Providers' perspectives of barriers and facilitators to scale-up of mental health care in the public health delivery system of Mozambique: a qualitative inquiry.

BACKGROUND: A central challenge to closing the mental health treatment gap in low- and middle-income countries (LMICs) is determining the most effective pathway for delivering evidence-based mental health services. We are conducting a cluster-randomized, Type 2 hybrid implementation-effectiveness trial across 20 districts of Mozambique called the Partnerships in Research to Implement and Disseminate Sustainable and Scalable EBPs (PRIDE) program. Following training of nonspecialized providers in facilitation of evidence-based treatments for mental health and informed by the Consolidated Framework for Implementation Research (CFIR), we identified how PRIDE compares to care as usual and the perceived barriers and facilitators of implementation and modifications needed for widescale service delivery and scale-up. METHODS: We conducted rapid ethnographic assessment using freelisting among 34 providers, followed by four focus group discussions (n = 29 participants) with a subsample of psychiatric technicians and primary care providers from 14 districts in Nampula Province. We used Thematic Analysis to inductively apply open codes to transcripts and then deductively applied the CFIR domains and constructs to organize open codes. RESULTS: The main Outer Setting constructs relevant to implementation were recognition that patient mental health needs were significant. Additionally, numerous community-level characteristics were identified as barriers, including distance between clinics; shortage of providers; and low awareness of mental health problems, stigma, and discrimination among community members towards those with mental health struggles. The PRIDE program was perceived to offer a relative advantage over usual care because of its use of task-sharing and treating mental illness in the community. PRIDE addressed Inner Setting barriers of having available resources and training and provider low self-efficacy and limited knowledge of mental illness. Providers recommended leadership engagement to give support for supervision of other task-shared professionals delivering mental healthcare. CONCLUSIONS: Primary care providers and psychiatric technicians in Mozambique perceived the relative advantage of the PRIDE program to address mental health treatment access barriers and offered recommendations for successful sustainment and scale up of integrated mental health care.

Leveraging Social Networks to Integrate Depression Treatment into Primary Health and Tuberculosis Care in Brazil.

Background: Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems. Objective: To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil. Methods: We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot. Results: Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative. Conclusions: The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

Validation of screening instruments for common mental disorders and suicide risk in south African primary care settings.

INTRODUCTION: In South Africa, there is limited mental health infrastructure and resources. Valid screening tools are needed to facilitate identification and linkage to care. We evaluated the performance of Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Primary Care Post Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5), and the Columbia Suicide Severity Rating Scale (C-SSRS) among adults in South Africa against a diagnostic gold standard. METHODS: Adults present at healthcare facilities were screened with the PHQ-9, GAD-7, PC-PTSD-5, and the C-SSRS. Nurses used a structured diagnostic interview to identify depression, anxiety, panic disorder, PTSD and elevated suicide risk. We assessed the internal consistency, criterion validity, and the sensitivity and specificity of these tools. RESULTS: Of the 1885 participants, the prevalence of common mental disorders and suicide risk was 24.4 % and 14.9 %, respectively. The PHQ-9, GAD-7, and PC-PTSD-5 showed good internal consistency (0.80-0.89). All screeners demonstrated good criterion validity. For depression, a cut-off of ≥5 on the PHQ-9 yielded sensitivity of 84.24 %, while ≥10 yielded sensitivity of 48.77 %. For anxiety, the GAD-7 performed similarly. A cut-off of ≥4 on the PC-PTSD yielded sensitivity of 61.96 %. The C-SSRS yielded lower sensitivity than expected. LIMITATIONS: The prevalence data is not generalizable to the larger South African adult population given the use of a targeted, healthcare facility-based sampling and recruitment strategy. CONCLUSIONS: The performance of the PHQ-9, GAD-7, and PC-PTSD-5 demonstrated good internal consistency and criterion validity, though sensitivity and specificity trade-offs were enhanced with lower cut-offs. Further research into suicide risk screening is warranted.

Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States.

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa.

In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool's performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.

Leveraging a Digitized Mental Wellness (DIGImw) Program to Provide Mental Health Care for Internally Displaced People.

A local insurgency has displaced many people in the northern Mozambican province of Cabo Delgado. The authors' global team (comprising members from Brazil, Mozambique, South Africa, and the United States) has been scaling up mental health services across the neighboring province of Nampula, Mozambique, now host to >200,000 displaced people. The authors describe how mental health services can be expanded by leveraging digital technology and task-shifting (i.e., having nonspecialists deliver mental health care) to address the mental health needs of displaced people. These methods can serve as a model for other researchers and clinicians aiming to address mental health needs arising from humanitarian disasters in low-resource settings.

Should We Trust You? Strategies to Improve Access to Mental Healthcare to BIPOC Communities During the COVID-19 Pandemic.

