Debate: Involuntary treatment and detention are a necessary part of mental health care - a perspective from low and middle-income countries.

Mental health care is underpinned by human rights. However, certain mental health presentations can be associated with increased risk to self or others. Thus, appropriate and effective care plan to mitigate the risk may include a temporary restriction of the person's human rights. Legal frameworks are required to ensure appropriate safeguards for the affected person, and clarity about boundaries of necessity and proportionality for clinicians. The restriction needs to be proportionate, for the shortest possible period, done in a humane manner, and in a safe environment. Effective early mental interventions can reduce need for human right restrictions by preventing acute escalations in risk-related behaviours. While these principles apply across all regions, we discuss the particular circumstances in low and middle-income countries.

Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria.

PURPOSE: This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process. METHODS: This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews. RESULTS: Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers. CONCLUSIONS: Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers. TRIAL REGISTRATION: This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .

Cascade training for scaling up care for perinatal depression in primary care in Nigeria.

BACKGROUND: Task-shared care is a demonstrated approach for integrating mental health into maternal and child healthcare (MCH) services. Training and continued support for frontline providers is key to the success of task sharing initiatives. In most settings this is provided by mental health specialists. However, in resource constrained settings where specialists are in short supply, there is a need to explore alternative models for providing training and supportive supervision to frontline maternal care providers. This paper reports on the impact of a cascade training (train-the-trainers) approach in improving the knowledge and attitudes of primary healthcare workers (PHCW) to perinatal depression. METHODS: Senior primary health care providers selected from across participating local government areas were trained to provide training to other PHCWs. The training sessions facilitated by these trainers were observed and rated for fidelity by specialist trainers, while the trainees provided their impression of and satisfaction with the training sessions using predesigned assessment forms. Training outcomes assessed included knowledge of depression (using mhGAP training questions and knowledge of depression questionnaire) and attitude towards providing care for depression (revised depression attitude questionnaire (R-DAQ)) measured pre and post training as well as six months after training. RESULTS: Trainees were 198 PHCWs (94.4% female), who routinely provide MCH services in 28 selected primary care clinics and had between 6- and 34-years' experience. Training was provided by 11 trained trainers who were general physicians or senior nurses. Training sessions were rated high in fidelity and on training style. Sessions were rated excellent by 77.8% of the trainees with the trainers described as knowledgeable, effective and engaging. Knowledge of depression mean score improved from a pre-training level of 12.3 ± 3.5 to 15.4 ± 3.7, immediately post-training and 14.7 ± 3.2, six months post-training (both comparisons: p < 0.001). The proportion of PHCW workers endorsing statements indicative of positive attitudes on the professional confidence and the generalist perspective modules of the R-DAQ also increased with training. CONCLUSION: Our findings suggest that cascade training can be an effective model for rapidly providing training and upskilling frontline PHCWs to deliver care for women with perinatal depression in resource limited settings. TRIAL REGISTRATION: This study was retrospectively registered 03 December 2019. https://doi.org/10.1186/ISRCTN 94,230,307.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries.

BACKGROUND: There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES: To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS: Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS: Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS: The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Task-sharing psychosocial interventions for the prevention of common mental disorders in the perinatal period in low- and middle-income countries: A systematic review and meta-analysis.

AIM: to assess the efficacy of psychosocial interventions delivered through task-sharing approaches for preventing perinatal common mental disorders among women in low- and middle-income countries. METHODS: We conducted a systematic review of randomized controlled trials following a prespecified protocol registered in the Open Science Framework (osf.io/qt4y3). We searched MEDLINE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL) through June 2022. Two reviewers independently extracted the data and evaluated the risk of bias of included studies using the Cochrane risk of bias tool. We performed random-effects meta-analyses and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: We included 23 studies with 24,442 participants. At post-intervention, task-shared psychosocial interventions, were effective in preventing the development of mental disorders in general (RR 0.57, 95% CI [0.35, 0.91]), and specifically depression (RR 0.51, 95% CI [0.35, 0.75]), but not anxiety disorders (RR 0.46, 95% CI [0.06, 3.33]). Similarly, psychosocial interventions reduced psychological distress (SMD -1.32, 95% CI [-2.28, -0.35]), and depressive symptoms (SMD -0.50, 95% CI [-0.80, -0.16]), and increased parenting self-efficacy (SMD -0.76, 95% CI [-1.13, -0.38]) and social support (SMD -0.72, 95% CI [-1.22, -0.22]). No effect was detected for anxiety symptoms at post-intervention. At follow-up the beneficial effects of interventions progressively decreased. CONCLUSIONS: Psychosocial interventions delivered through the task-sharing modality are effective in preventing perinatal common mental disorders and fostering positive mental health among women in low- and middle-income countries. However, our findings are tentative, due to the low number of preventative intervention strategies considering outcomes as the incidence of mental disorders, especially in the long-term. This evidence supports calls to implement and scale up psychosocial prevention interventions for perinatal common mental disorders in low- and middle-income countries.

