Prevalence and factors associated with psychological distress among pregnant and non-pregnant youth living with HIV in rural Uganda: a comparative study.

Youth living with HIV (YLHIV) are prone to psychological distress, which may have detrimental effects on health outcomes. Pregnant youth have poor access to HIV care increasing the risk of vertical transmission of HIV to their infants. Both HIV and pregnancy are independently associated with poor mental health among adolescents. The factors that predispose women to poor mental health may also increase their risk of contracting HIV. Despite their desire to have children YLHIV are at a high risk of psychological distress. However, factors associated with psychological distress among YLHIV in rural Uganda are not well explored. Therefore, the purpose of this study was to determine the prevalence of, and factors associated with psychological distress among pregnant and non-pregnant YLHIV in south western Uganda. We enrolled 224 YLHIV aged 15-24 years both pregnant and nonpregnant (ratio 1:1) between December 2018 and March 2019. We obtained information on psychological distress and factors hypothesized to affect mental health outcomes among people living with HIV including internalized HIV stigma, intimate partner violence, self-esteem and social support. Bivariate and multivariable logistic regression analysis were used to estimate factors independently associated with psychological distress. The prevalence of psychological distress was 48.2%% among pregnant YLHIV and 32.14% among non-pregnant YLHIV. Factors significantly associated with psychological distress among pregnant YLHIV were HIV stigma (AOR=4.61; 95% CI 1.63-13.84; P=0.004), physical abuse (AOR=4.97; 95% CI 1.41- 17.56; P= 0.013), and separation from partner (AOR =0.03; 95% CI 0.001-0.580; P=0.020).

Long-Term Effect of Group Support Psychotherapy on Depression and HIV Treatment Outcomes: Secondary Analysis of a Cluster Randomized Trial in Uganda.

OBJECTIVE: We aimed to determine the effect of group support psychotherapy (GSP) compared with group HIV education (GHE) on depression and HIV treatment outcomes 24 months after treatment. We further aimed to investigate the mediating role of depression and antiretroviral therapy (ART) adherence in the relationship between GSP and viral load suppression. METHODS: Thirty HIV clinics across three districts were randomly assigned to deliver either GSP or GHE for depression. Depression and optimal (≥95%) ART adherence was assessed at baseline and 6, 12, 18, and 24 months after treatment. Viral load was drawn from the medical charts at baseline and 12 and 24 months after treatment. Multilevel mixed-effects regression models and generalized structural equation modeling were used to estimate 24-month outcomes and mediation effects. RESULTS: Participants ( N = 1140) were enrolled from HIV clinics offering either GSP ( n = 578 [51%]) or GHE ( n = 562 [49%]). Fewer GSP than GHE participants met the criteria for depression at 24 months after treatment (1% versus 25%; adjusted odds ratio [aOR] = 0.002, 95% confidence interval [CI] = 0.0002-0.018). More GSP than GHE participants reported optimal (≥95%) ART adherence (96% versus 88%; aOR = 20.88, 95% CI = 5.78-75.33) and improved viral suppression (96% versus 88%; aOR = 3.38, 95% CI = 1.02-11.02). The indirect effects of GSP through sequential reduction in depression and improvement in ART adherence at 12 months may partially explain the higher viral suppression rates at 24 months in GSP than GHE groups. CONCLUSION: In settings where the HIV epidemic persists, depression treatment with GSP may be critical for optimal HIV treatment outcomes.Trial Registration: The Pan African Clinical Trials Registry, number PACTR201608001738234.

Health-related quality of life among patients with bipolar disorder in rural southwestern Uganda: a hospital based cross sectional study.

BACKGROUND: Bipolar disorder is a psychiatric disorder that alters mood and affects over 55 million people globally with an estimated lifetime prevalence of approximately 0.8-1.1%. In Africa, the lifetime prevalence of the bipolar spectrum disorders is slightly lower at 0.1-0.6%. Bipolar disorder is ranked the sixth leading cause of disability with high rates of morbidity and mortality and negatively impacts quality of life of those affected. METHODS: The aim of the study was to determine the health-related quality of life of patients with bipolar disorder attending a mental health clinic in south western Uganda. We enrolled a consecutive sample of 169 participants and evaluated their health-related quality of life using the medical outcomes health survey short form-36 (SF-36) scale. We used bivariate and multivariable logistic regression to determine associations between quality of life, sociodemographic and clinical factors setting the physical and mental component categories of quality life scale as the main outcome variables. RESULTS: The mean age of the participants was 37.23 (12.83) and slightly over half (54.4%) were females. More than half (66.86%) of the participants had poor physical component summary (mean = 45.06, SD = 8.44) while 81% of the participants had poor mental component summary (mean = 41.95, SD = 8.45). Poor physical quality of life had a statistically significant association with history of suicidal thoughts (OR = 2.75, 95% CI = 1.14-6.63, P = 0.02), while poor mental quality of life had a statistically significant association with history of suicidal thoughts (OR = 3.94, CI = 1.22-12.71, P = 0.02) and history of psychotic symptoms (OR = 2.46, CI = 1.07-5.64, P = 0.03). CONCLUSION: The mental and physical quality of life of our participants was poor and history of suicidal thoughts and psychotic symptoms were associated with poor quality of life. There is need to address psychotic symptoms and suicidal thoughts in the management of patients with bipolar disorder to improve health related outcomes and quality of life.

