Healthcare use and costs among individuals receiving mental health services for depression within primary care in Nepal.

BACKGROUND: Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources. METHODS: Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference. RESULTS: The study included 192 primary care service users (TG = 60, TG + P = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (- 11%, p = 0.51) among TG + P and lower (- 35%, p = 0.01) among UC compared to TG. Visits increased 2.30 times (p < 0.001) at 3 months among TG, with a 50% greater increase (p = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (- 1%, p = 0.97) and cost changes did not significantly differ at three (- 16%, p = 0.67) or 12 months (- 45%, p = 0.13). Costs among UC were 54% lower than TG at baseline (p = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare. CONCLUSION: Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

Group problem solving therapy for perinatal depression in primary health care settings in rural Uganda: an intervention cohort study.

BACKGROUND: Perinatal depression is of substantial public health importance in low and middle income countries. The study aimed to evaluate the impact of a mental health intervention delivered by non-specialist health workers on symptom severity and disability in women with perinatal depression in Uganda. METHODS: Pregnant women in the second and third trimester were consecutively screened using the Luganda version of the 9-item Patient Health Questionnaire (PHQ-9). Women who scored ≥5 on the PHQ-9 and who were confirmed to have depression by a midwife were recruited into a treatment cohort and offered a psychological intervention in a stepped care fashion. Women were assessed with PHQ-9 and WHODAS-2.0 at baseline and again at 3 and 6 months after the intervention. Negative regression analysis was done to examine change in PHQ-9 and WHODAS-2.0 scores from baseline to end line. Data were analysed using STATA version 14. RESULTS: A total of 2652 pregnant women (98.3%) consented to participate in the study and 153 (5.8%) were diagnosed as depressed. Over a quarter (28.8%) reported having experienced physical interpersonal violence (IPV) while (25.5%) reported sexual IPV in the past year. A third (34.7%) of women diagnosed with depression received 4 or more group PST sessions. There was a mean reduction in PHQ-9 score of 5.13 (95%CI - 6.79 to - 3.47, p < 0.001) and 7.13 (95%CI - 8.68 to - 5.59, p < 0.001) at midline and endline, respectively. WHODAS scores reduced significantly by - 11.78 points (CI 17.64 to - 5.92, p < 0.001) at midline and - 22.92 points (CI 17.64 to - 5.92, p < 0.001) at endline. Clinical response was noted among 69.1% (95%CI 60.4-76.6%) and 93.7% (95%CI 87.8-96.8%) of respondents at midline and endline, respectively. CONCLUSION: An evidence based psychological intervention implemented in primary antenatal care by trained and supervised midwives in a real-world setting may lead to improved outcomes for women with perinatal depression. Future randomised studies are needed to confirm the efficacy of this intervention and possibility for scale up.

Examining the dynamics between young people's mental health, poverty and life chances in six low- and middle-income countries: protocol for the CHANCES-6 study.

PURPOSE: Poverty and poor mental health are closely related and may need to be addressed together to improve the life chances of young people. There is currently little evidence about the impact of poverty-reduction interventions, such as cash transfer programmes, on improved youth mental health and life chances. The aim of the study (CHANCES-6) is to understand the impact and mechanisms of such programmes. METHODS: CHANCES-6 will employ a combination of quantitative, qualitative and economic analyses. Secondary analyses of longitudinal datasets will be conducted in six low- and middle-income countries (Brazil, Colombia, Liberia, Malawi, Mexico and South Africa) to examine the impact of cash transfer programmes on mental health, and the mechanisms leading to improved life chances for young people living in poverty. Qualitative interviews and focus groups (conducted among a subset of three countries) will explore the views and experiences of young people, families and professionals with regard to poverty, mental health, life chances, and cash transfer programmes. Decision-analytic modelling will examine the potential economic case and return-on-investment from programmes. We will involve stakeholders and young people to increase the relevance of findings to national policies and practice. RESULTS: Knowledge will be generated on the potential role of cash transfer programmes in breaking the cycle between poor mental health and poverty for young people, to improve their life chances. CONCLUSION: CHANCES-6 seeks to inform decisions regarding the future design and the merits of investing in poverty-reduction interventions alongside investments into the mental health of young people.