Transforming access to care for serious mental disorders in slums (the TRANSFORM Project): rationale, design and protocol.

This paper introduces the TRANSFORM project, which aims to improve access to mental health services for people with serious and enduring mental disorders (SMDs - psychotic disorders and severe mood disorders, often with co-occurring substance misuse) living in urban slums in Dhaka (Bangladesh) and Ibadan (Nigeria). People living in slum communities have high rates of SMDs, limited access to mental health services and conditions of chronic hardship. Help is commonly sought from faith-based and traditional healers, but people with SMDs require medical treatment, support and follow-up. This multicentre, international mental health mixed-methods research project will (a) conduct community-based ethnographic assessment using participatory methods to explore community understandings of SMDs and help-seeking; (b) explore the role of traditional and faith-based healing for SMDs, from the perspectives of people with SMDs, caregivers, community members, healers, community health workers (CHWs) and health professionals; (c) co-design, with CHWs and healers, training packages for screening, early detection and referral to mental health services; and (d) implement and evaluate the training packages for clinical and cost-effectiveness in improving access to treatment for those with SMDs. TRANSFORM will develop and test a sustainable intervention that can be integrated into existing clinical care and inform priorities for healthcare providers and policy makers.

Assessment of anxiety and depression, and coping mechanisms during COVID-19 lockdown among pregnant women.

Background: COVID-19 lockdown was associated with disruption of daily life, economy, essential health services including maternal health service, and psychological reflexes such as panic, sleep disorders, fear, anxiety, and depression. Aim: To assess the perception of pregnant women on the COVID-19 pandemic lockdown and the prevalence of common mental health disorders (CMHD) among pregnant women. Methods: A cross-sectional study was conducted among 380 pregnant women at the University College Hospital (UCH) Ibadan; participants were enrolled using a simple random sampling technique. Data was collected using pretested interviewer-administered questionnaire. Information obtained - sociodemographic and obstetric characteristics, perception and reaction to the COVID-19 pandemic and lockdown, effect on ANC, coping mechanisms, and presence of CMHD (anxiety and depression) were measured using Hospital Anxiety and Depression Scale (HADS). Data were analysed using STATA 16.0 Software. Descriptive and bivariate statistics were performed. The level of significance was p-value < 0.05. Results: The mean age was 32 ± 4.78 years, most respondents were <35 years (75%), married (97.1%), had a higher education (89%) and multiparous (70%). About 43.9% were worried that COVID-19 would affect pregnancy care, 42.9% reported it affected care and 81.6% were not worried it would affect the delivery care. Among respondents, 96.6% were able to cope with the effects of the pandemic and 96.8% enjoyed good social support. Respondents did not have CMHD (88.16%), 7.9% had CMHD (4.74% had depression and 3.16% had anxiety) and 3.95% had co-morbid depression and anxiety. On multinomial regression analysis, relative to anxiety or depression only, respondents with combined depression and anxiety had higher odds of having no delivery plan and thought COVID-19 may affect their delivery. Conclusion: Only a few women reported anxiety and depression symptoms during the lockdown and those with anxiety or combined symptoms of anxiety and depression had no birth plan and believed that COVID-19 would affect their delivery.

Escaping social rejection, gaining total capital: the complex psychological experience of female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria.

