric and neonatal care. FUNDING: Economic and Social Research Council.

Effect of psychosocial interventions on social functioning in depression and schizophrenia: meta-analysis.

BACKGROUND: Psychosocial interventions may contribute to reducing the burden of mental disorders in low- and middle-income (LAMI) countries by improving social functioning, but the evidence has not been systematically reviewed. AIMS: Systematic review and meta-analysis of the effect of psychosocial interventions on social functioning in people with depression and schizophrenia in LAMI countries. METHOD: Studies were identified through database searching up to March 2011. Randomised controlled trials were included if they compared the intervention group with a control group receiving placebo or treatment as usual. Random effects meta-analyses were performed separately for depressive disorders and schizophrenia and for each intervention type. RESULTS: Of the studies that met the inclusion criteria (n = 24), 21 had sufficient data to include in the meta-analysis. Eleven depression trials showed good evidence for a moderate positive effect of psychosocial interventions on social functioning (standardised mean difference (SMD) = 0.46, 95% CI 0.24-0.69, n = 4009) and ten schizophrenia trials showed a large positive effect on social functioning (SMD = 0.84, 95% CI 0.49-1.19, n = 1671), although seven of these trials were of low quality. Excluding these did not substantially affect the size or direction of effect, although the precision of the estimate was substantially reduced (SMD = 0.89, 95% CI 0.05-1.72, n = 863). CONCLUSIONS: Psychosocial interventions delivered in out-patient and primary care settings are effective at improving social functioning in people with depression and should be incorporated into efforts to scale up services. For schizophrenia there is an absence of evidence from high-quality trials and the generalisabilty of the findings is limited by the over-representation of trials conducted in populations of hospital patients in China. More high-quality trials of psychosocial interventions for schizophrenia delivered in out-patient settings are needed.

Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial.

BACKGROUND: Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders. METHODS: In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407. FINDINGS: 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide. INTERPRETATION: A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities. FUNDING: The Wellcome Trust.

Social capital and mental health: a comparative analysis of four low income countries.

Women and the poor are disproportionately affected by common mental disorders (CMD), and women in low income countries are particularly at risk. Social capital may explain some of the geographical variation in CMD, but the association between social capital and CMD in low income countries has rarely been studied. This paper aims to explore the relationship between individual and ecological measures of social capital and maternal CMD in four low income countries. Cross-sectional data from the Young Lives (YL) study with information across 234 communities in Peru, Ethiopia, Vietnam and Andhra Pradesh (India) were used. The mental health of mothers of one-year-old children (n=6909), and the individual cognitive and structural social capital of all respondents was assessed. Ecological social capital was calculated by aggregating individual responses to the community level. Multi-level modelling was used to explore the association between individual and ecological (community level) social capital and maternal CMD in each of the four countries, adjusting for a wide range of individual and community level confounders. The analysis shows that individual cognitive social capital is associated with reduced odds of CMD across all four countries. The results for structural social capital are more mixed and culturally specific, with some aspects associated with increased odds of CMD. This suggests that structural social capital has context-specific effects and cognitive social capital more universal effects on maternal CMD.

Maternal social capital and child nutritional status in four developing countries.

Social capital has been shown to be positively associated with a range of health outcomes, yet no studies have explored the association between maternal social capital and child nutritional status. Using data from the Young Lives study comprising 7242 1-year-old children from Peru, Ethiopia, Vietnam and the state of Andhra Pradesh in India, we find significant differences in the levels of, in particular, structural social capital (group membership and citizenship) between countries. While few associations were found between structural measures of social capital, support from individuals and cognitive social capital (e.g. trust, social harmony) displayed fairly consistent positive associations with child nutritional status across countries.

Maternal social capital and child health in Vietnam.

STUDY OBJECTIVE: To explore the association between maternal social capital and child physical and mental health in Vietnam. DESIGN: Cross sectional survey. Measures of maternal structural social capital comprised group membership, citizenship, and social support. Measures of cognitive social capital comprised trust, social harmony, sense of fairness, and belonging. Child health was measured by anthropometrics and mothers' reports of acute and chronic physical health problems and child mental health. PARTICIPANTS: 2907 mothers and their 1 year old or 8 year old children from five provinces in Vietnam. MAIN RESULTS: The study found low levels of group membership and citizenship and high levels of cognitive social capital and support, and generally higher levels of social capital among the mothers of 8 year old compared with 1 year old children. All but one association was in the hypothesised direction (that is, higher levels of social capital associated with reduced risk of child health problems). There were more statistically significant relations between maternal social capital and the health of 1 year olds compared with 8 year old children, and between measures of social support and cognitive social capital and child health, than with group membership and involvement in citizenship activities. CONCLUSION: This study is the first to explore the association between multiple dimensions of social capital and a range of different child health outcomes in the developing world. These results now need to be tested using longitudinal data.

Psychometric and cognitive validation of a social capital measurement tool in Peru and Vietnam.

