Marketing mental health services: a mixed-methods analysis of racially and ethnically diverse college students' engagement with and perspectives on U.S. university mental health clinics' websites.

BACKGROUND: The United States (U.S.) faces a significant mental health crisis, with around 52.9 million adults experiencing mental health disorders, with young adults (18-25 years old), such as college students, having the highest prevalence and lowest service utilization rates. While efforts to expand mental health services through "push" strategies are in place (e.g., training therapists in evidence-based therapies), limited initial engagement suggests a need for "pull strategies" and targeted marketing that make services attractive to college students and increase demand. This mixed-methods study identifies U.S. university mental health clinic websites and website characteristics that are attractive and engaging to college students interested in seeking mental health services (i.e., students were considering or actively looking for mental health support). METHODS: Eleven U.S. university websites were chosen (10 randomly and one from the university where students were attending) from a pool of 44 Psychological Clinical Science Accreditation System training clinics websites. Fifty-seven college students (Mage = 20.95, SD = 2.97; 81% female; 68% racial/ethnic minority) were videorecorded engaging with two U.S. university mental health clinic websites, completed self-report engagement measures, and gave detailed feedback about websites through semi-structured interviews. RESULTS: Likert scale scores revealed moderate engagement with all websites (e.g., they were interesting and helpful). Qualitative results indicated that websites that provided important and easily understood information about key features of services (e.g., types, evidence-base, and cost), therapist backgrounds, psychoeducation, used lay language, and had an appealing website layout (e.g., color, font, images, organization, and interactive components) generated greater consumer interest and trust in their mental health services. CONCLUSIONS: This study emphasizes the importance of using marketing strategies to enhance college students' engagement through mental health service websites. Salient features, psychoeducation, and effective promotional strategies (e.g., how information is presented) were identified as crucial for website engagement and subsequent mental health service uptake. Using marketing strategies, such as tailoring language to consumer literacy levels, describing the evidence-base of services, and improving website design may address college students' needs and enhance initial mental health service engagement.

A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care.

To support implementation of integrated behavioral health care (IBHC) models in local settings, providers may benefit from clinical decision-making support. The present analysis examines perspectives on patient characteristics appropriate or inappropriate for, and currently managed within, IBHC at a large medical center to inform recommendations for provider decision-making. Twenty-four participants (n = 13 primary care providers; n = 6 behavioral health providers; n = 5 administrators) in an IBHC setting were interviewed. Thematic analysis was conducted with acceptable interrater reliability (κ = 0.75). Responses indicated behavioral health symptom and patient characteristics that impact perceptions of appropriateness for management in IBHC, with high variability between providers. Many patients with characteristics identified as inappropriate for IBHC were nonetheless currently managed in IBHC. Interactions between patient ability to engage in care and provider ability to manage patient needs guided decisions to refer a patient to IBHC or specialty care. A heuristic representing this dimensional approach to clinical decision-making is presented to suggest provider decision-making guidance informed by both patient and provider ability.

"Being who I am means everything bad can happen": Chronic structural stressors in trauma focused therapy sessions with marginalized adolescents.

OBJECTIVE: Exposure to chronic structural stressors (e.g., poverty, community violence, and discrimination) exacerbates posttraumatic stress disorder (PTSD) symptoms and reduces how adolescents benefit from trauma-focused interventions. However, current evidence-based PTSD interventions seldom include concrete guidance regarding how to target chronic structural stressors in care. METHOD: This study utilized qualitative thematic analysis of audio-recorded PTSD therapy sessions with 13 racially diverse, low socioeconomic status adolescents to elucidate (a) how often adolescents disclose chronic structural stressors in therapy, (b) the types of chronic structure stressors that are disclosed, and (c) the context in which chronic structural stressors are disclosed and the content of these disclosures. RESULTS: 77% of adolescents disclosed at least one chronic structural stressor and that the presence of stressors exacerbated psychological distress, reduced treatment engagement, and decreased perceptions of intervention effectiveness. CONCLUSIONS: Our findings suggest that there is a missed opportunity to improve the effectiveness of treatment for PTSD by incorporating intervention elements that directly target structural stressors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mental health disparities of sexual minority refugees and asylum seekers: Provider perspectives on trauma exposure, symptom presentation, and treatment approach.

Refugees and asylum seekers who identify as sexual minorities and/or who have been persecuted for same-sex acts maneuver through multiple oppressive systems at all stages of migration. Sexual minority refugees and asylum seekers (SM RAS) report experiencing a greater number of persecutory experiences and worse mental health symptoms than refugees and asylum seekers persecuted for reasons other than their sexual orientation (non-SM RAS). SM RAS are growing in numbers, report a need and desire for mental health treatment, and are often referred to therapy during the asylum process. However, little research has been conducted on the treatment needs of SM RAS in therapy or the strategies therapists use to address these needs. This study sought to identify these factors through qualitative interviews with providers at a specialty refugee mental health clinic (N = 11), who had experience treating both SM RAS and non-SM RAS. Interviews were transcribed and coded for themes of similarities and differences between SM RAS and non-SM RAS observed during treatment and factors that could be leveraged to reduce mental health disparities between SM RAS and non-SM RAS. Clinicians reported that compared to the non-SM RAS, SM RAS reported greater childhood trauma exposure, increased isolation, decreased support, identity-related shame, difficulty trusting others, and continued discrimination due to their SM identitiy. Suggested adaptations included reducing isolation, preparing for ongoing identity-based challenges, creating safe spaces to express SM identity, and a slower treatment pace. Providers reported benefits and drawbacks to centering the client's SM identity in treatment and encouraging community involvement for SM RAS, and noted additional training in cultural awareness would be beneficial. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Experience of traumatic events in people with severe mental illness in a low-income country: a qualitative study.