Prevalence and factors associated with major depressive disorder in children and adolescents at the Uganda Cancer Institute.

BACKGROUND: The prevalence and factors associated with major depressive disorder (MDD) among adults with cancer have been documented in the scientific literature. However, this data is limited among children and adolescents with cancer; especially in low resource settings such as Uganda. We assessed the prevalence and factors associated with MDD in children and adolescents attending the Uganda cancer institute out-patient clinic. METHODS: This was a cross-sectional study in which three hundred and fifty-two children and adolescents with any cancer diagnosis were screened for depression using the Child Depression Inventory (CDI) and evaluated with the mini neuropsychiatric interview for children and adolescents (MINI-KID). Associated factors were assessed using a standardized questionnaire that assessed child and caregiver demographic and psychosocial characteristics. Multiple logistic regression models were used to assess factors independently associated with MDD. RESULTS: Of the 352 children and adolescents recruited in the study 134(38%) scored above a cut-off point of 13 on the CDI indicating significant depression symptoms. However, 91(26%) met criteria for MDD. The majority of those with MDD (n = 59 64.8%) had CDI scores of 13-19 indicating mild depression, 30(33%) had scores of 20-25 indicating moderate depression and 2(2.2%) had scores of 25 and above indicating severe depression. Protective factors against MDD were having a special person in the respondent's life (p = 0.002) and using self-distraction as a coping method (p = < 0.001). Risk factors were being an adolescent(p = < 0.001). CONCLUSION: The prevalence of MDD is substantial in children and adolescents with cancer in Uganda. Given that the majority had a mild-moderate depression, there is an urgent need to integrate psychotherapy-the first-line treatment for depression into the routine care of children and adolescents with cancer.

Process Evaluation of a Randomized Controlled Trial of Group Support Psychotherapy for Depression Treatment Among People with HIV/AIDS in Northern Uganda.

We describe the process evaluation for a randomized controlled trial that compared group support psychotherapy (GSP) with group HIV education for treatment of depression among people with HIV. Process data were obtained using mixed methods. Variables evaluated were indicators of feasibility and acceptability; causal mediating processes and contextual influences. GSP was feasible and acceptable. Potential mediating variables between GSP and reduction of depression were improved emotional and social support, better coping strategies, and pursuit of livelihoods. Culturally sensitive intervention content facilitated intervention delivery. These data complement the trial outcomes, and may provide a contextualized description of how GSP treats depression.

Implementation and scale-up of psycho-trauma centers in a post-conflict area: a case study of a private-public partnership in northern Uganda.

As one article in an ongoing series on Global Mental Health Practice, Etheldreda Nakimuli-Mpungu and colleagues describe a private-public partnership that implemented and scaled psycho-trauma centers in Northern Uganda.

The effect of group support psychotherapy on adherence to anti-retroviral therapy and viral suppression among HIV positive young people: Study protocol for a pilot randomized controlled trial.