BACKGROUND: While the deleterious effects of FGM/C on physical health are well documented, the psychological experience of this harmful practice is a neglected area of research, which limits global mental health actions. As FGM/C was a traditional practice in some areas of Nigeria, the study aimed to understand the psychological experience of FGM/C in context. METHODS: This qualitative study was completed in urban and rural Izzi communities in Southeast Nigeria where FGM/C was widely practiced. In-depth interviews were completed with 38 women of the same ethnicity using the McGill Illness Narrative Interview (MINI) to explore the collective psychological experience of FGM/C before, during and after the procedure. The MINI was successfully adapted to explore the meaning and experience of FGM/C. We completed thematic content analysis and used the concepts of total capital and habitus by Bourdieu to interpret the data. RESULTS: During the period of adolescence, Izzi young women who had not yet undergone FGM/C reported retrospectively being subjected to intense stigma, humiliation and rejection by their cut peers. Alongside the social benefits from FGM/C the ongoing psychological suffering led many to accept or request to be cut, to end their psychological torture. Virtually all women reported symptoms of severe distress before, during and after the procedure. Some expressed the emotion of relief from knowing their psychological torture would end and that they would gain social acceptance and total capital from being cut. Newly cut young women also expressed that they looked forward to harassing and stigmatizing uncut ones, therein engaging in a complex habitus that underscores their severe trauma as well as their newly acquired enhanced social status. CONCLUSION: FGM/C is profoundly embedded in the local culture, prevention strategies need to involve the whole community to develop preventive pathways in a participatory way that empowers girls and women while preventing the deleterious psychological effects of FGM/C and corresponding stigma. Results suggest the need to provide psychological support for girls and women of practicing Izzi communities of Southeast Nigeria.

Aftermath of anti-police protests in Nigeria: Burden and predictors of psychiatric morbidity among protesters and non-protesters.

OBJECTIVES: Anti-police (#EndSARS) protests took place in October 2020 across several Nigerian cities, resulting in deaths, injuries and loss of property, but the psychological sequelae of these protests have not been studied. METHOD: In a cross-sectional online survey, we collected data on psychiatric morbidity and potential risk factors from 426 Nigerian social media users, who self-identified as participants or non-participants in a recent anti-police protest. RESULTS: We found elevated rates of psychiatric morbidity, with worse outcomes for protesters compared to non-protesters (psychological distress [44.2% vs 29.8%], depression [26.0% vs 14.9%], anxiety [51.0% vs 29.8%], post-traumatic stress disorder [7.4% vs 1.8%], current substance use [11.2% vs 4.5%] and suicidal ideation [7.1% vs 4.4%], respectively). After adjusting for the effects of COVID-19 pandemic and previous mental health diagnosis, the predictors of poor mental health among non-protesters were being unmarried (odds ratio = 7.4, p = 0.01) and low resilience (odds ratio range = 4.1-5.4, p < 0.03) while for the protesters, the predictors were low resilience (odds ratio range = 2.9-4.7, p < 0.01), being from Northern Nigeria (odds ratio = 4.7, p < 0.01) or residing in Northern Nigeria (odds ratio = 2.8, p = 0.03), being under-/unemployed (odds ratio range = 2.1-2.5, p < 0.04), holding the view that the protest was caused by the state of the economy (odds ratio = 2.0, p = 0.01), belief that the protest had a direct negative impact on the protester (odds ratio = 2.3, p = 0.04) and willingness to participate in future protests (odds ratio = 4.13, p = 0.02). CONCLUSION: We conclude that participating in the #EndSARS protest was associated with significant psychiatric morbidity. There is need to recognise and address the mental health sequelae of collective actions, and invest in programmes that build resilience and address socio-political determinants of mental health, especially with a focus on youth.

Scaling up care for perinatal depression for improved maternal and infant health (SPECTRA): protocol of a hybrid implementation study of the impact of a cascade training of primary maternal care providers in Nigeria.

