Inequality on the frontline: A multi-country study on gender differences in mental health among healthcare workers during the COVID-19 pandemic.

Healthcare workers (HCWs) were at increased risk for mental health problems during the COVID-19 pandemic, with prior data suggesting women may be particularly vulnerable. Our global mental health study aimed to examine factors associated with gender differences in psychological distress and depressive symptoms among HCWs during COVID-19. Across 22 countries in South America, Europe, Asia and Africa, 32,410 HCWs participated in the COVID-19 HEalth caRe wOrkErS (HEROES) study between March 2020 and February 2021. They completed the General Health Questionnaire-12, the Patient Health Questionnaire-9 and questions about pandemic-relevant exposures. Consistently across countries, women reported elevated mental health problems compared to men. Women also reported increased COVID-19-relevant stressors, including insufficient personal protective equipment and less support from colleagues, while men reported increased contact with COVID-19 patients. At the country level, HCWs in countries with higher gender inequality reported less mental health problems. Higher COVID-19 mortality rates were associated with increased psychological distress merely among women. Our findings suggest that among HCWs, women may have been disproportionately exposed to COVID-19-relevant stressors at the individual and country level. This highlights the importance of considering gender in emergency response efforts to safeguard women's well-being and ensure healthcare system preparedness during future public health crises.

Arabic validation of the "Mental Health Knowledge Schedule" and the "Reported and Intended Behavior Scale".

Objectives: Mental illness affects one in eight people in the world according to the WHO. It is a leading cause of morbidity and a major public health problem. Stigma harms the quality of life of people with mental illness. This study aimed at validating the Arabic version of the Mental Health Knowledge Schedule (MAKS) and the Reported and Intended Behavior Scale (RIBS) in a sample of Tunisian students and determining socio-demographic and clinical factors correlated with stigma. Methods: This cross-sectional study was conducted on 2,501 Tunisian students who filled in the MAKS, the RIBS, and a sociodemographic and clinical questionnaire. The validation of the questionnaires in Arabic was carried out using the validity criteria: face and content validity, reliability, and construct validity. Next, the associations between stigma and sample characteristics have been studied using multivariate linear regression. Results: Face and content validity of the measures MAKS and RIBS were satisfactory, with adequate internal consistency. There were significant positive correlations between the items and scales, and test-retest reliability was excellent. The internal validity showed that the items were well-aligned with the intended factors, and the external validity revealed a significant positive relationship between the MAKS and RIBS. Besides, gender, the field of study, psychiatric history, and contact with someone with a mental illness were all contributing factors to mental illness stigma. Additionally, men performed better than women in terms of behavior toward people with mental illness, while women had a greater level of knowledge about mental health. Conclusion: The Arabic versions of the MAKS and RIBS have appropriate psychometric properties, making them effective tools for evaluating mental illness stigma. With multiple factors contributing to this issue, these instruments can help focus anti-stigma efforts and promote a more inclusive society.

"To fast or not to fast?" Ramadan and religiosity through the eyes of people with bipolar disorder: an exploratory study.

Background: The month of Ramadan, due to its changes in social rhythms, can seriously affect the course of bipolar disorder (BD). Therefore, psychiatrists sometimes find it necessary to discourage Ramadan practices, especially fasting, although taking part in this practice can give a sense of belonging and accomplishment to patients. Research on this subject is limited. Aim: The aim of the present work was to explore: (i) religious practices with special attention to Ramadan before and after the onset of BD, (ii) the perceptions and behaviors related to not fasting during Ramadan in patients with BD and their families' attitudes, (iii) religiosity and self-stigmatization and their relationships with religious practices, and (iv) the doctor-patient relationship around fasting. Methods: We conducted a retrospective, cross-sectional and descriptive study in clinically stabilized patients with BD in a public mental hospital and in a private psychiatric practice in Tunis, Tunisia. Socio-demographic and clinical data, as well as data related to general religious practices and Ramadan practices were collected using a self-established questionnaire. We assessed (i) religiosity of the patients with the Duke University Religion Index and (ii) self-stigma using the Internalized Stigma of Mental Illness scale. Results: Our sample consisted of 118 patients of whom 65.3% were fasting regularly before BD onset. More than half had stopped this practice following BD onset. Of the patients who did not fast, 16% felt guilty about this and 4.9% reported receiving negative remarks from their surroundings. High self-stigma scores were observed in 11% of the patients. Self-stigma was associated significantly with negative perception of not fasting, negative remarks regarding not fasting and taking both meals at regular times during Ramadan. The decision whether to fast or not was taken without seeking medical advice in 71.2% of the sample, and 16.9% of the sample reported that their psychiatrist had spontaneously approached the issue of Ramadan fasting. Conclusion: Religiosity and more specifically the practice of Ramadan remains an important point that should be considered when treating patients with psychiatric problems. It seems necessary that healthcare professionals should integrate the positive and the negative side of fasting into their reflections. Our results remain exploratory and encourage further work on the subject.