Major depressive disorder and its association with adherence to antiretroviral therapy and quality of life: cross-sectional survey of people living with HIV/AIDS in Northwest Ethiopia.

BACKGROUND: Major depression is believed to affect treatment adherence and overall quality of life (QoL) of people living with HIV/AIDS (PLWHA). Comorbid major depression contributes to a two-fold higher risk of mortality among PLWHA. Understanding the relationships of major depression, adherence to antiretroviral therapy (ART) and QoL is important to identify areas for intervention. The aim of this study is to examine relationship of major depressive disorder (MDD) and adherence to ART with QoL, and to investigate socio-demographic and clinical factors associated with MDD, adherence and QoL among PLWHA in Northwest Ethiopia. METHOD: A cross-sectional study was conducted in the ART clinic of Felege-Hiwot referral hospital in Northwest Ethiopia from July to October 2019. Adult PLWHA were selected using a systematic random sampling technique. Data were collected using interview administered questionnaires and chart reviews. Mini International Neuropsychiatric Interview and WHOQOL-HIV-BREF-Eth instruments were used to measure MDD and QoL respectively. Adherence to ART was assessed using pill count data from patients' adherence monitoring chart. Univariate and multivariate Poisson regressions were used to assess associations of socio-demographic and clinical factors with MDD and adherence to ART. A multivariate linear regression was used to examine the associations of both MDD and adherence with overall QoL. RESULT: Of the total of 393 invited participants, 391 (99.5%) completed the interviews. MDD was negatively associated with overall QoL: participants with MDD had a lower QoL score of 0.17 points compared to those with no MDD. MDD was associated with reduced adherence to ART when functional disability was controlled (RR = 1.43; 95%CI = 1.05, 1.96; p = 0.025). However, there was no statistical association between adherence to ART and overall QoL. Functional disability was associated with both MDD (RR = 5.07; 95%CI = 3.27,7.86; p < 0.001) and overall QoL (ß = 0.29; 95%CI = 0.21,0.36; p < 0.001). CONCLUSION: The relationship between MDD and QoL indicates the need for feasible, acceptable and evidence-based mental health interventions to reduce depression and improve overall QoL of PLWHA. We recommend future studies investigate causal relationships of MDD, adherence to ART and QoL of PLWHA to better understand priority areas for intervention.

Acute and chronic toxicity of nickel on freshwater and marine tropical aquatic organisms.

Water quality guidelines and ecological risk assessment of chemical substances like nickel (Ni) in tropical regions such as South East Asia and Melanesia are often based on temperate information as a result of fewer Ni ecotoxicity data available for tropical species. This leaves an unknown margin of uncertainty in the risk assessment in the tropics. In order to fill this data gap, this study was designed to conduct standard toxicity tests on Ni with two freshwater species (acute tests) and three marine species (acute and chronic tests) originated from tropical Hong Kong. All tests were carried out using measured concentrations of Ni with control mortality below 15%. The median lethal concentrations (LC50s) were determined as 2520 (95% confidence interval: 2210, 2860) and 426 (351, 515) µg Ni L-1 for the freshwater gastropods Pomacea lineata (48 h) and Sulcospira hainanensis (96 h), respectively, while 96 h LC50s of 4300 (3610, 5090), 18,200 (6470, 51,200), 62,400 (56,800, 68,500), and 71,700 (68,200, 75,400) µg Ni L-1 were derived for the marine copepod Tigriopus japonicus, the gastropod Monodonta labio, juvenile and adult of the marine fish Oryzias melastigma, respectively. The chronic effect concentration of 10% (EC10) based on the intrinsic rate of increase of the population of T. japonicus was 29 (12, 69) µg Ni L-1. In terms of growth inhibition, the chronic EC10 for M. labio was 34 (17, 67) µg Ni L-1. The results also indicated that T. japonicus in maturation stage (LC10: 484 (349, 919) µg Ni L-1) was less sensitive than its nauplii stage (LC10: 44 (27, 72) µg Ni L-1). This study represents an important addition of high-quality toxicity data to the tropical Ni toxicity database which can be used for future ecological risk assessment of Ni and derivation of its water quality guidelines in tropical regions.

Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation.

BACKGROUND: In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing. METHODS AND FINDINGS: A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment. CONCLUSIONS: These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal.

BACKGROUND: Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). METHOD: Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. RESULTS: Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, ß = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, ß = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). CONCLUSION: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone.

Perinatal depressive symptoms among low-income South African women at risk of depression: trajectories and predictors.

BACKGROUND: The aim of the study was to identify trajectories of perinatal depressive symptoms and their predictors among women living in a low-resource setting in South Africa, and who present with a risk of depression during pregnancy. METHODS: This is a secondary analysis of a randomised controlled trial among 384 women living in Khayelitsha, a low income setting in South Africa, recruited at their first antenatal visit if they scored 13 or above on the Edinburgh Postnatal Depression Scale, were at least 18 years of age, less than 29 weeks pregnant and spoke isiXhosa. Participants were followed up at 8 months gestation, 3 and 12 months postpartum. Latent trajectories of depressive symptoms were identified using growth mixture modelling, based on the Hamilton Depression Rating Scale (HDRS). There were no differences in HDRS scores between the control and intervention arms, so all participants were assessed together. Health, social and economic predictors of trajectories were investigated to identify high-risk groups with greater or more chronic depressive symptoms, using univariate logistic regression. RESULTS: Two trajectories were identified: antenatal only (91.4%), with moderate to severe symptoms at baseline which later subside; and antenatal and postnatal (8.6%), with severe depressive symptoms during pregnancy and later in the postpartum period, which subside temporarily to moderate levels at 3 months postpartum. Predictors for the antenatal and postnatal trajectory include severe food insecurity, intimate partner violence, lower social support, greater functional impairment, problematic drinking and suicide risk. CONCLUSIONS: A small proportion of women who are at risk for depression antenatally remain at risk throughout the perinatal period, and can be differentiated from those who show a natural remission. Identification and referral strategies should be developed with these findings in mind, especially given the limited mental health resources in low-income settings.

Change in treatment coverage and barriers to mental health care among adults with depression and alcohol use disorder: a repeat cross sectional community survey in Nepal.

BACKGROUND: Despite the availability of evidence-based treatment, there is a substantial gap between the number of individuals in need of mental health care and those who receive treatment. The aim of this study was to assess changes in treatment coverage and barriers to mental health care among adults with depression and alcohol use disorder (AUD) before and after implementation of a district mental health care plan (MHCP) in Nepal. METHODS: The repeat population-based cross-sectional community survey was conducted with randomly selected adults in the baseline (N = 1983) and the follow-up (N = 1499) surveys, 3 years and 6 months apart. The Patient Health Questionnaire and Alcohol Use Disorder Identification Test were used to screen people with probable depression and AUD. Barriers to seeking mental health care were assessed by using a standardized tool, the Barriers to Care Evaluation Scale (BACE). RESULTS: The proportion of the participants receiving treatment for depression increased by 3.7 points (from 8.1% in the baseline to 11.8% in the follow-up) and for AUD by 5.2 points (from 5.1% in the baseline to 10.3% in the follow-up study), however, these changes were not statistically significant. There was no significant reduction in the overall BACE score in both unadjusted and adjusted models for both depression and AUD. The possible reasons for non-significant changes in treatment coverage and barriers to care could be that (i) the method of repeat population level surveys with a random sample was too distal to the intervention to be able to register a change and (ii) the study was underpowered to detect such changes. CONCLUSION: The study found non-significant trends for improvements in treatment coverage and barriers to mental health care following implementation of the district mental health care plan. The key areas for improvement in the current strategy to improve treatment coverage and barriers to mental health care included change in the content of the existing community sensitization program, particularly for changing attitude and intention of people with mental illness for seeking care.

