Reliability and validity of depression anxiety stress scale (DASS)-21 in screening for common mental disorders among postpartum women in Malawi.

BACKGROUND: Approximately one in five women who have recently given birth suffer from common mental disorder (CMD), particularly depression and/or anxiety. Most available CMD screening tools in most low- and middle-income countries do not screen for more than one mental health problem. Having a screening tool that is free to use, short in assessment time, and used to screen for more than one CMD is appealing in a resource-constrained setting. METHOD: We conducted a criterion validation study of the Chichewa translated and adapted DASS-21 instrument against gold standard diagnoses of depression and anxiety disorders using an independently administered Structured Clinical Interview for DSM-IV (SCID). We compared the performance of the DASS-depression subscale with the Edinburgh Postpartum Depression Scale (EPDS). Internal reliability was reported using both Cronbach's alpha and ordinal alpha. The DASS-21 and EPDS ability to discriminate cases from non-cases was assessed by receiver operating characteristics (ROC) analysis. We selected cut-off points for DASS-21 and EPDS that maximise both sensitivity and specificity. RESULTS: One hundred fifteen participants were administered all the measures. Approximately 11.3% and 14.8% had depression and anxiety diagnoses respectively using SCID. The overall Cronbach's alpha for the DASS-21 scale was 0.74. The DASS-21 subscales had Cronbach's alpha values of 0.66, 0.29 and 0.52 for depression (DASS-D), anxiety (DASS-A) and stress (DASS-S), respectively. The ordinal alpha for DASS-D, DASS-A and DASS-S subscales were 0.83, 0.74 and 0.87, respectively. The area under the ROC curve was 0.76 (95% CI: 0.61; 0.91) for DASS-D and 0.65 for DASS-A. At a cut-off point of one or more, the sensitivity and specificity for DASS-D were 69.2% and 75.5%, whilst DASS-A was 52.9% and 75.5%, respectively. Pearson correlation coefficient for the association between DASS-D and EPDS was r = 0.61, p < 0.001. CONCLUSION: The DASS-21 had good internal reliability (Cronbach's alpha), and its ordinal alpha demonstrated good internal reliability for all its sub-scales. Regarding the criterion validation, only the DASS-D and EPDS demonstrated a satisfactory ability to discriminate cases from non-cases. Our findings suggest that health practitioners can use DASS-D as an alternative tool in screening depression as it has fewer questions than EPDS.

Overestimation of Postpartum Depression Prevalence Based on a 5-item Version of the EPDS: Systematic Review and Individual Participant Data Meta-analysis.

OBJECTIVE: The Maternal Mental Health in Canada, 2018/2019, survey reported that 18% of 7,085 mothers who recently gave birth reported "feelings consistent with postpartum depression" based on scores ≥7 on a 5-item version of the Edinburgh Postpartum Depression Scale (EPDS-5). The EPDS-5 was designed as a screening questionnaire, not to classify disorders or estimate prevalence; the extent to which EPDS-5 results reflect depression prevalence is unknown. We investigated EPDS-5 ≥7 performance relative to major depression prevalence based on a validated diagnostic interview, the Structured Clinical Interview for DSM (SCID). METHODS: We searched Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and the Web of Science Core Collection through June 2016 for studies with data sets with item response data to calculate EPDS-5 scores and that used the SCID to ascertain depression status. We conducted an individual participant data meta-analysis to estimate pooled percentage of EPDS-5 ≥7, pooled SCID major depression prevalence, and the pooled difference in prevalence. RESULTS: A total of 3,958 participants from 19 primary studies were included. Pooled prevalence of SCID major depression was 9.2% (95% confidence interval [CI] 6.0% to 13.7%), pooled percentage of participants with EPDS-5 ≥7 was 16.2% (95% CI 10.7% to 23.8%), and pooled difference was 8.0% (95% CI 2.9% to 13.2%). In the 19 included studies, mean and median ratios of EPDS-5 to SCID prevalence were 2.1 and 1.4 times. CONCLUSIONS: Prevalence estimated based on EPDS-5 ≥7 appears to be substantially higher than the prevalence of major depression. Validated diagnostic interviews should be used to establish prevalence.

The validity of the patient health Questionnaire-9 to screen for depression in patients with type-2 diabetes mellitus in non-communicable diseases clinics in Malawi.