BACKGROUND: The large treatment gap for mental disorders in low- and middle-income countries (LMIC) necessitates task-sharing approaches in scaling up care for mental disorders. Previous work have shown that primary health care workers (PHCW) can be trained to recognize and respond to common mental disorders but there are lingering questions around sustainable implementation and scale-up in real world settings. METHOD: This project is a hybrid implementation-effectiveness study guided by the Replicating Effective Programmes Framework. It will be conducted in four overlapping phases in maternal care clinics (MCC) in 11 local government areas in and around Ibadan metropolis, Nigeria. In Phase I, engagement meetings with relevant stake holders will be held. In phase II, the organizational and clinical profiles of MCC to deliver chronic depression care will be assessed, using interviews and a standardized assessment tool administered to staff and managers of the clinics. To ascertain the current level of care, 167 consecutive women presenting for antenatal care for the first time and who screened positive for depression will be recruited and followed up till 12 months post-partum. In phase III, we will design and implement a cascade training programme for PHCW, to equip them to identify and treat perinatal depression. In phase IV, a second cohort of 334 antenatal women will be recruited and followed up as in Phase I, to ascertain post-training level of care. The primary implementation outcome is change in the identification and treatment of perinatal depression by the PHCW while the primary effectiveness outcome is recovery from depression among the women at 6 months post-partum. A range of mixed-method approaches will be used to explore secondary implementation outcomes, including fidelity and acceptability. Secondary effectiveness outcomes are measures of disability and of infant outcomes. DISCUSSION: This study represents an attempt to systematically assess and document an implementation strategy that could inform the scaling up of evidence based interventions for perinatal depression using the WHO mhGAP-IG in LMIC. Trial registration This study was registered on 03 December, 2019. https://doi.org/10.1186/ISRCTN94230307 .

Reducing anxiety and depression in infertility among Nigerian women: an exploratory psycho-educational intervention trial (RADIANT) study protocol.

RATIONALE: high premium is placed on infertility in Nigerian culture. Data is limited on its association with emotional problems in Nigeria. AIMS: to develop content for a culturally relevant and cost-effective psychoeducational intervention package and to evaluate its effectiveness for reducing symptoms of anxiety and depression. Sample size estimate: Methods and design: a multi-method study design including development and validation (which includes focus group discussions) of an audio-visual tool which will serve as the intervention in a randomized controlled trial. Data will be analyzed with interim and survival analyses. POPULATION STUDIED: one hundred and 138 (68 per group) infertile women attending infertility clinic in Ibadan. STUDY OUTCOMES: anxiety and depressions scores assessed with the hospital depression and anxiety scale (HADS) at 0, 3 and 6 weeks. DISCUSSION: it is hoped that the use of the audio-visual tool will improve participants depression and anxiety scores and that the tool will be used for education in routine clinic use and community awareness on psychosocial effects of infertility.

Becoming a Xhosa traditional healer: The calling, illness, conflict and belonging.

BACKGROUND: Traditional healers (THs) are an important part of the healthcare system in sub-Saharan Africa. Understanding their training, experiences of becoming healers and their perceived roles in society is critical. AIM: This study aimed to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs. SETTING: This study was conducted amongst Xhosa THs in the Western Cape, South Africa. METHODS: In-depth phenomenological interviews (n = 4) were conducted with Xhosa THs and analysed using Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis. RESULTS: The experience of becoming a TH can be summarised in the context of three units of significance: (1) the gift of healing as an illness; (2) the experience of conflict (including with their families, the church and self-conflict); and (3) the experience of belonging. Familial conflict, specifically, was fuelled by the financial burden of becoming a TH and a lack of understanding of the process. CONCLUSION: To develop a workable model of collaboration in the future, it is crucial that mental healthcare providers develop a better understanding of the experiences of THs in becoming care providers. The findings highlight an appreciation of the challenging process of becoming a TH. Finally, further research and culturally appropriate psychoeducation can provide trainee THs and their family members with the skills and knowledge to support each other through a difficult process.

Common mental health problems and associated factors among medical students of University of Ibadan, Nigeria.

BACKGROUND: The burden of mental health problems among medical students is on the increase especially when compared with their counterparts in other disciplines. This has counterproductive impact on the society. Understanding the prevalence and predictors of common mental health problems can inform early intervention to curb this menace. AIMS: This study was conducted to determine the prevalence, pattern and correlates of common mental health problems (anxiety and depression) amongst medical students of the University of Ibadan, Nigeria. METHODOLOGY: A descriptive cross-sectional survey was conducted among 690 pre-clinical and clinical medical students of the University of Ibadan. Data were analyzed using descriptive statistics, Chi-square test and binary logistic regression at p < 0.05. RESULTS: The prevalence of anxiety and depression were 26.5% and 10.1%, respectively, with 6.8% having both. Perceived risk factors included overwhelming academic workload (65.2%) and failure to meet up with academic expectations (64.1%). The predictors of comorbid anxiety and depression were: polygamous family setting (OR 2.7: 95% CI: 1.156-6.536) and preclinical studentship (OR: 6.2; 95% CI: 2.282-16.868). CONCLUSION: This study shows that the prevalence of mental health problems is high among medical students.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

BACKGROUND: Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. AIMS: To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. METHOD: Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. RESULTS: A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. CONCLUSIONS: Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

Depression and experience of incarceration in North Central Nigeria: a situation analysis at Makurdi medium security prison.