The impact of MDQ positivity on quality of life impairment: Does it support the hypothesis of "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS)?

Background: DSM-5 separates bipolar (BD) from depressive disorders, but some experts consider BD as part of a spectrum of mood disorders. The interpretation of numerous false positives of BD screened by the Mood Disorders Questionnaire (MDQ) is part of this debate. Recent study results suggest that the worsening of health-related quality of life (H-Qol) associated with MDQ positivity does not depend solely on mood disorders. This study aims to clarify whether the impairment may be due to other concomitant disorders, unrelated to mood disorders, leading to a worsening of H-Qol. Additionally, the study aims to explore if MDQ positivity itself observe clinical significance. Design and methods: The study involved pairs of cases (MDQ+) and controls (MDQ-) matched for sex, age, and absence of DSM-IV psychiatric comorbidity. The impact of MDQ positivity on the quality of life in a sample of MDQ+ comorbid with MDD was measured and compared to impact of MDD in other chronic disorders. Results: The H-Qol was significantly worse in MDQ+ than in controls (both groups without any psychiatric co-morbidity). The worsening was similar to severe chronic disorders The burden of worsening quality of life due to MDD was mild in another sample of MDQ positives with comorbid MDD. Conclusion: The study hypothesizes that MDQ positivity may be related to hyperactivation and dysregulation of rhythms typical of stress disorders. In fact, MDQ+ was found strongly related to sleep disturbances. Future studies could verify if a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), causes worsening the H-Qol in MDQ+.

Accuracy of the Personal Economic Distress Index Among Arabic Unemployed.

Objectives: Studies about The Index of Personal Economic Distress (IPED) in Arab countries since the onset of the COVID-19 pandemic have been alarming. This study aimed to explore the reliability, factor structure, and criterion validity of the Arabic IPED in a sample of unemployed Tunisians during the past 6 months. Methods: The Arabic version of the IPED and the validated Hospital Anxiety and Depression Scale (HADS) were administered to a total of 2011 unemployed people originating from all Tunisian regions. Principal component analysis (PCA) with confirmatory factor analysis (CFA) was used to establish the spontaneous distribution of the 8 items and possible factors of the IPED. Receiver operating characteristic (ROC) analysis was conducted to assess the ability of the IPED to distinguish between unemployed individuals with no economic distress and those in distress. The correlation between the IPED and the HADS were explored. Results: The reliability of the Arabic version of the IPED was adequate. The PCA suggested two main components of the Arabic version of the IPED: the first component including five items focused on financial responsibilities towards state structures and the second dimension containing three items focused on well-being. A statistically significant association (p = 0.01; r = 0.05) was found between the well-being dimension of the IPED and the Anxiety subscale of HADS. Conclusion: This validated version of the IPED is an important tool to study the impact of economic crises on the mental health of unemployed people, as demonstrated in the link found in this study between economic distress and anxiety.

Reducing stigma and improving access to care for people with mental health conditions in the community: protocol for a multi-site feasibility intervention study (Indigo-Local).

Background: Stigma and discrimination towards people with mental health conditions by their communities are common worldwide. This can result in a range of negative outcomes for affected persons, including poor access to health care. However, evidence is still patchy from low- and middle-income countries (LMICs) on affordable, community-based interventions to reduce mental health-related stigma and to improve access to mental health care. Methods: This study aims to conduct a feasibility (proof-of-principle) pilot study that involves developing, implementing and evaluating a community-based, multi-component, public awareness-raising intervention (titled Indigo-Local), designed to reduce stigma and discrimination and to increase referrals of people with mental health conditions for assessment and treatment. It is being piloted in five LMICs - China, Ethiopia, India, Nepal and Tunisia - and includes several key components: a stakeholder group workshop; a stepped training programme (using a 'Training of Trainers' approach) of community health workers (or similar cadres of workers) and service users that includes repeated supervision and booster sessions; awareness-raising activities in the community; and a media campaign. Social contact and service user involvement are instrumental to all components. The intervention is being evaluated through a mixed-methods pre-post study design that involves quantitative assessment of stigma outcomes measuring knowledge, attitudes and (discriminatory) behaviour; quantitative evaluation of mental health service utilization rates (where feasible in sites); qualitative exploration of the potential effectiveness and impact of the Indigo-Local intervention; a process evaluation; implementation evaluation; and an evaluation of implementation costs. Discussion: The outcome of this study will be contextually adapted, evidence-based interventions to reduce mental health-related stigma in local communities in five LMICs to achieve improved access to healthcare. We will have replicable models of how to involve people with lived experience as an integral part of the intervention and will produce knowledge of how intervention content and implementation strategies vary across settings. The interventions and their delivery will be refined to be acceptable, feasible and ready for larger-scale implementation and evaluation. This study thereby has the potential to make an important contribution to the evidence base on what works to reduce mental health-related stigma and discrimination and improve access to health care.