BACKGROUND: Depression is a global problem, affecting populations worldwide, but is too often under-diagnosed. The identification of depression among patients with diabetes is important because depression is prevalent in this group and can complicate diabetes management. OBJECTIVES: The aim of the study was to determine the sensitivity and specificity of the PHQ-9 in the detection of depression among patients with type-2 diabetes mellitus attending non-communicable diseases (NCD) clinics in Malawi. METHODS: We conducted a validation study of the Patient Health Questionnaire (PHQ-9) among 323 patients with type-2 diabetes mellitus who attended two NCD clinics in one of the 28 districts of Malawi. The participants were screened consecutively using the nine-item PHQ-9 in Chichewa by a research assistant and completed a diagnostic interview using the Structured Clinical Interview for DSM-IV (SCID) for depression with a mental health clinician. We evaluated both content validity based on expert judgement and criterion validity of the Patient Health Questionnaire (PHQ-9) based on performance against the SCID. The PHQ-9 cutpoint that maximized sensitivity plus specificity was selected to report test characteristics. RESULTS: Using the SCID for depression, the prevalence of minor or major depression was 41% (133/323). The internal consistency estimate for the PHQ-9 was 0.83, with an area under the receiver operator curve (AUC) of 0.93 (95% CI, [0.91-0.96]). Using the optimal cut-point of ≥9, the PHQ-9 had a sensitivity of 64% and a specificity of 94% in detecting both minor and major depression, with likelihood ratio-positive = 10.1 and likelihood ratio negative =0.4 as well as overall correct classification (OCC) rate of 81%. CONCLUSIONS: This is the first validation study of the PHQ-9 in NCD clinics in Malawi. Depression was highly prevalent in this sample. The PHQ-9 demonstrated reasonable accuracy in identifying cases of depression and is a useful screening tool in this setting. Health care workers in NCD clinics can use the PHQ-9 to identify depression among their patients with those having a positive screen followed up by additional diagnostic assessment to confirm diagnosis. TRIAL REGISTRATION: PACTR201807135104799 . Retrospectively registered on 12 July 2018.

Associations between antenatal depression and neonatal outcomes in Malawi.

Studies from several low- and middle-income countries have shown that antenatal depression may be a risk factor for poor neonatal outcomes. However, those studies conducted in sub-Saharan Africa have not consistently demonstrated this association. We set out to investigate whether antenatal depression is associated with shorter duration of pregnancy and reduced newborn size in rural Malawi. Pregnant women recruited from four antenatal clinics to the International Lipid-Based Nutrient Supplements Project-DYAD-Malawi (iLiNS-DYAD-M) randomised controlled trial of nutrient supplementation were screened for antenatal depression in the second or third trimester using a locally validated version of the Self Reporting Questionnaire (SRQ). Outcomes were duration of pregnancy, birthweight, newborn length for age z-score (LAZ), head circumference z-score, and mid-upper arm circumference (MUAC). Other potential confounding factors and predictors of birth outcome were measured and adjusted for in the analysis. 1,391 women were enrolled to the trial. 1,006/1,391 (72.3%) of these women completed an SRQ and gave birth to a singleton infant whose weight was measured within 2 weeks of birth. 143/1,006 (14.2%) scored SRQ ≥ 8, indicating likely depression. Antenatal depression was not associated with birth weight, duration of pregnancy, newborn LAZ, or head-circumference Z-score. There was an inverse association with newborn MUAC (adjusted mean difference - 0.2 cm (95% CI -0.4 to 0, p = 0.021) the significance of which is unclear. The study was conducted within a randomised controlled trial of nutritional supplementation and there was a high proportion of missing data in some enrolment sites; this may have affected the validity of our findings.

Predictors and pathways of language and motor development in four prospective cohorts of young children in Ghana, Malawi, and Burkina Faso.