Background: Several studies have demonstrated an association between psychological risk factors and HIV disease progression. However, there is limited information on the use of psychological interventions to improve HIV treatment outcomes in young people living with HIV. Objective: This pilot trial aims to evaluate the feasibility, acceptability and preliminary effectiveness of group support psychotherapy in improving adherence to anti-retroviral therapy and viral suppression in young people living with HIV in Uganda. Methods: We recruited 120 young people with HIV, aged 10-18 years, who had non-viral suppression 6 months after initiating first-line anti-retroviral therapy (ART) from community based HIV clinics in Kitgum district, northern Uganda. Participants were randomly assigned to receive GSP plus IAC (N = 60) or IAC alone (N = 60). Primary outcomes will be indicators of feasibility and acceptability as well as preliminary effectiveness of GSP in improving ART adherence and viral suppression analysed by intention to treat using cluster-adjusted t tests and permutation tests. Secondary outcomes will be measures of depression, anxiety and cost-effectiveness. Results: The trial has been approved by the Makerere College of Health Sciences School of Health Sciences Research Ethics Committee, and the Uganda National Council of Science and Technology. Recruitment began in June 2021 and 120 young people living with HIV with their adult caregivers have been recruited to the trial. An analysis of baseline and 6-month data is in progress. The results of this trial will not only be presented at national and international conferences but also submitted for publication in peer-reviewed journals and as a report to the funding agencies. Conclusions: This pilot trial will provide critical evidence to support the ongoing mental health integration into routine HIV care in Uganda. Trial Registration: Pan African Clinical Trials Registry (PACTR): 202006601935462.

Depression, alcohol use and adherence to antiretroviral therapy in sub-Saharan Africa: a systematic review.

This study evaluated estimates of depression symptoms, major depression, alcohol use or disorders and their association with ART adherence in sub-Saharan Africa. Studies published between January 1, 2006 and July 31, 2011 that documented rates of these mental health problems were identified through electronic databases. A pooled analysis of 23 studies reporting rates of depression symptoms and six studies reporting rates of major depression indicated a pooled estimate of 31.2% (95% CI 25.5-38.2%, Tau(2) = 0.23) and 18% (95% CI 12.3-25.8%, Tau(2) = 0.19) respectively. Few studies reported rates of alcohol use or disorders, and so we did not pool their estimates. Likelihood of achieving good adherence was 55% lower among those with depression symptoms compared to those without (pooled OR = 0.45 (95% CI 0.31-0.66, Tau(2) = 0.20, P value = 0.000). Interventions to improve mental health of HIV-positive individuals and to support adherence are desperately needed in sub-Saharan Africa.

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

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

Prevalence and Factors Associated With Suicidal Ideation Among Children and Adolescents Attending a Pediatric HIV Clinic in Uganda.

Background: Suicidal behavior and HIV/AIDS are vital public health challenges especially in low and middle-income countries. As suicide in adults is perturbing for those closest to them, this sentiment is much more intense and generalized in the case of a child or adolescent. Knowledge of factors associated with suicidal ideation in HIV infected children and adolescents may inform suicide prevention strategies needed to improve their quality of life. This study aimed to assess the prevalence and factors associated with suicidal ideation among HIV infected children and adolescents attending a pediatric HIV clinic in Uganda. Methods: Data from a sample of 271 children and adolescents aged 6-18 years living with HIV/AIDS attending a pediatric HIV clinic was analyzed. Child characteristics and clinical variables were assessed using a socio-demographic questionnaire and medical records respectively. Suicidal ideation and depression were assessed using the Child Depression Inventory. The types of behavioral problems and the parent-child relationship were assessed using Child Behavioral Check List (6-18 years) and the Parent Child Relationship Scale respectively. Child exposure to different stressful life events was assessed with a series of standardized questions. Logistic regression models were used to explore factors independently associated with suicidal ideation. Results: The prevalence of suicidal ideation was 17%. In the multivariate analysis; Child exposure to family or friend's death (prevalence rate ratio (PRR = 2.02; 95% CI, 1.01-4.03), p = 0.046), HIV wasting syndrome (PRR = 0.39; 95% CI, 0.21-0.75, p = 0.04), Depression (PRR = 1.08; 95% CI, 1.03-1.12, p = 0.001), Anxiety symptoms (PRR = 1.10; 95% CI, 1.01-1.20, p = 0.024) and Rule breaking behavior (PRR = 1.06; 95% CI, 0.99-1.13, p = 0.051) were independently associated with suicidal ideations. Conclusion: The prevalence of suicidal ideation among children and adolescents living with HIV/AIDS is substantial. Children and adolescents with exposure to family or friend's death, those with higher depression scores, anxiety symptoms and rule breaking behavior are more likely to report suicidal ideation. Those with HIV wasting syndrome were less likely to report suicidal ideation. There is urgent need for HIV care providers to screen for suicide and link to mental health services.

How COVID-19 has fundamentally changed clinical research in global health.