Association between perinatal depressive symptoms and suicidal risk among low-income South African women: a longitudinal study.

PURPOSE: The aim of this study was to assess the association between depressive symptoms and suicidal risk over time among perinatal women at risk for depression antenatally, and assess modifying effects of age, perinatal stage and depressive symptom trajectory. METHODS: A total of 384 adult pregnant women were recruited from two antenatal clinics in an informal settlement near Cape Town, South Africa, and followed up at eight months gestation, and at 3- and 12-month postpartum. The MINI 6.0 Suicidality module and the Hamilton Depression Rating Scale (HDRS) were used to measure suicidal risk and depression, respectively. Generalised Estimating Equations were used to assess the association between change in depressive symptoms from one assessment to the next (predictor) and change in suicide score or change in suicidal risk (score ≥ 9) (outcomes). RESULTS: HDRS scores were positively correlated with suicide score (95% CI 0.35, 0.78; p < 0.001), and with odds of being at moderate risk for suicide, after controlling for risk of suicide at the previous assessment (adjusted odds ratio = 1.15; 95% CI 1.09, 1.22; p < 0.001). Age was a significant effect modifier: change in HDRS scores was not associated with change in suicide scores among participants aged 35-45 years. Secondary analyses indicated that a decrease in HDRS score was associated with a decrease in suicide scores, but an increase in HDRS score was not associated with change in suicide score. CONCLUSIONS: Depression and suicide are overlapping but relatively independent phenomena, especially among older or more chronically depressed perinatal women.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months.

PURPOSE: Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed. METHODS: This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes. RESULTS: Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories. CONCLUSIONS: Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

Sediment nickel bioavailability and toxicity to estuarine crustaceans of contrasting bioturbative behaviors--an evaluation of the SEM-AVS paradigm.

Robust sediment quality criteria require chemistry and toxicity data predictive of concentrations where population/community response should occur under known geochemical conditions. Understanding kinetic and geochemical effects on toxicant bioavailability is key, and these are influenced by infaunal sediment bioturbation. This study used fine-scale sediment and porewater measurement of contrasting infaunal effects on carbon-normalized SEM-AVS to evaluate safe or potentially toxic nickel concentrations in a high-binding Spartina saltmarsh sediment (4%TOC; 35-45 µmol-S2-·g(-1)). Two crustaceans producing sharply contrasting bioturbation--the copepod Amphiascus tenuiremis and amphipod Leptocheirus plumulosus--were cultured in oxic to anoxic sediments with SEM[Ni]-AVS, TOC, porewater [Ni], and porewater DOC measured weekly. From 180 to 750 µg-Ni·g(-1) sediment, amphipod bioturbation reduced [AVS] and enhanced porewater [Ni]. Significant amphipod uptake, mortality, and growth-depression occurred at the higher sediment [Ni] even when [SEM-AVS]/foc suggested acceptable risk. Less bioturbative copepods produced higher AVS and porewater DOC but exhibited net population growth despite porewater [Ni] 1.3-1.7× their aqueous [Ni] LOEC. Copepod aqueous tests with/without dissolved organic matter showed significant aqueous DOC protection, which suggests porewater DOC attenuates sediment Ni toxicity. The SEM[Ni]-AVS relationship was predictive of acceptable risk for copepods at the important population-growth level.

Effectiveness of combining prevention psychological interventions with interventions that address the social determinants of mental health in low and middle-income countries: protocol of a systematic review and meta-analysis.