BACKGROUND: Human rights watchdogs have described conditions in Nigerian correctional facilities and detention centers as damaging to the physical and mental health of inmates. While the prevalence of mental disorders is high, access to appropriate healthcare is grossly inadequate. Understanding the current state of prison inmates' mental health and well-being is an essential first step to addressing this important issue. This study aims to document the mental health and experiences of incarceration of inmates of the largest medium security prison in Nigeria's Benue State. METHODS: A cross-sectional survey and descriptive analysis was carried out with a random sample of 381 prison inmates of Benue State Makurdi Medium Security Prison. Survey tools included: (1) a structured questionnaire on participants' experiences in prison, and (2) the Patient Health Questionnaire (PHQ-9), a screening tool for depression. RESULTS: Most participants were young men (95.5%, mean age 27.95) and had completed secondary school (63.5%). While prison authorities had identified only 27 participants as having a mental disorder, 144 (37.8%) screened positive for depression. Twenty six had received professional counseling while in prison. Of the six participants who were already taking a psychotropic medication at the time of imprisonment, four received medication after being imprisoned. Approximately half, (52%) of participants were dissatisfied with prison health care. CONCLUSIONS: Despite the high prevalence of depression among prison inmates, few cases are detected and treated. Prison staff may not recognize depression as a mental disorder, and the mental health care available is generally poor. Inadequate mental health and social care not only affects prison inmates' well-being, but may also impact recidivism and health outcomes upon release. Prison inmates should be screened routinely for depression and other less-commonly recognized mental health conditions, and appropriate treatment made available.

Promotion, prevention and treatment interventions for mental health in low- and middle-income countries through a task-shifting approach.

Recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic 'at risk', to experiencing 'mental distress', 'sub-syndromal symptoms' and finally 'mental disorders'. This new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. This concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. The present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective.

WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG): the first pre-service training study.

BACKGROUND: Despite the increasing burden of mental, neurological, and substance use (MNS) disorders, a significant treatment gap for these disorders continues to exist across the world, and especially in low- and middle-income countries. To bridge the treatment gap, the World Health Organization developed and launched the Mental Health Gap Action Programme (mhGAP) and the mhGAP Intervention Guide (mhGAP-IG) to help train non-specialists to deliver care. Although the mhGAP-IG has been used in more than 100 countries for in-service training, its implementation in pre-service training, that is, training prior to entering caregiver roles, is very limited. AIM OF THE STUDY: The aim of this study was to collect and present information about the global experience of academic institutions that have integrated WHO's mhGAP-IG into pre-service training. METHODS: A descriptive cross-sectional study was conducted using an electronic questionnaire, from December 2018 to June 2019. RESULTS: Altogether, eleven academic institutions across nine countries (Mexico, Nigeria, Liberia, Sierra Leone, Somaliland, Armenia, Georgia, Ukraine and Kyrgyzstan) participated in this study. Five of the institutions have introduced the mhGAP-IG by revising existing curricula, three by developing new training programmes, and three have used both approaches. A lack of financial resources, a lack of support from institutional leadership, and resistance from some faculty members were the main obstacles to introducing this programme. Most of the institutions have used the mhGAP-IG to train medical students, while some have used it to train medical interns and residents (in neurology or family medicine) and nursing students. Use of the mhGAP-IG in pre-service training has led to improved knowledge and skills to manage mental health conditions. A majority of students and teaching instructors were highly satisfied with the mhGAP-IG. CONCLUSIONS: This study, for the first time, has collected evidence about the use of WHO's mhGAP-IG in pre-service training in several countries. It demonstrates that the mhGAP-IG can be successfully implemented to train a future cadre of medical doctors and health nurses.

