Making cities mental health friendly for adolescents and young adults.

Urban life shapes the mental health of city dwellers, and although cities provide access to health, education and economic gain, urban environments are often detrimental to mental health1,2. Increasing urbanization over the next three decades will be accompanied by a growing population of children and adolescents living in cities3. Shaping the aspects of urban life that influence youth mental health could have an enormous impact on adolescent well-being and adult trajectories4. We invited a multidisciplinary, global group of researchers, practitioners, advocates and young people to complete sequential surveys to identify and prioritize the characteristics of a mental health-friendly city for young people. Here we show a set of ranked characteristic statements, grouped by personal, interpersonal, community, organizational, policy and environmental domains of intervention. Life skills for personal development, valuing and accepting young people's ideas and choices, providing safe public space for social connection, employment and job security, centring youth input in urban planning and design, and addressing adverse social determinants were priorities by domain. We report the adversities that COVID-19 generated and link relevant actions to these data. Our findings highlight the need for intersectoral, multilevel intervention and for inclusive, equitable, participatory design of cities that support youth mental health.

Impact of war on HIV-related healthcare services and health workers in eastern Ukraine: a qualitative study.

The 2022 Russian invasion of Ukraine has caused serious challenges for healthcare workers (HCWs) and HIV-related healthcare services. This study assessed the effects of the invasion on HCWs wellbeing and on continuity of HIV services, using in-depth interviews with HCWs from facilities offering HIV antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) services in the Donetsk region of Eastern Ukraine. A directed content analysis, with both inductive and deductive approaches, was conducted. Ten HCWs (6 [60%] doctors, 4 [40%] nurses; 9 [90%] female) were interviewed. Six respondents were displaced from their homes and worksites, and all described stress and threats to emotional wellbeing. HCWs used online consultations, encrypted mobile communication, and multi-month dispensing to support continuity of ART and PrEP services. They noted immediate needs for psychological and financial support, and access to laptop computers and mobile communications to ensure continuity of HIV services. Priorities for restoration of services include repair of health facilities, restoration of laboratory services and supply chains, and return of personnel and patients. HCWs made innovative, rapid adaptations to HIV services to keep ART and PrEP services running, demonstrating the resolve of Ukrainian HCWs to maintain continuity of HIV services despite the disruptions of war.

An Application of Evidence-Based Approaches to Engage Young People in the Design of a Global Mental Health Databank.

INTRODUCTION: Engaging youth in mental health research and intervention design has the potential to improve their relevance and effectiveness. Frameworks like Roger Hart's ladder of participation, Shier's pathways to participation and Lundy's voice and influence model aim to balance power between youth and adults. Hart's Ladder, specifically, is underutilized in global mental health research, presenting new opportunities to examine power dynamics across various contexts. Drawing on Hart's ladder, our study examined youth engagement in mental health research across high- and middle-income countries using Internet-based technologies, evaluating youth involvement in decision-making and presenting research stages that illustrate these engagements. METHODS: We conducted a directed content analysis of youth engagement in the study using primary data from project documents, weekly AirTable updates and discussions and interviews with youth and the research consortium. Using Hart's Ladder as a framework, we describe youth engagement along rungs throughout different research stages: cross-cutting research process, onboarding, formative research and quantitative and qualitative study designs. RESULTS: Youth engagement in the MindKind study fluctuated between Rung 4 ('Assign, but informed') and Rung 7 ('Youth initiated and directed') on Hart's Ladder. Engagement was minimal in the early project stages as project structures and goals were defined, with some youth feeling that their experiences were underutilized and many decisions being adult-led. Communication challenges and structural constraints, like tight timelines and limited budget, hindered youth engagement in highest ladder rungs. Despite these obstacles, youth engagement increased, particularly in developing recruitment strategies and in shaping data governance models and the qualitative study design. Youth helped refine research tools and protocols, resulting in moderate to substantial engagement in the later research stages. CONCLUSION: Our findings emphasize the value of youth-adult partnerships, which offer promise in amplifying voices and nurturing skills, leadership and inclusiveness of young people. Youth engagement in project decision-making progressed from lower to higher rungs on Hart's Ladder over time; however, this was not linear. Effective youth engagement requires dynamic strategies, transparent communication and mutual respect, shaping outcomes that authentically reflect diverse perspectives and mental health experiences. PATIENT OR PUBLIC CONTRIBUTION: There was substantial patient and public involvement in this study. This paper reports findings on youth engagement conducted with 35 young people from India, South Africa and the United Kingdom, all of whom had lived experience of mental health challenges. Youth engagement in the MindKind study was coordinated and led by three professional youth advisors (PYAs) in these contexts, who were also young people with lived experience of mental health challenges. Each of the three study sites embedded a full-time, community-based PYA within their study team to inform all aspects of the research project, including the development of informational materials and the facilitation of Young People's Advisory Group (YPAG) sessions referenced in this paper. Each PYA also consulted with a site-specific YPAG that met bi-monthly throughout the project, shaping the formation of study materials and serving as a test group in both the quantitative and qualitative studies. Youth participants in this study also contributed extensively, engaging in data collection and manuscript writing. The following youth advisory panels members (J.B., L.B., D.O.J., M.V.) and all PYAs (E.B., S.R., R.S.) in the MindKind study contributed to the writing of this manuscript and are acknowledged as co-authors.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania.