Knowledge, attitudes and mental health of sub-Saharan African migrants living in Tunisia during COVID-19 pandemic.

COVID-19 pandemic potentially impacted the mental health of migrants. Our objective was to measure the prevalence of psychological distress among a group of sub-Saharan African migrants living in Tunisia, and its association with knowledge about COVID-19. The Questionnaire of Knowledge towards COVID-19 (QK-COVID-19) was used to evaluate the level of Knowledge about COVID-19. The participants were asked about their attitudes for seeking information and healthcare services related to the pandemic using a multiple-choice questionnaire. The Hopkins Symptoms Checklist (HSCL-25)) was used to screen for anxiety and depression. A logistic regression was used to estimate the adjusted odds of having psychological distress across levels of QK-COVID-19 score. Among the 133 participants, 34.6% (95% CI: 26.5, 42.67) had psychological distress, 91% were unemployed and 96% uninsured. Of the respondants, 20% had low QK-COVID-19 score , and 44.36% had medium score. The adjusted odds of psychological distress for those with high and medium QK-COVID-19 scores were respectively 3.9 (95% CI: 1.08, 14.13) and 6.39 (95% CI: 1.79, 22.9) times that of those with low scores. Screening and early treatment of anxiety and depression among migrants during outbreaks is an imperative. Further investigations of the determinants of mental health of sub-Saharan African migrants are needed.

Toward a multi-level strategy to reduce stigma in global mental health: overview protocol of the Indigo Partnership to develop and test interventions in low- and middle-income countries.

There is increasing attention to the impacts of stigma and discrimination related to mental health on quality of life and access to and quality of healthcare. Effective strategies for stigma reduction exist, but most evidence comes from high-income settings. Recent reviews of stigma research have identified gaps in the field, including limited cultural and contextual adaptation of interventions, a lack of contextual psychometric information on evaluation tools, and, most notably, a lack of multi-level strategies for stigma reduction. The Indigo Partnership research programme will address these knowledge gaps through a multi-country, multi-site collaboration for anti-stigma interventions in low- and middle-income countries (LMICs) (China, Ethiopia, India, Nepal, and Tunisia). The Indigo Partnership aims to: (1) carry out research to strengthen the understanding of mechanisms of stigma processes and reduce stigma and discrimination against people with mental health conditions in LMICs; and (2) establish a strong collaborative research consortium through the conduct of this programme. Specifically, the Indigo Partnership involves developing and pilot testing anti-stigma interventions at the community, primary care, and mental health specialist care levels, with a systematic approach to cultural and contextual adaptation across the sites. This work also involves transcultural translation and adaptation of stigma and discrimination measurement tools. The Indigo Partnership operates with the key principle of partnering with people with lived experience of mental health conditions for the development and implementation of the pilot interventions, as well as capacity building and cross-site learning to actively develop a more globally representative and equitable mental health research community. This work is envisioned to have a long-lasting impact, both in terms of the capacity building provided to participating institutions and researchers, and the foundation it provides for future research to extend the evidence base of what works to reduce and ultimately end stigma and discrimination in mental health.

Accuracy of the Arabic HCL - 32 and MDQ in detecting patients with bipolar disorder.