BACKGROUND: Previous reviews have identified 44 risk factors for poor early child development (ECD) in low- and middle-income countries. Further understanding of their relative influence and pathways is needed to inform the design of interventions targeting ECD. METHODS: We conducted path analyses of factors associated with 18-month language and motor development in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Ghana (n = 1,023), Malawi (n = 675 and 1,385), and Burkina Faso (n = 1,122). In two cohorts, women were enrolled during pregnancy. In two cohorts, infants were enrolled at 6 or 9 months. In multiple linear regression and structural equation models (SEM), we examined 22 out of 44 factors identified in previous reviews, plus 12 additional factors expected to be associated with ECD. RESULTS: Out of 42 indicators of the 34 factors examined, 6 were associated with 18-month language and/or motor development in 3 or 4 cohorts: child linear and ponderal growth, variety of play materials, activities with caregivers, dietary diversity, and child hemoglobin/iron status. Factors that were not associated with child development were indicators of maternal Hb/iron status, maternal illness and inflammation during pregnancy, maternal perceived stress and depression, exclusive breastfeeding during 6 months postpartum, and child diarrhea, fever, malaria, and acute respiratory infections. Associations between socioeconomic status and language development were consistently mediated to a greater extent by caregiving practices than by maternal or child biomedical conditions, while this pattern for motor development was not consistent across cohorts. CONCLUSIONS: Key elements of interventions to ensure quality ECD are likely to be promotion of caregiver activities with children, a variety of play materials, and a diverse diet, and prevention of faltering in linear and ponderal growth and improvement in child hemoglobin/iron status.

The impact of maternal diet fortification with lipid-based nutrient supplements on postpartum depression in rural Malawi: a randomised-controlled trial.

Perinatal depression is highly prevalent in low-and-middle-income countries and has been linked to poor child health. Suboptimal maternal nutrition may be a risk factor for perinatal depression. In this randomised-controlled trial conducted in rural Malawi, we set out to test the hypothesis that women taking a fatty acid-rich lipid-based nutrient supplement (LNS) would have fewer depressive symptoms postpartum than those taking iron-folate (IFA) or multiple-micronutrient (MMN) capsules. Women were recruited from antenatal clinics and randomised to receive LNS or MMN during pregnancy and for 6 months postpartum, or IFA during pregnancy only. Maternal depressive symptoms were measured using validated translations of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS), antenatally (SRQ only) and at 6 months postpartum (SRQ and EPDS). Analysis was by modified intention to treat. One thousand three hundred and ninety one women were randomised (LNS = 462, MMN = 466, IFA = 463). The groups were similar across a range of baseline variables. At 6 months postpartum, 1078 (77.5%) had SRQ completed; mean (SD) scores were LNS 1.76(2.73), MMN 1.92(2.75), IFA 1.71(2.66), P = 0.541. One thousand and fifty seven (76.0%) had EPDS completed; mean (SD) scores were LNS 5.77(5.53), MMN 5.43(4.97), IFA 5.52(5.18), P = 0.676. There were no statistically significant differences between the groups on SRQ or EPDS scores (continuous or dichotomised) in unadjusted or adjusted models. In conclusion, fortification of maternal diet with LNS compared with MMN or IFA did not reduce postnatal depressive symptoms in this study.

Perinatal distress and depression in Malawi: an exploratory qualitative study of stressors, supports and symptoms.

Quantitative studies have demonstrated that depression and anxiety in the perinatal period are common amongst women in low- and middle-income countries and are associated with a range of psychosocial and health-related stressors. In this exploratory qualitative study conducted in southern Malawi, we investigated the thoughts and emotions experienced by women in pregnancy and the postnatal period, their expectations of support from husband and others, problems and difficulties faced and the impact of these on psychological wellbeing. We conducted 11 focus group discussions with a total of 98 parous women. A thematic analysis approach was used. Three major themes were identified: pregnancy as a time of uncertainty, the husband (and others) as support and stressor, and the impact of stressors on mental health. Pregnancy was seen as bringing uncertainty about the survival and wellbeing of both mother and unborn child. Poverty, lack of support, HIV, witchcraft and child illness were identified as causes of worry in the perinatal period. Husbands were expected to provide emotional, financial and practical support, with wider family and friends having a lesser role. Infidelity, abuse and abandonment were seen as key stressors in the perinatal period. Exposure to stressors was understood to lead to altered mental states, the symptoms of which are consistent with the concept of common perinatal mental disorder. This study confirms and expands on evidence from quantitative studies and provides formative data for the development of a psychosocial intervention for common perinatal mental disorder in Malawi.

Psychological distress in mothers of children admitted to a nutritional rehabilitation unit in Malawi - a comparison with other paediatric wards.