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Global Mental Health: Where We Are and Where We Are Going.

PURPOSE OF REVIEW: To summarize recent findings in global mental health along several domains including socioeconomic determinants, inequities, funding, and inclusion in global mental health research and practice. RECENT FINDINGS: Mental illness continues to disproportionately impact vulnerable populations and treatment coverage continues to be low globally. Advances in integrating mental health care and adopting task-shifting are accompanied by implementation challenges. The mental health impact of recent global events such as the COVID-19 pandemic, geo-political events, and environmental change is likely to persist and require coordinated care approaches for those in need of psychosocial support. Inequities also exist in funding for global mental health and there has been gradual progress in terms of building local capacity for mental health care programs and research. Lastly, there is an increasing effort to include people with lived experiences of mental health in research and policy shaping efforts. The field of global mental health will likely continue to be informed by evidence and perspectives originating increasingly from low- and middle-income countries along with ongoing global events and centering of relevant stakeholders.

The global gap in treatment coverage for major depressive disorder in 84 countries from 2000-2019: A systematic review and Bayesian meta-regression analysis.

BACKGROUND: The treatment coverage for major depressive disorder (MDD) is low in many parts of the world despite MDD being a major contributor to disability globally. Most existing reviews of MDD treatment coverage do not account for potential sources of study-level heterogeneity that contribute to variation in reported treatment rates. This study aims to provide a comprehensive review of the evidence and analytically quantify sources of heterogeneity to report updated estimates of MDD treatment coverage and gaps by location and treatment type between 2000 and 2019. METHODS AND FINDINGS: A systematic review of the literature was conducted to identify relevant studies that provided data on treatment rates for MDD between January 1, 2000, and November 26, 2021, from 2 online scholarly databases PubMed and Embase. Cohort and cross-sectional studies were included if treatment rates pertaining to the last 12 months or less were reported directly or if sufficient information was available to calculate this along with 95% uncertainty intervals (UIs). Studies were included if they made use of population-based surveys that were representative of communities, countries, or regions under study. Studies were included if they used established diagnostic criteria to diagnose cases of MDD. Sample and methodological characteristics were extracted from selected studies. Treatment rates were modeled using a Bayesian meta-regression approach and adjusted for select covariates that quantified heterogeneity in the data. These covariates included age, sex, treatment type, location, and choice of MDD assessment tool. A total of 149 studies were included for quantitative analysis. Treatment coverage for health service use ranged from 51% [95% UI 20%, 82%] in high-income locations to 20% [95% UI 1%, 53%] in low- and lower middle-income locations. Treatment coverage for mental health service use ranged from 33% [95% UI 8%, 66%] in high-income locations to 8% [95% UI <1%, 36%] in low- and lower middle-income countries. Minimally adequate treatment (MAT) rates ranged from 23% [95% UI 2%, 55%] in high-income countries to 3% [95% UI <1%, 25%]) in low- and lower middle-income countries. A primary methodological limitation was the lack of sufficient data from low- and lower middle-income countries, which precluded our ability to provide more detailed treatment rate estimates. CONCLUSIONS: In this study, we observed that the treatment coverage for MDD continues to be low in many parts of the world and in particular in low- and lower middle-income countries. There is a continued need for routine data collection that will help obtain more accurate estimates of treatment coverage globally.

Stigma and utilization of treatment for adolescent perinatal depression in Ibadan Nigeria.