BACKGROUND: Studies about the two most used and validated instruments for the early detection of Bipolar Disorder (BD), the 32 - item Hypomania Checklist (HCL - 32) and the Mood Disorder Questionnaire (MDQ), are scarce in non-Western countries. This study aimed to explore the reliability, factor structure, and criterion validity of their Arabic versions in a sample of Tunisian patients diagnosed with mood disorders. METHODS: The sample included 59 patients with BD, 86 with unipolar Major Depressive Disorder (MDD) and 281 controls. Confirmatory factor analysis was applied to show that a single global score was an appropriate summary measure of the screeners in the sample. Receiver Operating Characteristic analysis was used to assess the capacity of the translated screeners to distinguish patients with BD from those with MDD and controls. RESULTS: Reliability was good for both tools in all samples. The bifactor implementation of the most reported two-factor model had the best fit for both screeners. Both were able to distinguish patients diagnosed with BD from putatively healthy controls, and equally able to distinguish patients diagnosed with BD from patients with MDD. CONCLUSION: Both screeners work best in excluding the presence of BD in patients with MDD, which is an advantage in deciding whether or not to prescribe an antidepressant.

Psychiatric Symptoms in Stiff-Person Syndrome: A Systematic Review and a Report of Two Cases.

BACKGROUND: The clinical spectrum of stiff-person syndrome (SPS) encompasses a wide range of signs including psychiatric symptoms (PS). OBJECTIVE: Our objective was to provide an overview of the spectrum of PS in SPS through a systematic literature search and 2 illustrative case reports. METHODS: We reported 2 anti-glutamic acid decarboxylase-positive SPS cases that presented with phobic disorder, and we performed a systematic review by following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles published in PubMed, MEDLINE on Ovid, Embase, and via a manual search before October 20, 2020, were selected by 2 independent reviewers. Original studies, case reports, editorials, commentaries, and letters to the editor reporting cases of SPS with PS were all included. Conference abstracts, reviews and book chapters, unavailable articles, and those not reporting SPS cases or PS were excluded. Quantitative summary data were calculated. RESULTS: In addition to our 2 cases, we identified 237 cases of SPS with PS from 74 additional included publications totaling 239 patients. Anxiety (56%) and depression (45%) were the most common PS in SPS. Mean diagnostic delay was 4.7 years. Among the 3 SPS phenotypes, the classic form was predominant (77%), followed by stiff-limb syndrome (13%) and progressive encephalomyelitis with rigidity and myoclonus (10%). The most frequent etiology of SPS with PS was autoimmune (90%), followed by cryptogenic (7%) and paraneoplastic forms (7%). These patients were mainly treated with immune-mediated therapies and GABAergic drugs. CONCLUSIONS: Our review revealed that the most common PS of SPS are anxiety and depression occurring mostly in autoimmune and classic forms, allowing a clearer understanding of this entity, which may lead to earlier diagnosis and better outcome.

Measuring discrimination experienced by people with a mental illness: replication of the short-form DISCUS in six world regions.

BACKGROUND: The Discrimination and Stigma Scale (DISC) is a patient-reported outcome measure which assesses experiences of discrimination among persons with a mental illness globally. METHODS: This study evaluated whether the psychometric properties of a short-form version, DISC-Ultra Short (DISCUS) (11-item), could be replicated in a sample of people with a wide range of mental disorders from 21 sites in 15 countries/territories, across six global regions. The frequency of experienced discrimination was reported. Scaling assumptions (confirmatory factor analysis, inter-item and item-total correlations), reliability (internal consistency) and validity (convergent validity, known groups method) were investigated in each region, and by diagnosis group. RESULTS: 1195 people participated. The most frequently reported experiences of discrimination were being shunned or avoided at work (48.7%) and discrimination in making or keeping friends (47.2%). Confirmatory factor analysis supported a unidimensional model across all six regions and five diagnosis groups. Convergent validity was confirmed in the total sample and within all regions [ Internalised Stigma of Mental Illness (ISMI-10): 0.28-0.67, stopping self: 0.54-0.72, stigma consciousness: -0.32-0.57], as was internal consistency reliability (α = 0.74-0.84). Known groups validity was established in the global sample with levels of experienced discrimination significantly higher for those experiencing higher depression [Patient Health Questionnaire (PHQ)-2: p < 0.001], lower mental wellbeing [Warwick-Edinburgh Well-being Scale (WEMWBS): p < 0.001], higher suicidal ideation [Beck Hopelessness Scale (BHS)-4: p < 0.001] and higher risk of suicidal behaviour [Suicidal Ideation Attributes Scale (SIDAS): p < 0.001]. CONCLUSIONS: The DISCUS is a reliable and valid unidimensional measure of experienced discrimination for use in global settings with similar properties to the longer DISC. It offers a brief assessment of experienced discrimination for use in clinical and research settings.

Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources.