In a previous study we found a very high prevalence of psychological distress in mothers of children admitted to a nutritional rehabilitation unit (NRU) in Malawi, Africa. The objective of this study was to compare the prevalence and severity of maternal distress within the NRU with that in other paediatric wards. Given the known association between poor maternal psychological well-being and child undernutrition in low- and middle-income countries, we hypothesised that distress would be higher among NRU mothers. Mothers of consecutive paediatric inpatients in a NRU, a high-dependency (and research) unit and an oncology ward were assessed for psychological distress using the Self-Reporting Questionnaire (SRQ). Two hundred sixty-eight mothers were interviewed (90.3% of eligible). The prevalence of SRQ score ≥8 was 35/150 {23.3% [95% confidence interval (CI) 16.8- 30.9%]} on the NRU, 13/84 [15.5% (95% CI 8.5-25.0%)] on the high-dependency unit and 7/34 [20.6% (95% CI 8.7-37.9%)] on the oncology ward (χ(2) = 2.04, P = 0.36). In linear regression analysis, the correlates of higher SRQ score were child diarrhoea on admission, child diagnosed with tuberculosis, and maternal experience of abuse by partner; child height-for-age z-score fell only just outside significance (P = 0.05). In summary, we found no evidence of greater maternal distress among the mothers of severely malnourished children within the NRU compared with mothers of paediatric inpatients with other severe illnesses. However, in support of previous research findings, we found some evidence that poor maternal psychological well-being is associated with child stunting and diarrhoea.

Validation of the multi-dimensional scale of perceived social support (MSPSS) and the relationship between social support, intimate partner violence and antenatal depression in Malawi.

BACKGROUND: Lack of social support is an important risk factor for antenatal depression and anxiety in low- and middle-income countries. We translated, adapted and validated the Multi-dimensional Scale of Perceived Social Support (MSPSS) in order to study the relationship between perceived social support, intimate partner violence and antenatal depression in Malawi. METHODS: The MSPSS was translated and adapted into Chichewa and Chiyao. Five hundred and eighty-three women attending an antenatal clinic were administered the MSPSS, depression screening measures, and a risk factor questionnaire including questions about intimate partner violence. A sub-sample of participants (n = 196) were interviewed using the Structured Clinical Interview for DSM-IV to diagnose major depressive episode. Validity of the MSPSS was evaluated by assessment of internal consistency, factor structure, and correlation with Self Reporting Questionnaire (SRQ) score and major depressive episode. We investigated associations between perception of support from different sources (significant other, family, and friends) and major depressive episode, and whether intimate partner violence was a moderator of these associations. RESULTS: In both Chichewa and Chiyao, the MSPSS had high internal consistency for the full scale and significant other, family, and friends subscales. MSPSS full scale and subscale scores were inversely associated with SRQ score and major depression diagnosis. Using principal components analysis, the MSPSS had the expected 3-factor structure in analysis of the whole sample. On confirmatory factor analysis, goodness-of-fit indices were better for a 3-factor model than for a 2-factor model, and met standard criteria when correlation between items was allowed. Lack of support from a significant other was the only MSPSS subscale that showed a significant association with depression on multivariate analysis, and this association was moderated by experience of intimate partner violence. CONCLUSIONS: The MSPSS is a valid measure of perceived social support in Malawi. Lack of support by a significant other is associated with depression in pregnant women who have experienced intimate partner violence in this setting.

A cross-sectional study of antenatal depression and associated factors in Malawi.

Depression, and disabling levels of mixed depressive, anxious and somatic symptoms, termed common mental disorder, occurring in the perinatal period are an important health problem in low- and middle-income countries. In this cross-sectional study, pregnant women were recruited from a district hospital antenatal clinic in Malawi. Symptoms of depression and anxiety, and non-specific somatic symptoms commonly associated with distress, were measured using validated local versions of the Self Reporting Questionnaire (SRQ). In a sub-sample, Diagnostic Statistical Manual (DSM)-IV diagnoses of major and minor depressive disorders were made using the Structured Clinical Interview for DSM-IV. Maternal socio-demographic and health variables were measured, and associations with SRQ score and depression diagnosis were determined. Of 599 eligible women, 583 were included in the analysis. The adjusted weighted prevalence of current major depressive episode and current major or minor depressive episode were 10.7 % (95 % CI 6.9-14.5 %) and 21.1 % (95 % CI 15.5-26.6 %), respectively. On multivariate analysis, SRQ score was significantly associated with lower perceived social support, experience of intimate partner violence, having had a complication in a previous delivery, higher maternal mid-upper arm circumference and more years of schooling. Major depressive episode was associated with lower perceived social support and experience of intimate partner violence. This study demonstrates that antenatal depression/CMD is common in Malawi and is associated with factors that may be amenable to psychosocial interventions.