BACKGROUND: Depression is a common and severe disorder among low-income adolescent mothers in low-and middle-income countries where resources for treatment are limited. We wished to identify factors influencing health service utilization for adolescent perinatal depression, in Nigeria to inform new strategies of care delivery. METHODS: Focus Group Discussions (FGDs) were conducted among purposively selected low-income young mothers (with medical histories of adolescent perinatal depression), and separately with primary care clinicians treating this condition in Ibadan, Nigeria. Participants from this community-based study were from the database of respondents who participated in a previous randomized control trial (RCT) conducted between 2014 and 2016 in 28 primary health care facilities in the 11 Local government areas in Ibadan. Semi-structured interview guides, framed by themes of the Behavioral Model for Vulnerable Populations, was developed to obtain views of participants on the factors that promote or hinder help-seeking and engagement (see additional files 1 & 2). FGDs were conducted, and saturation of themes was achieved after discussions with six groups. Transcripts were analyzed using content analysis. RESULTS: A total of 42 participants, 17 mothers (who were adolescents at the time of the RCT), and 25 care providers participated in 6 FGDs. The availability of care for perinatal depression at the primary care level was an important enabling factor in healthcare utilization for the adolescents. Perceived health benefits of treatment received for perinatal depression were strong motivation for service use. Significant stigma and negative stereotypes expressed by care providers towards adolescent pregnancy and perinatal depression were obstacles to care. However, individual patient resilience was a major enabling factor, facilitating service engagement. Providers trained in the management of perinatal depression were perceived to deliver more tolerant and supportive care that adolescent mothers valued. CONCLUSIONS: Participants identified unsupportive and stigmatizing clinic environments towards pregnant and parenting adolescents as significant barriers to accessing available care. Interventions to reduce stigma among healthcare providers may improve services for this vulnerable population.

Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps.

Pamela Collins and colleagues explain the research and policy approaches needed globally to ensure children with developmental delays and disabilities are fully included in health and education services.

Passive Suicidal Ideation and Community Mental Health Resources in South Africa.

South African communities continue to experience elevated incidence and prevalence of HIV infection. Passive suicidal ideation (PSI) may be one expression of distress in high prevalence communities. We report the prevalence of PSI and examine the relationship between PSI and participation in community organizations in a semi-rural sample of South African adults (N = 594). The prevalence of PSI in the 2 weeks prior to the interview was 9.1 %. Members of burial societies (Χ (2) = 7.34; p = 0.01) and stokvels (Χ (2) = 4.1; p = 0.04) (community-based savings groups) reported significantly less PSI compared to other respondents. Using a multivariate model adjusted for demographic characteristics, psychological distress, and socioeconomic status, we found lower odds of reporting PSI for members of burial societies (OR 0.48, CI 0.25 -0.91). Participation in community organizations that provide contextually salient resources in settings with high levels of distress may be a resource for mental health.

Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review.

OBJECTIVE: People with serious mental illness (SMI) die at least 11 years earlier than the general U.S. population, on average, due largely to cardiovascular disease (CVD). Disparities in CVD morbidity and mortality also occur among some U.S. racial and ethnic minorities. The combined effect of race/ethnicity and SMI on CVD-related risk factors, however, remains unclear. To address this gap, we conducted a critical literature review of studies assessing the prevalence of CVD risk factors (overweight/obesity, diabetes mellitus, metabolic syndrome, hypercholesterolemia, hypertension, cigarette smoking, and physical inactivity) among U.S. racial/ethnic groups with schizophrenia-spectrum and bipolar disorders. METHODS AND RESULTS: We searched MEDLINE and PsycINFO for articles published between 1986 and 2013. The search ultimately yielded 40 articles. There was great variation in sampling, methodology, and study populations. Results were mixed, though there was some evidence for increased risk for obesity and diabetes mellitus among African Americans, and to a lesser degree for Hispanics, compared to non-Hispanic Whites. Sex emerged as an important possible effect modifier of risk, as women had higher CVD risk among all racial/ethnic subgroups where stratified analyses were reported. CONCLUSIONS: Compared to general population estimates, there was some evidence for an additive risk for CVD risk factors among racial/ethnic minorities with SMI. Future studies should include longitudinal assessment, stratification by sex, subgroup analyses to clarify the mechanisms leading to potentially elevated risk, and the evaluation of culturally appropriate interventions to eliminate the extra burden of disease in this population.

"A labor of love": Integrating mental health and HIV care: Lessons from a multicountry mental health learning network.