BACKGROUND: Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system. AIMS: We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia. METHODS: We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004. RESULTS: Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities. CONCLUSIONS: The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Incidence of treatment-resistant depression during the first mood depressive episode.

INTRODUCTION: In spite of several approaches and therapeutic measures, treatment-resistant depression (TRD) continues to inflict serious, individual and collective consequences. Therefore, there is a persistent need to scrutinize the concept of TRD in order to adapt the therapeutic strategies. AIM: To estimate the incidence of TRD in patients with a first major depressive episode (MDD), and study factors associated with resistance. METHODS: A descriptive prospective longitudinal study of outpatients with a first MDD, was conducted. Patients with a history of subthreshold hypomania were excluded. Eligible patients were put on a selective serotonin reuptake inhibitor (SSRI), either fluoxetine or sertraline. Participants were followed regularly until they had a therapeutic response or they met the criteria for TRD. RESULTS: The study involved 82 adults. The incidence of treatment-resistant depression was 19.4% CI95%=[5.5-33.3]. Among the sociodemographic and clinical factors, family history of psychosis (p=0.038) and chronic respiratory comorbidities (p=0.016) were associated with TRD. The small size of the sample is a potential limitation of this study. Besides, the use of only two SSRIs could influence the results. CONCLUSION: In this study, the incidence of TRD was at the lower limit of the rates reported in clinical studies. Clinical factors associated with TRD suggest the relevance of genotype analysis to identify patients with TRD. Furthermore, our results highlight the importance of heeding comorbidities to optimize care. Larger multicenter studies are needed to generalize.

Psychiatric disturbances in idiopathic epilepsy.

INTRODUCTION: The relationship between epilepsy and psychiatric disorders has been highlighted for a long time. Idiopathic epilepsy is known to have a benign course in most cases. However, the association of psychiatric disturbances could worsen the disease outcome. AIM: To study the frequency of psychiatric symptoms in patients with idiopathic epilepsy, and to assess the determinant factors in the patient group with these manifestations. METHODS: In one-year prospective study, consecutive patients diagnosed with idiopathic epilepsy were included. Those with a known psychiatric follow-up or with post ictal psychiatric disturbances were excluded. Psychiatric symptoms were evaluated with the Neurological Disorders Depression Inventory for Epilepsy, the Generalized Anxiety Disorder - 7 and the Neuropsychiatric Inventory Scale. Demographic and clinical data were collected and analyzed. RESULTS: Among 101 consecutive patients with idiopathic epilepsy, psychiatric symptoms were diagnosed in 61% of them. Anxiety (36.6%), psychotic features (21%) and depression (15.8 %) were the most commonly found psychiatric manifestations. Female gender (p < 10-3) and longer duration of epilepsy (p = 0.046) were significantly associated with occurrence of psychiatric disturbances. Patients under Carbamazepine and Valproic acid showed a lower frequency of depression (respectively p = 0.018 and p = 0.003). CONCLUSIONS: Occurrence of psychiatric disturbances was frequent in idiopathic epilepsy, with psychotic manifestations and anxiety being the most common of them. Female gender and long disease course were the main determining factors of psychiatric manifestations and should be considered in management of idiopathic epilepsy.

Training for mental health professionals in responding to experienced and anticipated mental health-related discrimination (READ-MH): protocol for an international multisite feasibility study.

BACKGROUND: Mental health and other health professionals working in mental health care may contribute to the experiences of stigma and discrimination among mental health service users but can also help reduce the impact of stigma on service users. However, few studies of interventions to equip such professionals to be anti-stigma agents took place in high-income countries. This study assesses the feasibility, potential effectiveness and costs of Responding to Experienced and Anticipated Discrimination training for health professionals working in mental health care (READ-MH) across low- and middle-income countries (LMICs). METHODS: This is an uncontrolled pre-post mixed methods feasibility study of READ-MH training at seven sites across five LMICs (China, Ethiopia, India, Nepal and Tunisia). OUTCOME MEASURES: knowledge based on course content, attitudes to working to address the impact of stigma on service users and skills in responding constructively to service users' reports of discrimination. The training draws upon the evidence bases for stigma reduction, health advocacy and medical education and is tailored to sites through situational analyses. Its content, delivery methods and intensity were agreed upon through a consensus exercise with site research teams. READ-MH will be delivered to health professionals working in mental health care immediately after baseline data collection; outcome measures will be collected post-training and 3 months post-baseline, followed by qualitative data collection analysed using a combined deductive and inductive approach. Fidelity will be rated during the delivery of READ-MH, and data on training costs will be collected. Quantitative data will be assessed using generalised linear mixed models. Qualitative data will be evaluated by thematic analysis to identify feedback about the training methods and content, including the implementability of the knowledge and skills learned. Pooled and site-specific training costs per trainee and per session will be reported. CONCLUSIONS: The training development used a participatory and contextualised approach. Evaluation design strengths include the diversity of settings, the use of mixed methods, the use of a skills-based measure and the knowledge and attitude measures aligned to the target population and training. Limitations are the uncertain generalisability of skills performance to routine care and the impact of COVID-19 restrictions at several sites limiting qualitative data collection for situational analyses.