Piloting a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer delivered (THPP), in a primary care setting in Lilongwe District, Malawi.

Despite the evidence for the effectiveness of psychosocial interventions for perinatal depression, their uptake is low in Low- and Middle-Income Countries. Reasons for this include the lack of contextually adapted interventions and mental health specialists to deliver them. This study aimed to test the acceptability and feasibility of a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer Delivered, adapted for use in rural Malawi. A multi-method evaluation of feasibility and acceptability of the intervention was conducted using a one-group pretest-posttest quasi-experimental design and an exploratory qualitative study. Pre-post intervention change in depression scores (paired t-test) and recruitment, retention and session adherence rates were calculated. Qualitative data were collected through 29 in-depth interviews (22 mothers and 7 peer volunteers) and 1 Focus Group Discussion (18 mothers). Thematic analysis approach was used to analyse qualitative data. Seven (7) out of 8 peer volunteers were successfully trained to deliver the intervention. A total of 31 pregnant women with Edinburgh Postnatal Depression Scale (EPDS) score ≥12 were offered intervention, of whom 24 were enrolled (recruitment rate 77.4%). Out of these 24 women, 22 completed the intervention (retention rate 91.6%). Mean difference between pre- and post-test EPDS scores one week after 8th session was 7.59 (95% CI 4.98 to 10.19), p<0.001. Qualitative evaluation showed that the intervention was acceptable despite some challenges including stigma and issues around incentivization of peer volunteers. The Thinking Healthy Programme-Peer Delivered, adapted for use in Malawi, was feasible to deliver and acceptable to its target population. The intervention may be useful in management of perinatal depression in primary care settings in Malawi. However, definitive trials are needed to evaluate its effectiveness.

Exploring the return-on-investment for scaling screening and psychosocial treatment for women with common perinatal mental health problems in Malawi: Developing a cost-benefit-calculator tool.

This study sought to develop a user-friendly decision-making tool to explore country-specific estimates for costs and economic consequences of different options for scaling screening and psychosocial interventions for women with common perinatal mental health problems in Malawi. We developed a simple simulation model using a structure and parameter estimates that were established iteratively with experts, based on published trials, international databases and resources, statistical data, best practice guidance and intervention manuals. The model projects annual costs and returns to investment from 2022 to 2026. The study perspective is societal, including health expenditure and productivity losses. Outcomes in the form of health-related quality of life are measured in Disability Adjusted Life Years, which were converted into monetary values. Economic consequences include those that occur in the year in which the intervention takes place. Results suggest that the net benefit is relatively small at the beginning but increases over time as learning effects lead to a higher number of women being identified and receiving (cost­)effective treatment. For a scenario in which screening is first provided by health professionals (such as midwives) and a second screening and the intervention are provided by trained and supervised volunteers to equal proportions in group and individual sessions, as well as in clinic versus community setting, total costs in 2022 amount to US$ 0.66 million and health benefits to US$ 0.36 million. Costs increase to US$ 1.03 million and health benefits to US$ 0.93 million in 2026. Net benefits increase from US$ 35,000 in 2022 to US$ 0.52 million in 2026, and return-on-investment ratios from 1.05 to 1.45. Results from sensitivity analysis suggest that positive net benefit results are highly sensitive to an increase in staff salaries. This study demonstrates the feasibility of developing an economic decision-making tool that can be used by local policy makers and influencers to inform investments in maternal mental health.

Can biosampling really be "non-invasive"? An examination of the socially invasive nature of physically non-invasive biosampling in urban and rural Malawi.