COVID-19 has had negative repercussions on the entire global population. Despite there being a common goal that should have unified resources and efforts, there have been an overwhelmingly large number of clinical trials that have been registered that are of questionable methodological quality. As the final paper of this Series, we discuss how the medical research community has responded to COVID-19. We recognise the incredible pressure that this pandemic has put on researchers, regulators, and policy makers, all of whom were doing their best to move quickly but safely in a time of tremendous uncertainty. However, the research community's response to the COVID-19 pandemic has prominently highlighted many fundamental issues that exist in clinical trial research under the current system and its incentive structures. The COVID-19 pandemic has not only re-emphasised the importance of well designed randomised clinical trials but also highlighted the need for large-scale clinical trials structured according to a master protocol in a coordinated and collaborative manner. There is also a need for structures and incentives to enable faster data sharing of anonymised datasets, and a need to provide similar opportunities to those in high-income countries for clinical trial research in low-resource regions where clinical trial research receives considerably less research funding.

The role and challenges of cluster randomised trials for global health.

Evaluating whether an intervention works when trialled in groups of individuals can pose complex challenges for clinical research. Cluster randomised controlled trials involve the random allocation of groups or clusters of individuals to receive an intervention, and they are commonly used in global health research. In this paper, we describe the potential reasons for the increasing popularity of cluster trials in low-income and middle-income countries. We also draw on key areas of global health research for an assessment of common trial planning practices, and we address their methodological shortcomings and pitfalls. Lastly, we discuss alternative approaches for population-level intervention trials that could be useful for research undertaken in low-income and middle-income countries for situations in which the use of cluster randomisation might not be appropriate.

Mental health interventions for persons living with HIV in low- and middle-income countries: a systematic review.

INTRODUCTION: Addressing the intersection between mental health and HIV is critical for the wellbeing of persons living with HIV (PLWH). This systematic review synthesized the literature on mental health interventions for PLWH in low- and middle-income countries (LMICs) to determine intervention components and explore their relationship with intervention effectiveness. METHODS: We included only controlled clinical trials of interventions aiming to improve the mental health of PLWH. We conducted a search in the following databases: PubMed, CINAHL, PsycINFO and EMBASE for eligible studies describing the evaluation of interventions for mental health problems among PLWH in LMICs published through August 2020. Two reviewers independently screened references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria. RESULTS: We identified a total of 30 eligible articles representing 6477 PLWH who were assigned to either the intervention arm (n = 3182) or control arm (n = 3346). The mental health interventions evaluated were psychological (n = 17, 56.67%), pharmacological (n = 6, 20.00%), combined psychological and pharmacological (n = 1, 3.33%) and complementary/alternative treatments (n = 6, 20.00%). The mental health problems targeted were depression (n = 22, 73.33 %), multiple psychological symptoms (n = 1, 3.33%), alcohol and substance use problems (n = 4, 13.33%), post-traumatic stress disorder (n = 1, 3.33%) and HIV-related neuro-cognitive impairment (n = 2, 6.67%). Studies of interventions with significant effects had significantly a higher number of active ingredients than those without significant effects [3.41 (2.24) vs. 1.84 (1.46) Mean (SD)] [Mean difference = -1.56, 95% CI = -3.03 to -0.09, p = 0.037]. CONCLUSIONS: There continue to be advances in mental health interventions for PLWH with mental illness in LMICs. However, more research is needed to elucidate how intervention components lead to intervention effectiveness. We recommend scale up of culturally appropriate interventions that have been successfully evaluated in low- and middle-income countries.

Targeting Treatments to Health Disparities.

These initial data suggest that with prenatal vitamins and choline supplements, we might decrease one risk factor associated with poorer health outcomes disproportionally affecting Black families, ie, preterm birth. Dissemination of this research fulfills the principle of Justice in the Belmont Report, to ensure that participants from different racial, ethnic and socioeconomic groups receive benefits from research directed to their specific problems.

Black American Maternal Prenatal Choline, Offspring Gestational Age at Birth, and Developmental Predisposition to Mental Illness.