Black, Indigenous, and People of Color (BIPOC) communities have weathered centuries of racism, causing transgenerational mental health consequences and hindering access to quality treatment. In this commentary, we describe the systemic challenges of engaging BIPOC to promote mental health equity during the COVID-19 pandemic. We then describe an initiative that illustrates these strategies, provide recommendations and further readings for academic institutions seeking to partner with community organizations to provide equitable mental health services to populations that have been traditionally overlooked.

The COVID-19 pandemic as a catalyst for integrated global mental healthcare and tuberculosis care.

Mental disorders are common among persons with tuberculosis (TB), and the COVID-19 pandemic has only amplified the mental and physical health consequences of this deadly synergy. Here, we call to attention the immense vulnerability of people with TB to mental disorders during the pandemic and highlight the unique challenges and opportunities that the pandemic brings to the future integration of global TB and mental healthcare. We argue that the pandemic era is an ideal period to accelerate this integration and we provide research and policy recommendations to actualise this urgent need.

An Ultra-Brief Proxy Measure for Early Mental and Substance Use Disorders and Suicide Risk Case Detection at the Community and Household Level: An Efficient and Feasible Clinical and Population-level Service Needs Screening Tool.

Valid mental and substance use disorders and suicide risk screening tools are needed for community case finding of individuals who may not otherwise seek care. We evaluated the Proxy Mental Wellness Tool-3 (mwTool-3-proxy) a three-item screener that asks about the mental health of another adult, against a diagnostic gold standard in Mozambique and South Africa. The mwTool-3-proxy adapts the three items of the Mental Wellness Tool-3, developed in Mozambique using Mini International Neuropsychiatric Interview diagnoses as the criterion standard, regression modeling and expert consultation to determine the best three items for identifying any mental disorder. The Mental Wellness Tool-3 has been validated in South Africa, Spain and the United States, and is being validated in three countries in the Asia-Pacific and Israel. Pairs of adults in South Africa and Mozambique at primary and tertiary healthcare facilities were separately screened with the mwTool-3-proxy and diagnosed using the Mini International Neuropsychiatric Interview. We calculated the sensitivities and specificities for predicting any mental and/or substance use disorder and suicide risk among the proxy individual. We performed additional analyses restricted to respondents who were relatives of one another and who lived in the same household. The prevalence of any Mini International Neuropsychiatric Interview-diagnosed disorder among the 229 pairs in both countries was 35.6% (38.5% in Mozambique; 32.9% in South Africa). The pooled sensitivity of the mwTool-3-proxy for identifying any disorder among the proxy individual was 73.01 (95%CI: 65.5-79.65) - 70.24 (95%CI: 59.27-79.73) in Mozambique and 80.00 (95%CI 69.17-88.35) in South Africa. The mwTool-3-proxy is a culturally-relevant, ultra-brief valid measure that can improve mental and substance use disorders and suicide risk case detection with strong sensitivity at the community and household level and offer a means to efficiently and feasibly collect clinical and population-level service needs data.

Lay HIV counselors' knowledge and attitudes toward depression: A mixed-methods cross-sectional study at primary healthcare centers in Mozambique.

Introduction: Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique. Methods: We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions. Results: The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding. Conclusion: Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy.

The impact of COVID-19 on self-reported burnout and health and mental health services in Nampula, Mozambique.

Background: The purpose of this study was to examine the impact of the COVID-19 pandemic on self-reported burnout of health workers, quality of care, and perceptions of COVID-19-related stigma in Mozambique. Method: We conducted a cross-sectional quantitative assessment of 170 frontline health workers in Nampula District, Mozambique, including 149 (87.6%) primary care providers and 21 (12.4%) mental health specialists. Results: Of the 170 frontline workers, only 10.1% of frontline workers were experiencing more professional burnout, whereas 33.3% felt it had lessened. The perceived impact on quality of care also varied, without any significant differences by sex, education level, or mental health training background. Compared to the beginning of the COVID-19 pandemic in March 2020, 42.3 and 38.1% providers felt that their ability to provide mental health and general health care, respectively, had worsened, compared to 57.7 and 61.9% who believed that either there was no change, or that the work had become easier. Likewise, 26.8% of providers felt that their ability to meet patients' needs had gotten more difficult, whereas 43.4% reported no change and 29.8% reported that it was easier. Twenty-two percent of providers reported an overall increase in caseloads since before the pandemic whereas the majority (67.9%) reported a decrease. Providers believed that 57.1% of people in general were afraid of people with COVID-19, 27.5% were afraid of a person recovered from COVID-19, and 39.9% were afraid of a person with family members with COVID-19. The perceived stigma about healthcare professionals was also low; only 27.4% believed that people in general were afraid of healthcare providers who deliver care to people with COVID-19. Conclusion: In contrast with other global studies, many healthcare workers in our sample reported a reduction in burnout, which may be associated with the lower overall caseloads seen during this period. Similarly, the quality of care was minimally impacted. More research is needed to determine whether the experience in Mozambique is unique, or similarly observed in other low-resource settings.