INTRODUCTION: Common mental health conditions (CMHCs), including depression, anxiety and post-traumatic stress disorder (PTSD), are highly prevalent in low and middle-income countries (LMICs). Preventive strategies combining psychological interventions with interventions addressing the social determinants of mental health may represent a key strategy for effectively preventing CMHCs. However, no systematic reviews have evaluated the effectiveness of these combined intervention strategies for preventing CMHCs. METHODS AND ANALYSIS: This systematic review will include randomised controlled trials (RCTs) focused on the effectiveness of interventions that combine preventive psychological interventions with interventions that address the social determinants of mental health in LMICs. Primary outcome is the frequency of depression, anxiety or PTSD at postintervention as determined by a formal diagnostic tool or any other standardised criteria. We will search Epistemonikos, Cochrane Controlled Trials Register (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Global Index Medicus, ClinicalTrials.gov (Ctgov), International Clinical Trials Registry Platform (ICTRP). Two reviewers will independently extract the data and evaluate the risk of bias of included studies using the Cochrane risk of bias tool 2. Random-effects meta-analyses will be performed, and certainty of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: This study uses data from published studies; therefore, ethical review is not required. Findings will be presented in a published manuscript. TRIAL REGISTRATION NUMBER: CRD42023451072.

Recommended updates to the USEPA Framework for Metals Risk Assessment: Aquatic ecosystems.

In 2007, the USEPA issued its "Framework for Metals Risk Assessment." The framework provides technical guidance to risk assessors and regulators when performing human health and environmental risk assessments of metals. This article focuses on advances in the science including assessing bioavailability in aquatic ecosystems, short- and long-term fate of metals in aquatic ecosystems, and advances in risk assessment of metals in sediments. Notable advances have occurred in the development of bioavailability models for assessing toxicity as a function of water chemistry in freshwater ecosystems. The biotic ligand model (BLM), the multiple linear regression model, and multimetal BLM now exist for most of the common mono- and divalent metals. Species sensitivity distributions for many metals exist, making it possible for many jurisdictions to develop or update their water quality criteria or guidelines. The understanding of the fate of metals in the environment has undergone significant scrutiny over the past 20 years. Transport and toxicity models have evolved including the Unit World Model allowing for estimation of concentrations of metals in various compartments as a function of loading and time. There has been significant focus on the transformation of metals in sediments into forms that are less bioavailable and on understanding conditions that result in resolubilization or redistribution of metals in and from sediments. Methods for spiking sediments have advanced such that the resulting chemistry in the laboratory mimics that in natural systems. Sediment bioavailability models are emerging including models that allow for prediction of toxicity in sediments for copper and nickel. Biodynamic models have been developed for several organisms and many metals. The models allow for estimates of transport of metals from sediments to organisms via their diet as well as their water exposure. All these advances expand the tool set available to risk assessors. Integr Environ Assess Manag 2023;00:1-28. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Validation of Nickel Bioavailability Models for Algae, Invertebrates, and Fish in Chinese Surface Waters.

Nickel (Ni) is used primarily in the production of alloys like stainless steel and is increasingly being used in the production of batteries for the electric vehicle market. Exposure of Ni to ecosystems is of concern because Ni can be toxic to aquatic organisms. The influence of water chemistry constituents (e.g., hardness, pH, dissolved organic carbon) on the toxicity of Ni has prompted the development and use of bioavailability models, such as biotic ligand models (BLMs), which have been demonstrated to accurately predict Ni toxicity in broadly different ecosystems, including Europe, North America, and Australia. China, a leading producer of Ni, is considering bioavailability-based approaches for regulating Ni emissions. Adoption of bioavailability-based approaches in China requires information to demonstrate the validity of bioavailability models for the local water chemistry conditions. The present study investigates the toxicity of Ni to three standard test species (Daphnia magna, Pseudokirchneriella subcapitata, and Danio rerio) in field-collected natural waters that are broadly representative of the range of water chemistries and bioavailabilities encountered in Chinese lakes and rivers. All experimental data are within a factor of 3 of the BLM predicted values for all tests with all species. For D. magna, six of seven waters were predicted within a factor of 2 of the experimental result. Comparison of experimental data against BLM predictions shows that the existing Ni bioavailability models are able to explain the differences in toxicity that result from water chemistry conditions in China. Validation of bioavailability models to water chemistries and bioavailability ranges within China provides technical support for the derivation of site-specific Ni water quality criteria in China. Environ Toxicol Chem 2023;42:1257-1265. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Updating the Chronic Freshwater Ecotoxicity Database and Biotic Ligand Model for Nickel for Regulatory Applications in Europe.