Akathisia Among Patients Undergoing Antipsychotic Therapy: Prevalence, Associated Factors, and Psychiatric Impact.

OBJECTIVES: The prevalence of akathisia is variably reported in the literature and its psychiatric impact is little studied. The aim of this study was to establish the prevalence, the associated factors, and the psychiatric impact of akathisia among patients undergoing antipsychotic treatment. METHODS: A cross-sectional descriptive study was carried out at the Department of Psychiatry A, at Razi Hospital, in Tunis. It included patients with psychosis, undergoing antipsychotic treatment, from June 2016 to February 2017. Akathisia was diagnosed according to the Barnes Akathisia Scale. RESULTS: The prevalence of akathisia was 19.5% (n = 24, schizophrenia/schizoaffective disorder, n = 20; bipolar disorder, n = 4). The delay between the diagnosis of the disease and the onset of akathisia was 7.1 ± 8.8 years. Among the sample of patients with akathisia, 20/24 were on monotherapy of which 14 on conventional antipsychotics and six on atypical antipsychotics. Patients with akathisia were on atypical (8/24), low-potency conventional (4/24), or high-potency conventional (17/24) antipsychotics. The average dose of antipsychotics in chlorpromazine equivalent was 2294.5 ± 3037.7 mg. After adjusting for confounders, the only factor significantly positively associated with the diagnosis of akathisia was the dose of antipsychotics prescribed ( P = 0.01). The following psychiatric manifestations were reported by patients with akathisia: dysphoria/irritability (16/23), anxiety (18/24), sadness (15/24), suicidal thoughts (11/24), heteroaggressivity (8/23), sleep disturbances (16/24), and suicidal attempts (9/24). CONCLUSIONS: Despite the high psychiatric and social burden of akathisia, it remains largely underdiagnosed and undertreated, because in part of its subjective component.

Training for mental health professionals in responding to experienced and anticipated mental health related discrimination (READ-MH): protocol for an international multisite feasibility study.

Background: Mental health and other health professionals working in mental health care may contribute to the experiences of stigma and discrimination among mental health service users, but can also help reduce the impact of stigma on service users. However the few studies of interventions to equip such professionals to be anti-stigma agents those took place in High-Income Countries. This study assesses the feasibility, potential effectiveness and costs of Responding to Experienced and Anticipated Discrimination training for health professionals working in mental health care (READ-MH) across Low- and Middle-Income Countries (LMICs). Methods: This is an uncontrolled pre-post mixed methods feasibility study of READ-MH training at seven sites across five LMICs (China, Ethiopia, India, Nepal, and Tunisia). Outcome measures: knowledge based on course content; attitudes to working to address the impact of stigma on service users; and skills in responding constructively to service users' reports of discrimination. The training draws upon the evidence bases for stigma reduction, health advocacy and medical education and is tailored to sites through situational analyses. Its content, delivery methods and intensity were agreed through a consensus exercise with site research teams. READ-MH will be delivered to health professionals working in mental health care immediately after baseline data collection; outcome measures will be collected post-training and three months post-baseline, followed by qualitative data collection. Fidelity will be rated during delivery of READ-MH, and data on training costs will be collected. Quantitative data will be assessed using generalised linear mixed models. Qualitative data will be evaluated by thematic analysis to identify feedback about the training methods and content, including the implementability of the knowledge and skills learned. Pooled and site-specific training costs per trainee and per session will be reported. Conclusions: The training development used a participatory and contextualized approach. Evaluation design strengths include the diversity of settings; the use of mixed methods; the use of a skills-based measure; and knowledge and attitude measures aligned to the target population and training. Limitations are the uncertain generalisability of skills performance to routine care, and the impact of COVID-19 restrictions at several sites limiting qualitative data collection for situational analyses.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study.

BACKGROUND: Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia. METHODS: Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level. RESULTS: As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly. CONCLUSIONS: This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.