Black Americans have increased risk for schizophrenia and other mental illnesses with prenatal origins. Prenatal choline promotes infant brain development and behavioral outcomes, but choline has not been specifically assessed in Black Americans. Pregnant women (N = 183, N = 25 Black Americans) enrolled in a study of prenatal stressors and interactions with prenatal choline. Black American women had lower 16-week gestation plasma choline than Whites. Lower choline was not related to obesity, income, or metabolic genotypes. Pregnant women in rural Uganda have higher choline levels than Black American women. Black Americans' lower choline was associated with higher hair cortisol, indicative of higher stress. Lower maternal choline was associated with offsprings' lower gestational age at birth and with decreased auditory P50 inhibition, a marker of inhibitory neuron development. Behavioral development was assessed on the Infant Behavior Questionnaire-R-SF (IBQ-R) at 3 months. Lower Black American maternal gestational choline was associated with lower infant IBQ-R Orienting/Regulation, indicating decreased attention and relation to caregivers. Additional evidence for developmental effects of choline in Black Americans comes from a randomized clinical trial of gestational phosphatidylcholine supplementation versus placebo that included 15 Black Americans. Phosphatidylcholine increased gestational age at birth and newborn P50 inhibition and decreased Social Withdrawn and Attention problems at 40 months of age in Black Americans' offspring compared to placebo. Inhibitory and behavioral deficits associated with lower prenatal choline in offspring of Black American women indicate potential developmental predispositions to later mental illnesses that might be ameliorated by prenatal choline or phosphatidylcholine supplementation.

Urgently seeking efficiency and sustainability of clinical trials in global health.

This paper shows the scale of global health research and the context in which we frame the subsequent papers in the Series. In this Series paper, we provide a historical perspective on clinical trial research by revisiting the 1948 streptomycin trial for pulmonary tuberculosis, which was the first documented randomised clinical trial in the English language, and we discuss its close connection with global health. We describe the current state of clinical trial research globally by providing an overview of clinical trials that have been registered in the WHO International Clinical Trial Registry since 2010. We discuss challenges with current trial planning and designs that are often used in clinical trial research undertaken in low-income and middle-income countries, as an overview of the global health trials landscape. Finally, we discuss the importance of collaborative work in global health research towards generating sustainable and culturally appropriate research environments.

Complementary Alternative Medicine (CAM) Use and Associated Factors among HIV Infected Children and Adolescents Seeking Mental Health Services in Uganda.

BACKGROUND: Given the limited integration of mental health services into pediatric HIV care in sub-Saharan Africa, there is limited information on the nature of mental health service use sought by caregivers of children and adolescents living with HIV/AIDS. METHODS: We analyzed data from a sample of 135 children and adolescents living with HIV/AIDS and attending a pediatric HIV care service whose parents or caregivers had sought for mental health care for their emotional or behavior problems in the past year. We assessed complementary alternative medicine use, socio-demographic characteristics and types of behavioral problems using a SOCIO-DEMOGRAPHIC questionnaire and the child behavioral checklist (6 - 18) respectively. Logistic regression models were used to explore factors independently associated with specific patterns of mental health service use. RESULTS: Of 135 parents/caregivers interviewed, 38 (28.15%) sought mental health care from only complementary and alternative medicine (CAM) providers (traditional or faith healers), 38 (28.15%) from only conventional medical providers (general physicians, general nurses, psychiatrists or HIV counselors) and 59 (43.70%) sought care from both). Severe HIV disease in the young children [PRR = 2.09, 95%CI = 1.36 to 3.2, p-value = 0.001] and thought problems [PRR 1.26, 95%CI = 0.81 to 1.72, p-value = 0.04] in adolescents were independently associated with complementary and alternative medicine use. CONCLUSION: Caregivers of children and adolescents with progressive HIV disease and thought problems were more likely to seek mental health services from complementary and alternative medicine providers.

Knowledge Gaps about Autism Spectrum Disorders and its Clinical Management among Child and Adolescent Health Care Workers in Uganda: A Cross-Sectional Study.

BACKGROUND: There is limited literature on the knowledge about Autism Spectrum Disorder (ASD) among child and adolescent health professionals from resource limited settings. METHODS: 40 child and adolescent health professionals were purposively sampled from the two national referral hospitals in Uganda. Participants completed a standardized questionnaire that collected data on socio-demographic characteristics, the Knowledge about Childhood Autism among Health Workers (KCAHW) and the challenges related to diagnosing and managing ASD. General linear model with the Poisson regression was used to evaluate bivariate and multivariate factors associated with limited knowledge about ASD. RESULTS: The study participation rate was 90% with the majority being females (N = 21, 58%). Also, most (N = 20, 55.6%) were mental health professionals working at the Butabika pediatric out-patient clinic while (N = 16, 44.4%) were pediatric health professionals working at the Mulago mental and neurological pediatric clinics. The mean score on KCAHW was 11.8 (SD = 3.75). The participants (36.1%) who scored below the mean score were regarded as having limited knowledge about ASD. Health workers with limited knowledge about ASD (KCAHW score < 11.8) were less likely to have a degree [adjusted Prevalence rate ratio (aPRR) = 0.26, 95%CI = 0.08 to 0.78, p-value = 0.018. Mental health and Non-mental health workers had comparable KCAHW mean scores. Clinical Psychologists, Psychiatrists, psychiatry residents and pediatric nurses had the highest KCAHW scores while psychiatric nurses and medical social workers had the lowest scores. CONCLUSION: The proportion of child and adolescent health professionals with limited knowledge about ASD is substantial. There is urgent need to increase focus on training in autism spectrum disorders especially among non-specialist health workers.