Bioavailability has been taken into account in the regulation of nickel in freshwater ecosystems in Europe for over a decade; during that time a significant amount of new information has become available covering both the sensitivity of aquatic organisms to nickel toxicity and bioavailability normalization. The ecotoxicity database for chronic nickel toxicity to freshwater organisms has been updated and now includes 358 individual data points covering a total of 53 different species, all of which are suitable for bioavailability normalization to different water chemistry conditions. The bioavailability normalization procedure has also been updated to include updates to the bioavailability models that enable more sensitive water chemistry conditions to be covered by the model predictions. The updated database and bioavailability normalization procedure are applicable to more than 95% of regulated European surface water conditions and have been used to calculate site-specific criteria for a variety of different water chemistry scenarios, to provide an indication of how the sensitivity to nickel varies between different water types. The hazardous concentration for 5% of a species (HC5) values for this diverse selection of water types range from 1.6 to 36 µg L-1 , clearly demonstrating the importance of accounting for nickel bioavailability in freshwaters. This updated database and bioavailability normalization procedure provide a robust basis for the derivation of regulatory thresholds for chronic nickel toxicity in freshwaters such as predicted no-effect concentrations and Environmental Quality Standards and are protective of the results of several mesocosm studies. Environ Toxicol Chem 2023;42:566-580. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people: A conceptual framework and lines of enquiry for research and policy.

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

Strengthening self-regulation and reducing poverty to prevent adolescent depression and anxiety: Rationale, approach and methods of the ALIVE interdisciplinary research collaboration in Colombia, Nepal and South Africa.

AIMS: Depression and anxiety are the leading contributors to the global burden of disease among young people, accounting for over a third (34.8%) of years lived with disability. Yet there is limited evidence for interventions that prevent adolescent depression and anxiety in low- and middle-income countries (LMICs), where 90% of adolescents live. This article introduces the 'Improving Adolescent mentaL health by reducing the Impact of poVErty (ALIVE)' study, its conceptual framework, objectives, methods and expected outcomes. The aim of the ALIVE study is to develop and pilot-test an intervention that combines poverty reduction with strengthening self-regulation to prevent depression and anxiety among adolescents living in urban poverty in Colombia, Nepal and South Africa. METHODS: This aim will be achieved by addressing four objectives: (1) develop a conceptual framework that identifies the causal mechanisms linking poverty, self-regulation and depression and anxiety; (2) develop a multi-component selective prevention intervention targeting self-regulation and poverty among adolescents at high risk of developing depression or anxiety; (3) adapt and validate instruments to measure incidence of depression and anxiety, mediators and implementation parameters of the prevention intervention; and (4) undertake a four-arm pilot cluster randomised controlled trial to assess the feasibility, acceptability and cost of the selective prevention intervention in the three study sites. RESULTS: The contributions of this study include the active engagement and participation of adolescents in the research process; a focus on the causal mechanisms of the intervention; building an evidence base for prevention interventions in LMICs; and the use of an interdisciplinary approach. CONCLUSIONS: By developing and evaluating an intervention that addresses multidimensional poverty and self-regulation, ALIVE can make contributions to evidence on the integration of mental health into broader development policy and practice.