Glucocorticoids are understood to represent useful biomarkers of stress and can be measured in saliva, hair, and breastmilk. The collection of such biosamples is increasingly included in biobank and cohort studies. While collection is considered "non-invasive" by biomedical researchers (compared to sampling blood), community perspectives may differ. This cross-sectional, qualitative study utilising eight focus groups aimed to determine the feasibility and acceptability of collecting ostensibly "non-invasive" biological samples in Malawi. Breastfeeding women, couples, field workers, and healthcare providers were purposively sampled. Data about prior understandings of, barriers to, and feasibility of "non-invasive" biosampling were analysed. Participants described biomaterials intended for "non-invasive" collection as sometimes highly sensitive, with sampling procedures raising community concerns. Sampling methods framed as physically "non-invasive" within biomedicine can consequently be considered socially "invasive" by prospective sample donors. Biomedical and community framings of "invasiveness' can therefore diverge, and the former must respond to and be informed by the perspectives of the latter. Further, considerations of collection procedures are shaped by therapeutic misconceptions about the immediate health-related utility of biomedical and public health research. When researchers engage with communities about biosampling, they must ensure they are not furthering therapeutic misconceptions and actively seek to dispel these.

Association between physical multimorbidity and common mental health disorders in rural and urban Malawian settings: Preliminary findings from Healthy Lives Malawi long-term conditions survey.

In low-income Africa, the epidemiology of physical multimorbidity and associated mental health conditions is not well described. We investigated the multimorbidity burden, disease combinations, and relationship between physical multimorbidity and common mental health disorders in rural and urban Malawi using early data from 9,849 adults recruited to an on-going large cross-sectional study on long-term conditions, initiated in 2021. Multimorbidity was defined as having two or more measured (diabetes, hypertension) or self-reported (diabetes, hypertension, disability, chronic pain, HIV, asthma, stroke, heart disease, and epilepsy) conditions. Depression and anxiety symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder scale (GAD-7) and defined by the total score (range 0-27 and 0-21, respectively). We determined age-standardized multimorbidity prevalence and condition combinations. Additionally, we used multiple linear regression models to examine the association between physical multimorbidity and depression and anxiety symptom scores. Of participants, 81% were rural dwelling, 56% were female, and the median age was 30 years (Inter Quartile Range 21-43). The age-standardized urban and rural prevalence of multimorbidity was 14.1% (95% CI, 12.5-15.8%) and 12.2% (95% CI, 11.6-12.9%), respectively. In adults with two conditions, hypertension, and disability co-occurred most frequently (18%), and in those with three conditions, hypertension, disability, and chronic pain were the most common combination (23%). Compared to adults without physical conditions, having one (B-Coefficient (B) 0.79; 95% C1 0.63-0.94%), two- (B 1.36; 95% CI 1.14-1.58%), and three- or more- physical conditions (B 2.23; 95% CI 1.86-2.59%) were associated with increasing depression score, p-trend <0.001. A comparable 'dose-response' relationship was observed between physical multimorbidity and anxiety symptom scores. While the direction of observed associations cannot be determined with these cross-sectional data, our findings highlight the burden of multimorbidity and the need to integrate mental and physical health service delivery in Malawi.

Maternal mental health research in Malawi: Community and healthcare provider perspectives on acceptability and ethicality.

Maternal mental health (MMH) is recognised as globally significant. The prevalence of depression and factors associated with its onset among perinatal women in Malawi has been previously reported, and the need for further research in this domain is underscored. Yet, there is little published scholarship regarding the acceptability and ethicality of MMH research to women and community representatives. The study reported here sought to address this in Malawi by engaging with communities and healthcare providers in the districts where MMH research was being planned. Qualitative data was collected in Lilongwe and Karonga districts through 20 focus group discussions and 40 in-depth interviews with community representatives and healthcare providers from January through April 2021. All focus groups and interviews were audio recorded, transcribed verbatim (in local languages Chichewa and Tumbuka), translated into English, and examined through thematic content analysis. Participants' accounts suggest that biopsychosocial MMH research could be broadly acceptable within the communities sampled, with acceptability framed in part through prior encounters with biomedical and public health research and care in these regions, alongside broader understandings of the import of MMH. Willingness and consent to participate do not depend on specifically biomedical understandings of MMH, but rather on familiarity with individuals regarded as living with mental ill-health. However, the data further suggest some 'therapeutic misconceptions' about MMH research, with implications for how investigations in this area are presented by researchers when recruiting and working with participants. Further studies are needed to explore whether accounts of the acceptability and ethicality of MMH research shift and change during and following research encounters. Such studies will enhance the production of granular recommendations for further augmenting the ethicality of biomedical and public health research and researchers' responsibilities to participants and communities.

Prevalence of mental distress in adults with and without a history of tuberculosis in an urban Zambian community.