Prevalence and associated factors of alcohol use patterns among university students in Uganda.

INTRODUCTION: majority of alcohol use pattern studies among university students are from developed countries. Information about the different alcohol use patterns and their correlates among university students in sub-Saharan Africa is limited. The aim of this study was to examine the prevalence and cardinal demographic and psychosocial factors associated with specific alcohol use patterns among Ugandan university students. METHODS: a cross section study conducted over 5-months among university students using a standardized socio-demographic questionnaire screened for alcohol use problems, depression symptoms and academic stress using the alcohol use disorders identification test (AUDIT), self-reporting questionnaire (SRQ-20) and the higher education stress inventory (HESI) respectively. Multivariate multinomial regression models were used to determine factors independently associated with a specific alcohol use pattern with low-risk drinkers as the reference group. RESULTS: a thousand out of 1200 students completed all study requirements for which 60% were males; median age was 22.3 (SD=2.36). The prevalence estimates of any alcohol use, low-risk drinking, heavy episodic drinking and alcohol misuse were 31%, 17.3%, 4.5% and 8.9% respectively. In comparison to low-risk drinkers, students reporting heavy episodic drinking were more likely to report high levels of academic stress (P-value <0.10). Those with alcohol misuse were more likely to be males and with significant depression symptoms (P-value ≤0.05). Non-alcohol users were more likely to report high levels of academic stress (P-value ≤0.05). CONCLUSION: the prevalence of maladaptive alcohol use patterns is high among Ugandan university students. Integrating peer led psychological interventions into student health services is desperately needed.

Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomised trial.

BACKGROUND: WHO recommends the use of psychological interventions as first-line treatment for depression in low-income and middle-income countries. However, evaluations of the effectiveness and cost-effectiveness of such interventions among people with HIV are scarce. Our aim was to establish the effectiveness of group support psychotherapy (GSP) delivered by lay health workers for depression treatment among people living with HIV in a rural area of Uganda on a large scale. METHODS: In this cluster-randomised trial, we included 30 health centres offering HIV care. These were randomly assigned to deliver either GSP or group HIV education (GHE). Randomisation, in a ratio of 1:1, was achieved by health centre managers separately picking a paper containing the intervention allocation from a basket. Participants were people living with HIV, aged 19 years and older, with mild to moderate major depression assessed with the Mini International Neuropsychiatric Interview depression module, taking antiretroviral therapy, and antidepressant-naive. Group sessions were led by trained lay health workers once a week for 8 weeks. The primary outcomes were the proportion of participants with major depression and function scores at 6 months post-treatment, analysed by intention to treat by means of multilevel random effect regression analyses adjusting for clustering in health centres. This trial is registered with the Pan African Clinical Trials Registry, PACTR201608001738234. FINDINGS: Between Sept 13 and Dec 15, 2016, we assessed 1473 individuals, of whom 1140 were recruited from health centres offering GSP (n=578 [51%]) or GHE (n=562 [49%]). Two (<1%) participants in the GSP group were diagnosed with major depression 6 months post-treatment compared with 160 (28%) in the GHE group (adjusted odds ratio=0·01, 95% CI 0·003-0·012, p<0·0001). The mean function scores 6 months post-treatment were 9·85 (SD 0·76) in the GSP group and 6·83 (2·85) in the GHE group (ß=4·12; 95% CI 3·75-4·49, p<0·0001). 36 individuals had 63 serious adverse events, which included 25 suicide attempts and 22 hospital admissions for medical complications. The outcomes of these serious adverse events included 16 deaths, 4 of which were completed suicides (GSP=2; GHE=2), and 12 of which were HIV-related medical complications (GSP=8; GHE=4). Cost-effectiveness estimates showed an incremental cost-effectiveness ratio of US$13·0 per disability-adjusted life-year averted, which can be considered very cost-effective in Uganda. INTERPRETATION: Integration of cost-effective psychological treatments such as group support psychotherapy into existing HIV interventions might improve the mental health of people living with HIV. FUNDING: MQ Transforming Mental Health and Grand Challenges Canada.