Social capital is a relatively new concept which has attracted significant attention in recent years. No consensus has yet been reached on how to measure social capital, resulting in a large number of different tools available. While psychometric validation methods such as factor analysis have been used by a few studies to assess the internal validity of some tools, these techniques rely on data already collected by the tool and are therefore not capable of eliciting what the questions are actually measuring. The Young Lives (YL) study includes quantitative measures of caregiver's social capital in four countries (Vietnam, Peru, Ethiopia, and India) using a short version of the Adapted Social Capital Assessment Tool (SASCAT). A range of different psychometric methods including factor analysis were used to evaluate the construct validity of SASCAT in Peru and Vietnam. In addition, qualitative cognitive interviews with 20 respondents from Peru and 24 respondents from Vietnam were conducted to explore what each question is actually measuring. We argue that psychometric validation techniques alone are not sufficient to adequately validate multi-faceted social capital tools for use in different cultural settings. Psychometric techniques show SASCAT to be a valid tool reflecting known constructs and displaying postulated links with other variables. However, results from the cognitive interviews present a more mixed picture with some questions being appropriately interpreted by respondents, and others displaying significant differences between what the researchers intended them to measure and what they actually do. Using evidence from a range of methods of assessing validity has enabled the modification of an existing instrument into a valid and low cost tool designed to measure social capital within larger surveys in Peru and Vietnam, with the potential for use in other developing countries following local piloting and cultural adaptation of the tool.

Validated Screening Tools for Common Mental Disorders in Low and Middle Income Countries: A Systematic Review.

BACKGROUND: A wide range of screening tools are available to detect common mental disorders (CMDs), but few have been specifically developed for populations in low and middle income countries (LMIC). Cross-cultural application of a screening tool requires that its validity be assessed against a gold standard diagnostic interview. Validation studies of brief CMD screening tools have been conducted in several LMIC, but until now there has been no review of screening tools for all CMDs across all LMIC populations. METHODS: A systematic review with broad inclusion criteria was conducted, producing a comprehensive summary of brief CMD screening tools validated for use in LMIC populations. For each validation, the diagnostic odds ratio (DOR) was calculated as an easily comparable measure of screening tool validity. Average DOR results weighted by sample size were calculated for each screening tool, enabling us to make broad recommendations about best performing screening tools. RESULTS: 153 studies fulfilled our inclusion criteria. Because many studies validated two or more screening tools, this corresponded to 273 separate validations against gold standard diagnostic criteria. We found that the validity of every screening tool tested in multiple settings and populations varied between studies, highlighting the importance of local validation. Many of the best performing tools were purposely developed for a specific population; however, as these tools have only been validated in one study, it is not possible to draw broader conclusions about their applicability in other contexts. CONCLUSIONS: Of the tools that have been validated in multiple settings, the authors broadly recommend using the SRQ-20 to screen for general CMDs, the GHQ-12 for CMDs in populations with physical illness, the HADS-D for depressive disorders, the PHQ-9 for depressive disorders in populations with good literacy levels, the EPDS for perinatal depressive disorders, and the HADS-A for anxiety disorders. We recommend that, wherever possible, a chosen screening tool should be validated against a gold standard diagnostic assessment in the specific context in which it will be employed.

Treatment Contact Coverage for Probable Depressive and Probable Alcohol Use Disorders in Four Low- and Middle-Income Country Districts: The PRIME Cross-Sectional Community Surveys.

CONTEXT: A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. OBJECTIVE: To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. METHODS: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. SETTING: Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda. PARTICIPANTS: 8036 adults residing in these districts between May 2013 and May 2014. MAIN OUTCOME MEASURES: Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. RESULTS: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. CONCLUSIONS: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans.

Maternal mental health and child nutritional status in four developing countries.

OBJECTIVE: To test the hypothesis that maternal common mental disorders (CMD) are associated with poorer child nutritional status in four developing countries (Ethiopia, India, Vietnam, and Peru). DESIGN: Community based cross sectional survey in 20 sites in each of the four countries. Maternal CMD measured by the self reporting questionnaire 20 items (SRQ20). Potential confounding factors include: household poverty, household composition, maternal characteristics such as age and education, child characteristics such as birth weight, age, and sex. Possible mediating factors included the child's physical health and breast feeding status. SETTING: Urban and rural, poor and middle income areas in each country. PARTICIPANTS: 2000 mothers and their children aged 6-18 months in each country. MAIN OUTCOME MEASURES: Child stunting and underweight measured using standard anthropometric techniques. RESULTS: Levels of maternal CMD and child malnutrition are high in each study setting. After adjusting for confounding factors, the odds ratios (OR) for the association of maternal CMD with child stunting are: India 1.4 (95%CI 1.2 to 1.6), Peru 1.1 (0.9 to 1.4), Vietnam 1.3 (0.9 to 1.7), and Ethiopia 0.9 (0.7 to 1.2). For child underweight, the confounder adjusted ORs are: India 1.1 (0.9 to 1.4), Peru 0.9 (0.6 to 1.2), Vietnam 1.4 (1.1 to 1.8), and Ethiopia 1.1 (0.9 to 1.4). No clear evidence for effect modification by the child's age or sex was found. Possible mediating factors for the effect of maternal CMD on child malnutrition did not provide strong suggestions for potential mechanisms. CONCLUSIONS: There was a relation between high maternal CMD and poor child nutritional status in India and Vietnam. However, the findings from Peru and Ethiopia do not provide clear evidence for a similar association being present in non-Asian countries. Regardless of the direction of the relation, child nutrition programmes in Asia should consider incorporating promotion of maternal mental health.