Responding to the challenge of Adolescent Perinatal Depression (RAPiD): protocol for a cluster randomized hybrid trial of psychosocial intervention in primary maternal care.

BACKGROUND: Adolescent pregnancy is a pressing public health issue globally, and particularly in low and middle-income countries. Depression occurring in the perinatal period is common among women and more so among adolescent mothers. Effective treatments for the condition have been demonstrated in adults but the needs of adolescents are often unique, making such treatments unlikely to meet those needs. METHOD/STUDY DESIGN: A hybrid effectiveness-implementation research study is described in which a cluster randomized trial design is used to explore the effectiveness as well as the utility in routine practice of an intervention package specifically designed for adolescents with perinatal depression. Consenting pregnant adolescents (aged less than 20 years) who are newly registered for antenatal care are enrolled into the trial if their fetal gestational age is less than 36 weeks and they score 12 or more on the Edinburgh Postnatal Depression Scale (EPDS). The intervention package consists of structured sessions of behavior activation, problem-solving treatment, and parenting skills training, and is delivered by primary maternal health care providers, complemented by support provided by a "neighborhood mother" identified by the adolescent. Mothers in the control arm receive care as usual. The trial is conducted in clinics where the maternal providers are trained to deliver routine depression care with the use of the WHO Mental Health Gap Action Programme, intervention guide. Assessments are undertaken by trained blinded assessors at baseline, at childbirth, and at 3 and 6 months postpartum. The primary outcome, assessed at 6 months, is the level of maternal depression (measured with the EPDS). The secondary outcome is parenting skills (assessed with the Home Observation Measurement of the Environment, Infant-Toddler version), while tertiary outcomes include measures of disability, quality of life, mother-child bonding, as well as infants' nutritional and growth indices. DISCUSSION: This, to the best of our knowledge, will be the first fully-powered trial of an intervention package specifically designed to address the unique needs of adolescents with perinatal depression. TRIAL REGISTRATION: ISRCTN16775958. Registered on 30 April 2019.

Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review.

BACKGROUND: Mental health conditions are leading causes of disability worldwide. Psychosocial interventions for these conditions might have a key role in their treatment, although applicability of findings to poor-resource settings might be a challenge. We aimed to evaluate the strength and credibility of evidence generated in low-income and middle-income countries (LMICs) on the efficacy of psychosocial interventions for various mental health outcomes. METHODS: We did an umbrella review of meta-analyses of randomised studies done in LMICs. Literature searches were done in Medline, Embase, PsychINFO, CINAHL, Cochrane Library, and Epistemonikos from Jan 1, 2010, until May 31, 2019. Systematic reviews of randomised studies investigating the efficacy of psychosocial interventions for mental health conditions in LMICs were included. Systematic reviews of promotion, prevention, and protection interventions were excluded, because the focus was on treatment interventions only. Information on first author, year of publication, outcomes, number of included studies, and reported summary meta-analytic estimates was extracted from included meta-analyses. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects, and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was assessed using quantitative umbrella review criteria, and credibility of evidence using the GRADE approach. This study is registered with PROSPERO, number CRD42019135711. FINDINGS: 123 primary studies from ten systematic reviews were included. The evidence on the efficacy of psychosocial interventions in adults with depression in humanitarian settings (standardised mean difference 0·87, 95% CI 0·67-1·07; highly suggestive association, GRADE: moderate) and in adults with common mental disorders (0·49, 0·36-0·62; highly suggestive association, GRADE: moderate) was supported by the most robust evidence. Highly suggestive strength of association was found for psychosocial interventions in adults with schizophrenia for functional outcomes, in adults with depression, and in adults with post-traumatic stress disorder in humanitarian settings. In children in humanitarian settings, and in children with disruptive behaviour, psychosocial interventions were supported by suggestive evidence of efficacy. INTERPRETATION: A relatively large amount of evidence suggests the benefit of psychosocial interventions on various mental health outcomes in LMICs. However, strength of associations and credibility of evidence were quite variable, depending on the target mental health condition, type of population and setting, and outcome of interest. This varied evidence should be considered in the development of clinical, policy, and implementation programmes in LMICs and should prompt further studies to improve the strength and credibility of the evidence base. FUNDING: University of Verona.