Mental health conditions among people living with HIV (PLWH) are important to address as they adversely affect quality of life, impede adherence to HIV treatment and increase mortality. Planning for integrating mental health care in resource-limited HIV care settings requires substantial effort. Learning networks are a useful way to exchange knowledge between countries about best and current practices in planning mental health care for PLWH. This paper describes the launch of a mental health learning network within a global health implementing center and the lessons learned across participating members from six countries: the United States, Jamaica, Trinidad and Tobago, Zimbabwe, Malawi and India. Lessons learned from the learning network sessions spanned four broad domains: (i) the need for routine and integrated mental health data collection, (ii) developing standardized protocols to implement mental health care, (iii) adequate training and supervision of health care staff and (iv) prioritization of mental health care integration by program funders. We find that time and resource constraints can be barriers to shared leadership and sustainability of learning networks. Prioritizing learning networks as an important component of integrated HIV and mental health care programs is one of the potential strategies to ensure long-term continuity.

Training community health volunteers to use mobile platform during the COVID-19 pandemic: The Kenya experience.

This study describes an alternative to face-to-face training method for community health volunteers (CHVs) as used by a collaborative group from the University of Nairobi, University of Washington and the Nairobi Metropolitan Mental Health Team during the COVID-19 lockdown in Kenya. This qualitative study describes the experiences of 17 CHVs enrolled in a training study, required to utilize different digital platforms (Google Meet or Jitsi) as a training forum for the first time. Verbatim extracts of the participants' daily experiences are extracted from a series of write-ups in the group WhatsApp just before the training. Daily failures and success experiences in joining a Google meet or Jitsi are recorded. Then, 17 participants, 10 women and 7 men, aged between 21 and 51 years (mean = 33), owning a smartphone, were enrolled in the study. None had used Jitsi or Google meet before. Different challenges were reported in login to either and a final decision to use Jitsi, which became the training platform. Training CHVs to deliver a psychosocial intervention using smartphones is possible. However, the trainer must establish appropriate and affordable methods when resources are constrained.

A mixed methods analysis of youth mental health intervention feasibility and acceptability in a North American city: Perspectives from Seattle, Washington.

In March 2021, the Governor of Washington declared a youth mental health crisis. State data revealed high rates of youth suicide and inadequate access to services. This study aims to ascertain the kinds of support across the mental health care continuum recommended by young people and key stakeholders who could assist with implementation in Seattle. We interviewed 15 key informants to identify the contextual, structural, and individual-level factors that increase the risk of poor mental health and deter access to care among youth. We complimented these data with a 25-item survey of 117 participants in King County to assess the feasibility and acceptability of interventions for youth mental health. We conducted a deductive thematic qualitative analysis of the interviews and performed descriptive analyses of the quantitative data, using t-tests and χ2 tests to summarize and compare participant characteristics stratified by age group. Qualitative informants attributed challenges to youth mental health to social isolation and relational problems. Example interventions included creating environments that increase belonging and implementation of culturally congruent mental health services. Quantitative study participants rated all evidence-based mental health interventions presented as highly acceptable. However, youth preferred interventions promoting social connectedness, peer support, and holistic approaches to care, while non-youth preferred interventions focused on suicide, and substance abuse prevention. Key informants and survey participants identified schools as the most important setting for mental health interventions. There were no significant differences among quantitative outcomes. Our findings highlight the need for interventions that reduce isolation and increase social connectedness to support youth mental health. As the city designs youth responsive interventions, schools and digital platforms should be prioritized. Engaging multiple stakeholders, particularly young people, tackling cultural stigma surrounding mental health, and improving access to safe community spaces are important considerations for youth mental health interventions.

Combining mHealth Technology and Pharmacotherapy to Improve Mental Health Outcomes and Reduce Human Rights Abuses in West Africa: Intervention Field Trial.