Social capital and mental illness: a systematic review.

STUDY OBJECTIVE: The concept of social capital has influenced mental health policies of nations and international organisations despite its limited evidence base. This papers aims to systematically review quantitative studies examining the association between social capital and mental illness. DESIGN AND SETTING: Twenty electronic databases and the reference sections of papers were searched to identify published studies. Authors of papers were contacted for unpublished work. Anonymised papers were reviewed by the authors of this paper. Papers with a validated mental illness outcome and an exposure variable agreed as measuring social capital were included. No limitations were put on date or language of publication. MAIN RESULTS: Twenty one studies met the inclusion criteria for the review. Fourteen measured social capital at the individual level and seven at an ecological level. The former offered evidence for an inverse relation between cognitive social capital and common mental disorders. There was moderate evidence for an inverse relation between cognitive social capital and child mental illness, and combined measures of social capital and common mental disorders. The seven ecological studies were diverse in methodology, populations investigated, and mental illness outcomes, making them difficult to summarise. CONCLUSIONS: Individual and ecological social capital may measure different aspects of the social environment. Current evidence is inadequate to inform the development of specific social capital interventions to combat mental illness.

Social capital and common mental disorder: a systematic review.

OBJECTIVE: This study aims to systematically review all published quantitative studies examining the direct association between social capital and common mental disorders (CMD). Social capital has potential value for the promotion and prevention of CMD. The association between different types of social capital (individual cognitive and structural, and ecological cognitive and structural) and CMD must be explored to obtain conclusive evidence regarding the association, and to ascertain a direction of causality. DESIGN: 10 electronic databases were searched to find studies examining the association between social capital and CMD published before July 2014. The effect estimates and sample sizes for each type of social capital were separately analysed for cross-sectional and cohort studies. From 1857 studies retrieved, 39 were selected for inclusion: 31 cross-sectional and 8 cohort studies. 39 effect estimates were found for individual level cognitive, 31 for individual level structural, 9 for ecological level cognitive and 11 for ecological level structural social capital. MAIN RESULTS: This review provides evidence that individual cognitive social capital is protective against developing CMD. Ecological cognitive social capital is also associated with reduced risk of CMD, though the included studies were cross-sectional. For structural social capital there was overall no association at either the individual or ecological levels. Two cross-sectional studies found that in low-income settings, a mother's participation in civic activities is associated with an increased risk of CMD. CONCLUSIONS: There is now sufficient evidence to design and evaluate individual and ecological cognitive social capital interventions to promote mental well-being and prevent CMD.

Development of a Community-Based Rehabilitation Intervention for People with Schizophrenia in Ethiopia.

BACKGROUND: Community-based rehabilitation (CBR) is a multi-sectoral strategy to improve the functioning and quality of life of people with disabilities. The RISE (Rehabilitation Intervention for people with Schizophrenia in Ethiopia) trial will evaluate the effectiveness of CBR for people with schizophrenia in Ethiopia. Nevertheless, the components of CBR that are both feasible and likely to prove effective in low and middle-income countries such as Ethiopia are unclear. METHODS: In this study intervention development work was undertaken to design a CBR intervention that is acceptable and feasible in the local context. The development work consisted of five phases. 1: Identify potential components of CBR for schizophrenia, 2: Situational analysis, 3: Determine feasibility of CBR (Theory of Change workshops with experts and local stakeholders), 4: Determine acceptability of CBR (16 in-depth interviews and five focus group discussions with people with schizophrenia, caregivers, health workers and community leaders) and 5: Synthesise results to finalise intervention. A Theory of Change map was constructed showing the causal pathway for how we expect CBR to achieve its impact. RESULTS: People with schizophrenia in rural Ethiopia experience family conflict, difficulty participating in work and community life, and stigma. Stakeholders perceived CBR to be acceptable and useful to address these problems. The focus of CBR will be on the individual developing the skills and confidence to perform their previous or desired roles and activities. To ensure feasibility, non-health professionals will be trained to deliver CBR and provide supervision, rather than mental health specialists. Novel components of CBR for schizophrenia included family intervention and dealing with distressing symptoms. Microfinance was excluded due to concerns about stress and exploitation. Community mobilisation was viewed as essential to ensure the effectiveness and sustainability of CBR. CONCLUSION: Extensive formative research using a variety of methods has enabled the design of a culturally appropriate CBR intervention for people with schizophrenia that is acceptable and feasible.