People with tuberculosis (TB) are susceptible to mental distress. Mental distress can be driven by biological and socio-economic factors including poverty. These factors can persist beyond TB treatment completion yet there is minimal evidence about the mental health of TB survivors. A cross-sectional TB prevalence survey of adults was conducted in an urban community in Zambia. Survey participants were administered the five-item Self Reporting Questionnaire (SRQ-5) mental health screening tool to measure mental distress. Associations between primary exposure (history of TB) and other co-variates with mental distress were investigated using logistic regression. Of 3,393 study participants, 120 were TB survivors (3.5%). The overall prevalence of mental distress (SRQ-5 ≥ 4) in the whole study population was 16.9% (95% CI 15.6%-18.1%). Previous TB history was not associated with mental distress (OR 1.20, 95% CI 0.75-1.92, p-value 1.66). Mental distress was associated with being female (OR 1.23 95% CI 1.00-1.51), older age (OR 1.71 95% CI 1.09-2.68) and alcohol abuse (OR 1.81 95% CI 1.19-2.76). Our findings show no association between a previous TB history and mental distress. However, approximately one in six people in the study population screened positive for mental distress.

Pathways to care for psychosis in Malawi.

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Attitudes towards mental illness in Malawi: a cross-sectional survey.

BACKGROUND: Stigma and discrimination associated with mental illness are strongly linked to suffering, disability and poverty. In order to protect the rights of those with mental disorders and to sensitively develop services, it is vital to gain a more accurate understanding of the frequency and nature of stigma against people with mental illness. Little research about this issue has been conducted in Sub- Saharan Africa. Our study aimed to describe levels of stigma in Malawi. METHODS: A cross-sectional survey of patients and carers attending mental health and non-mental health related clinics in a general hospital in Blantyre, Malawi. Participants were interviewed using an adapted version of the questionnaire developed for the "World Psychiatric Association Program to Reduce Stigma and Discrimination Because of Schizophrenia". RESULTS: 210 participants participated in our study. Most attributed mental disorder to alcohol and illicit drug abuse (95.7%). This was closely followed by brain disease (92.8%), spirit possession (82.8%) and psychological trauma (76.1%). There were some associations found between demographic variables and single question responses, however no consistent trends were observed in stigmatising beliefs. These results should be interpreted with caution and in the context of existing research. Contrary to the international literature, having direct personal experience of mental illness seemed to have no positive effect on stigmatising beliefs in our sample. CONCLUSIONS: Our study contributes to an emerging picture that individuals in Sub-Saharan Africa most commonly attribute mental illness to alcohol/ illicit drug use and spirit possession. Our work adds weight to the argument that stigma towards mental illness is an important global health and human rights issue.

Views and experiences of traditional and Western medicine practitioners on potential collaboration in the care of people living with mental illness in Malawi.

Introduction: Collaboration between traditional and biomedical medicine can lead to holistic care and improved health outcomes for people with mental illnesses. The current study aimed to explore the views and experiences of traditional and western medicine practitioners on potential collaboration in the care of people living with mental illness in Blantyre, Malawi. Method: A phenomenological qualitative research design was used. Data were collected using both one-on-one in-depth interviews (IDIs) and focus group discussions (FGDs). Participants were traditional healers and western medicine practitioners in Blantyre, Malawi. We conducted 10 in-depth interviews with traditional healers, 4 focus group discussions (2 for traditional healers and 2 for western medicine practitioners) and 6 key informant interviews with leaders of the two groups. The sample was determined based on data saturation. Thematic analysis was used to analyse the data. We used a combination of deductive and inductive coding. Results: Five broad themes were identified from the data: experiences with collaboration, views on collaboration, models of collaboration, barriers to collaboration, and factors that can facilitate collaboration. participants had no experience of formal collaboration between traditional healers and western healthcare workers in the management of mental illness. However, some reported experience of successful collaborations in other health areas such as safe motherhood, tuberculosis and HIV/AIDS. Many participants showed a positive attitude toward collaboration and were in support of it. Barriers to collaboration included negative attitudes and a lack of resources. Factors that can facilitate collaboration were dialogue, training and respect. Referral and training were the preferred forms of collaboration. Conclusion: With proper structures and respectful dialogue, a collaboration between traditional and western medicine practitioners is possible in Blantyre, Malawi.