Background: In West Africa, healers greatly outnumber trained mental health professionals. People with serious mental illness (SMI) are often seen by healers in "prayer camps" where they may also experience human rights abuses. We developed "M&M," an 8-week-long dual-pronged intervention involving (1) a smartphone-delivered toolkit designed to expose healers to brief psychosocial interventions and encourage them to preserve human rights (M-Healer app), and (2) a visiting nurse who provides medications to their patients (Mobile Nurse). Objective: We examined the feasibility, acceptability, safety, and preliminary effectiveness of the M&M intervention in real-world prayer camp settings. Methods: We conducted a single-arm field trial of M&M with people with SMI and healers at a prayer camp in Ghana. Healers were provided smartphones with M-Healer installed and were trained by practice facilitators to use the digital toolkit. In parallel, a study nurse visited their prayer camp to administer medications to their patients. Clinical assessors administered study measures to participants with SMI at pretreatment (baseline), midtreatment (4 weeks) and post treatment (8 weeks). Results: Seventeen participants were enrolled and most (n=15, 88.3%) were retained. Participants had an average age of 44.3 (SD 13.9) years and 59% (n=10) of them were male. Fourteen (82%) participants had a diagnosis of schizophrenia and 2 (18%) were diagnosed with bipolar disorder. Four healers were trained to use M-Healer. On average, they self-initiated app use 31.9 (SD 28.9) times per week. Healers watched an average of 19.1 (SD 21.2) videos, responded to 1.5 (SD 2.4) prompts, and used the app for 5.3 (SD 2.7) days weekly. Pre-post analyses revealed a significant and clinically meaningful reduction in psychiatric symptom severity (Brief Psychiatric Rating Scale score range 52.3 to 30.9; Brief Symptom Inventory score range 76.4 to 27.9), psychological distress (Talbieh Brief Distress Inventory score range 37.7 to 16.9), shame (Other as Shamer Scale score range 41.9 to 28.5), and stigma (Brief Internalized Stigma of Mental Illness Scale score range 11.8 to 10.3). We recorded a significant reduction in days chained (1.6 to 0.5) and a promising trend for reduction in the days of forced fasting (2.6 to 0.0, P=.06). We did not identify significant pre-post changes in patient-reported working alliance with healers (Working Alliance Inventory), depressive symptom severity (Patient Health Questionnaire-9), quality of life (Lehman Quality of Life Interview for the Mentally Ill), beliefs about medication (Beliefs about Medications Questionnaire-General Harm subscale), or other human rights abuses. No major side effects, health and safety violations, or serious adverse events occurred over the course of the trial. Conclusions: The M&M intervention proved to be feasible, acceptable, safe, and clinically promising. Preliminary findings suggest that the M-Healer toolkit may have shifted healers' behaviors at the prayer camp so that they commit fewer human rights abuses.

Competency-based training and supervision: development of the WHO-UNICEF Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) initiative.

Globally, there has not been a standardised approach to ensure that the growing number of people who are not licensed clinicians but are delivering psychological interventions and mental health services have the competencies to deliver those interventions and services safely. Therefore, WHO and UNICEF developed Ensuring Quality in Psychosocial and Mental Health Care (EQUIP). EQUIP is a free resource with a digital platform that can be used to guide competency assessment. We describe EQUIP's 5-year development (2018-23) and the rationale supporting its contents and use. Development phases included establishing consensus for competency-based strategies; selecting foundational competencies; evaluating feasibility of assessments, role plays, and technology; piloting EQUIP when training non-specialists; and public dissemination and ongoing adaptations to increase scalability. From the public launch in March, 2022, through to March, 2024, EQUIP's digital platform has been used in 794 training programmes in 36 countries with 3760 trainees resulting in 10 001 competency assessments.

Cumulative exposure to depressive symptoms and all-cause mortality among adults with HIV in Kenya, Nigeria, Tanzania, and Uganda.

OBJECTIVE: We estimated the effects of cumulative exposure to depressive symptoms on risk of all-cause mortality among people with HIV (PWH) in four African countries. DESIGN: An analysis of prospective cohort data. METHODS: The African Cohort Study (AFRICOS) is a prospective cohort of people receiving care at twelve clinics in Kenya, Nigeria, Tanzania, and Uganda. Every 6 months from January 2013 to May 2020, participants underwent laboratory monitoring, structured surveys, and assessment of depressive symptom severity using the Center for Epidemiologic Studies Depression Scale (CES-D). All-cause mortality was the outcome of interest. The predictor of interest was a time-updated measure of the percentage of days lived with depression (PDD). Marginal structural Cox proportional hazards regression models were used, adjusting for potential confounders including time-varying alcohol use, drug use, and viral load. RESULTS: Among 2520 enrolled participants, 1479 (59%) were women and the median age was 38 (interquartile range [IQR]: 32-46). At enrollment, 1438 (57%) were virally suppressed (<200 copies/ml) and 457 (18%) had CES-D at least 16, indicating possible depression. Across 9093 observed person-years, the median PDD was 0.7% (IQR: 0-5.9%) with 0.8 deaths per 100 person-years. Leading causes of death included cancer (18% of deaths) and accidents (14%). Models suggested that each 25% absolute increase in PDD was associated with a 69% increase in the risk of all-cause mortality (hazard ratio: 1.69; 95% confidence interval: 1.18-2.43). CONCLUSION: Cumulative exposure to depressive symptoms was substantially associated with the risk of mortality in this cohort of PWH in Africa.