Assessing the Extent of Environmental Risks From Nickel in European Freshwaters: A Critical Reflection of the European Commission's Current Approach.

Nickel (Ni) has a been a Priority Substance under the European Water Framework Directive since 2008. As such it is deemed to present an European Union-wide risk to surface waters. Since 2013, the Ni Environmental Quality Standard (EQS) has been bioavailability-based, and new European Guidance supports accounting for bioavailability in assessing Ni compliance with the EQS. The European Commission has developed an approach to determine whether Priority Substances present a sufficient European Union-wide risk to justify an ongoing statutory monitoring programme, effectively to deselect a substance. This is a key step to ensure that finite monitoring resources are targeted at delivering environmental benefit, when there is an ever-growing burden of determinands to measure for all regulators. When the European Commission performed this exercise for Ni without accounting for bioavailability, they concluded that Ni should not be deselected, and Ni is an European Union-wide risk. Performing this same exercise with the same methodology, using regulatory monitoring data for over 300 000 samples, from more than 19 000 sites across Europe, and accounting for bioavailability, as detailed in the Directive, >99% of sites comply with the Ni EQS. Nickel shows very low risks for all of the criteria identified by the European Commission that need to be met for deselection. Accounting for bioavailability is key in the assessment of Ni risks in surface waters to deliver ecologically relevant outcomes. Environ Toxicol Chem 2022;41:1604-1612. © 2022 NiPERA. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Variation in chronic nickel toxicity to Daphnia magna among Japanese river waters and performance evaluation of bioavailability models in predicting the toxicity.

Nickel (Ni) ecotoxicity is dictated by water chemistry characteristics such as pH, water hardness, and amount of dissolved organic carbon. Bioavailability models have been developed to predict Ni toxicity and validated for European, Australian, and US natural waters. In this study, chronic toxicity tests in Ni-spiked Japanese river waters were conducted on a strain of Daphnia magna to test whether the chronic toxicity differs among Japanese natural waters with different water chemistries. Based on the results of chronic Ni toxicity tests, we assessed the performance of existing D. magna bioavailability models, which were developed in artificial waters (Model 1) and calibrated in European natural waters (Model 2), in terms of the accuracy and the bias of model predictions. Furthermore, we also calibrated the two models by using toxicity test results to develop a bioavailability model for Ni chronic toxicity to the strain of D. magna in Japanese river waters. The 10%, 20%, and 50% effect concentrations (EC10, EC20, and EC50) of dissolved Ni on reproduction of the D. magna strain were within ranges from 8.1 to 44.9 µg/L, 9.0 to 57.1 µg/L, and 10.9 to 86.1 µg/L, respectively. Results indicate that differences in water chemistry among Japanese river waters influenced chronic Ni toxicity to the model organism. Model 1predicted 43% of the observed EC10, EC20, and EC50 values within a factor of 2 and 100%, 100%, and 43% within a factor of 3, respectively. Model 2 predicted 14%, 14%, and 29% of the observed EC10, EC20, and EC50 values within a factor of 2 and 43% within a factor of 3. The values of model bias based on the geometric mean of ratios of EC10, EC20 and EC50 values predicted by each of the two models and observed EC10, EC20, and EC50 values were 0.71, 0.65, and 0.62 for Model 1 and 0.27, 0.26, and 0.29 for Model 2, respectively. After calibrating two models using the results of toxicity tests, refined Model 1 predicted 71%, 57%, and 57% of observed EC10, EC20, and EC50 values within a factor of 2 and 100%, 86%, and 100% within a factor of 3; refined Model 2 predicted 71% of observed EC10, EC20, and EC50 values within a factor 2 and 100%, 86%, and 86% within a factor of 3, respectively. Our results indicate that calibrating the Ni bioavailability models in Japanese natural waters increased their predictive capacity by a factor of up to approximately five.