Lay hiv counsellors' knowledge and attitudes toward depression: a mixed-methods cross-sectional study at primary healthcare centers in mozambique

Introduction Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique. Methods We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions. Results The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding. Conclusion Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy.

The relationship between mental health and risk of active tuberculosis: a systematic review.

OBJECTIVES: Tuberculosis (TB) and mental illnesses are highly prevalent globally and often coexist. While poor mental health is known to modulate immune function, whether mental disorders play a causal role in TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures. DESIGN: Systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. SEARCH STRATEGY AND SELECTION CRITERIA: MEDLINE, PsycINFO and PsycEXTRA databases were searched alongside reference list and citation searching. Inclusion criteria were original research studies published 1 January 1970-11 May 2020 reporting data on the association between mental health and TB risk. DATA EXTRACTION, APPRAISAL AND SYNTHESIS: Data were extracted on study design and setting, sample characteristics, measurement of mental illness and TB, and outcomes including effect size or prevalence. Studies were critically appraised using Critical Appraisal Skills Programme (CASP) and Appraisal Tool for Cross-Sectional Studies (AXIS) checklists. RESULTS: 1546 records published over 50 years were screened, resulting in 10 studies included reporting data from 607 184 individuals. Studies span across Asia, South America and Africa, and include mood and psychotic disorders. There is robust evidence from cohort studies in Asia demonstrating that depression and schizophrenia can increase risk of active TB, with effect estimates ranging from HR=1.15 (95% CI 1.03 to 1.28) to 2.63 (95% CI 1.74 to 3.96) for depression and HR=1.52 (95% CI 1.29 to 1.79) to RR=3.04 for schizophrenia. These data align with evidence from cross-sectional studies, for example, a large survey across low-income and middle-income countries (n=242 952) reports OR=3.68 (95% CI 3.01 to 4.50) for a depressive episode in those with TB symptoms versus those without. CONCLUSIONS: Individuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally. PROSPERO REGISTRATION NUMBER: CRD42019158071.

Impact of mental disorders on active tuberculosis treatment outcomes: a systematic review and meta-analysis.

BACKGROUND: Comorbid mental disorders in patients with tuberculosis (TB) may exacerbate TB treatment outcomes. We systematically reviewed current evidence on the association between mental disorders and TB outcomes. METHODS: We searched eight databases for studies published from 1990-2018 that compared TB treatment outcomes among patients with and without mental disorders. We excluded studies that did not systematically assess mental disorders and studies limited to substance use. We extracted study and patient characteristics and effect measures and performed a meta-analysis using random-effects models to calculate summary odds ratios (OR) with 95% confidence intervals (CI). FINDINGS: Of 7,687 studies identified, ten were included in the systematic review and nine in the meta-analysis. Measurement of mental disorders and TB outcomes were heterogeneous across studies. The pooled association between mental disorders and any poor outcome, loss to follow-up, and non-adherence were OR 2.13 (95% CI: 0.85-5.37), 1.90 (0.33-10.91), and 1.60 (0.81-3.02), respectively. High statistical heterogeneity was present. INTERPRETATION: Our review suggests that mental disorders in TB patients increase the risk of poor TB outcomes, but pooled estimates were imprecise due to small number of eligible studies. Integration of psychological and TB services might improve TB outcomes and progress towards TB elimination.

Mixed-methods evaluation of mental healthcare integration into tuberculosis and maternal-child healthcare services of four South African districts.

BACKGROUND: The South African National Mental Health Policy Framework and Strategic Plan 2013-2020 was adopted to address the country's substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa. METHODS: Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services. RESULTS: A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population. CONCLUSIONS: Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.

Correlations between caregiver psychiatric symptoms and offspring psychopathology in a low-resource setting

Objective: Associations between parental/caregiver depression and adverse child outcomes are well established and have been described through one or more mechanisms: child psychopathology following exposure to a depressed caregiver, child psychopathology exacerbating a caregiver's depression, and caregiver and offspring depression sharing the same etiology. Data from low and middle-income countries is scarce. We examined correlations between common symptoms of mental disorders in caregivers and their offspring's psychopathology in a Brazilian sample. Methods: In this cross-sectional study, adult caregivers were screened for depression during routine home visits by community health workers as part of the Brazilian Family Health Strategy. Caregivers with suspected depression were assessed using the Zung Self-Rating Depression Scale and the Self-Reporting Questionnaire (SRQ-20). Children's symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Results: The sample included 68 primary caregivers and 110 children aged 6 to 15 years. Higher caregiver scores on the SRQ-20 correlated significantly with psychiatric symptoms in offspring. Conclusion: These results substantiate our hypothesis that child psychopathology correlates with caregivers' psychiatric symptoms. This paper adds to the growing literature on community mental health assessment and can help guide future strategies for reducing the burden of common mental disorders in caregivers and children alike in low and middle-income countries.