Effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care in Uganda (the HIV + D trial): A protocol for a cluster-randomised trial.

BACKGROUND: An estimated 8-30 % of people living with HIV (PLWH) have depressive disorders (DD) in sub-Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV + D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda. METHODS: Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10-30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV + D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged ≥ 18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9 ≥ 10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months' post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV + D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5 L and OxCAP-MH). DISCUSSION: The study findings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings. TRIAL REGISTRATION: ISRCTN, ISRCTN86760765. Registered 07 September 2017, https://doi.org/10.1186/ISRCTN86760765 .

A call for change from impersonal risk assessment to a relational approach: professionals' reflections on the national guidelines for suicide prevention in mental health care in Norway.

PURPOSE: The purpose of the study is to explore how professionals working with suicide prevention experience the influence of the national guidelines on mental healthcare, and to gather recommendations for which steps to take next. METHODS: This is a qualitative study with an explorative design. We interviewed 22 professionals responsible for implementing suicide prevention action plans and guidelines, and/or conducting relevant research. We analysed the data by means of thematic analysis. RESULTS: We found that the participants had an ambivalent view on risk assessment-it may be a tool, but it may also compromise other important aspects in prevention. Moreover, the possibility of liability has resulted in the need for self-protection. Instead, the participants recommended a relational approach to suicide prevention. CONCLUSIONS: We found that the emphasis on standardized suicide risk assessment has negatively influenced suicide prevention in mental healthcare, and an approach emphasizing relational aspects is recommended. However, the prevailing objectifying concept of knowledge, the epistemological debate and the emergence of the New Public Management ideology may obstruct a fundamental emphasis on relationships. A paradigm shift in mental healthcare is called for with respect to the concept of knowledge, which forms our understandings and practices.

Cultural responses towards the aftermath of suicide among the Acholi in Northern Uganda.

BACKGROUND: Suicide is a public health problem in Uganda among indigenous societies, and different societies manage its aftermath differently. AIM: To explore how the Acholi in Northern Uganda manage the aftermath of suicide. METHODS: We conducted a qualitative study in Gulu district, a post-conflict area in Northern Uganda. We conducted a total of four focus group discussions (FGDs) and 12 key informant (KI) interviews. KI interviews were conducted with community leaders, while the FGDs were conducted with members of the general population. We analysed the data by means of Grounded Theory. RESULTS: Our findings indicate that rituals form a large part in managing suicide among the Acholi. Study communities practised distancing (symbolically and physically) as a way of dealing with the threat of suicide. CONCLUSION: Distancing was organized into two broad themes: affect regulation and securing future generations. It is recommended that public health interventions should utilize cultural institutions in the prevention of suicide.

Suicide among men in Ghana: The burden of masculinity.

In Ghana, some studies have reported a high rate for both fatal and non-fatal suicidal behaviors among men. The current study aimed at understanding the psychosocial circumstances involved in male suicides. We interviewed between two to seven close relations of each of 12 men who died by suicide. Interpretative phenomenological analysis of data indicates that experiences of shame related to loss of economic control, breach of patriarchal norms, and threats to sexual competence contributed to the suicides. Addressing socioeconomic issues, creating opportunities for men to disclose their emotions, and identifying sources of these emotions may help prevent suicide among men.

The experiences of caregivers of children living with HIV and AIDS in Uganda: a qualitative study.

BACKGROUND: Home-based care for HIV patients is popular in contexts severely affected by the epidemic and exacts a heavy toll on caregivers. This study aimed at understanding the experiences of caregivers and their survival strategies. METHODS: A total of 18 caregivers (3 males and 15 females) were interviewed using a semi-structured interview guide, and thematic analysis was used to analyse the data. RESULTS: Analysis suggests that the caregivers are burdened with insecure provisions for food and difficulties in accessing health care. They however survived these strains through managing their relationships, sharing burden with care-recipients, social networks and instrumental spirituality. These findings are discussed under two major themes: 1). Labour of caregiving and 2). Survivalism. CONCLUSIONS: Home-based care presents huge opportunities for community response to the HIV/AIDS epidemic in African settings. It is however burdensome and thus should not be left for families alone to shoulder. There is therefore an urgent need for protecting home-based care for HIV children in Uganda. Implications for improving and strengthening social interventions in home-based care of HIV/AIDS in the Ugandan context are addressed.