BACKGROUND: This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting. METHODS: A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers. RESULTS: Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure. CONCLUSIONS: Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI.

Effective training practices for non-specialist providers to promote high-quality mental health intervention delivery: A narrative review with four case studies from Kenya, Ethiopia, and the United States.

Mental health needs and disparities are widespread and have been exacerbated by the COVID-19 pandemic, with the greatest burden being on marginalized individuals worldwide. The World Health Organization developed the Mental Health Gap Action Programme to address growing global mental health needs by promoting task sharing in the delivery of psychosocial and psychological interventions. However, little is known about the training needed for non-specialists to deliver these interventions with high levels of competence and fidelity. This article provides a brief conceptual overview of the evidence concerning the training of non-specialists carrying out task-sharing psychosocial and psychological interventions while utilizing illustrative case studies from Kenya, Ethiopia, and the United States to highlight findings from the literature. In this article, the authors discuss the importance of tailoring training to the skills and needs of the non-specialist providers and their roles in the delivery of an intervention. This narrative review with four case studies advocates for training that recognizes the expertise that non-specialist providers bring to intervention delivery, including how they promote culturally responsive care within their communities.

Editorial: Youth Psychotherapy Interventions in Low- and Middle-Income Countries and Throughout the World: Beyond Efficacy, Toward Accessibility.

It is estimated that 13% of the world's children and adolescents have a mental health disorder.1 Fortunately, psychotherapy interventions are effective at improving mental health symptoms and associated functional difficulties.2 However, while the research literature on the efficacy of youth psychotherapy is robust, it may not be generalizable to all populations and across all contexts, particularly given the limited diversity of the research samples with which they have been tested.

A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth.

OBJECTIVE: This study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents. METHOD: Following routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14-22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity. RESULTS: Findings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in "real-life" safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care. CONCLUSIONS: The PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.

Development and pilot testing of a five item traumatic stress screener for use with adolescents in pediatric primary care.

BACKGROUND: Almost 80% of adolescents in the US have experienced a traumatic event, and approximately 7% have post-traumatic stress disorder. However, there is a lack of validated and feasible assessments for assessing traumatic stress symptoms in pediatric primary care, and traumatic stress symptoms are routinely unidentified. This study aimed to develop, pilot test, and assess the psychometric properties of the Adolescent Primary Care Traumatic Stress Screen (APCTSS), a five-item yes/no screener for post-traumatic stress symptoms in adolescents designed for use in pediatric primary care. METHODS: The APCTSS was developed by pediatricians, psychiatrists, psychologists, and social workers who all provide care to trauma-affected adolescent patients. The providers sought to create a developmentally appropriate tool that accurately reflected DSM-5 posttraumatic stress symptoms and that was feasible and acceptable for use in pediatric primary care. To develop the APCTSS, they combined and adapted the UCLA Post-traumatic Stress Disorder (PTSD) Reaction Index for DSM-5 with the adult Primary Care PTSD Screen for DSM-5. Next, 213 adolescent medicine patients were universally approached during routine clinic visits and 178 agreed to participate and were enrolled. The 178 patients were aged 13-22 (M=18.4, SD=2.3), 64.4% female; 62.1% Black or African-American, and 20.7% Hispanic/Latinx. Patients completed APCTSS, Patient Health Questionnaire for Adolescents (PHQ-A), and the Child PTSD Symptom Scale for DSM-5 Interview (CPSS-5-I), and 61 completed the Traumatic Events Screening Inventory for Children (TESI-C). RESULTS: 56.7% reported a criterion A trauma, 30.1% met criteria for DSM-5 PTSD, 7.4% met criteria for subsyndromal PTSD symptoms, and 19.0% for post-event impairing symptoms. Validity and reliability testing indicated that the APCTSS was internally consistent, had good concurrent and discriminant validity, and demonstrated good sensitivity and specificity in identifying adolescents at high risk for post-trauma symptoms. Over half of patients (56.0%) who screened positive on the APCTSS (score ≥2) would not have been identified as having a mental health concern using the PHQ-A, including 60.8% of patients who had probable PTSD, subsyndromal PTSD, or post-event impairing symptoms. CONCLUSIONS: Many youth with trauma-related mental health symptoms are unidentified in pediatric primary care, which is a missed opportunity for early identification and may contribute to a host of poor outcomes. The development of an effective and feasible traumatic stress screening tool for youth primary care may improve early intervention, and the health and well-being of trauma affected youth.

Demographic characteristics, torture experiences, and posttraumatic stress disorder symptoms among asylum seekers and refugees persecuted for same-sex behaviors.

Increasingly, lesbian, gay, and bisexual (LGB) individuals are fleeing the 67 countries that criminalize consensual same-sex intimate relationships, seeking asylum in countries such as the United States. Minority stress theory posits that compared with non-LGB refugees and asylum seekers (RAS), LGB RAS are likely to face persecution, rejection, and discrimination and have a higher risk of experiencing posttraumatic stress disorder (PTSD) symptoms. This study assessed differences in sociodemographic characteristics, persecution experiences, and mental health outcomes among 959 RAS persecuted for same-sex behavior (pLGB RAS) who presented for care and social services at the Boston Center for Refugee Health and Human Rights. Data were derived from intake interviews with RAS clients that elicited torture experiences and assessed PTSD symptoms using the Short Screening Scale for PTSD. Over 11% of the total sample were pLGB RAS. Compared with non-pLGB RAS, pLGB RAS reported higher PTSD symptom levels, ß = .08, p = .031; more difficulty loving others, d = 0.13, p < .001; and feeling more isolated, d = 0.10, p = .005. pLGB RAS reported more persecution, d = 0.31, p = .002; physical assaults, d = 0.22, p = .029; and psychological assaults, d = 0.20, p = .047; and were more likely to be asylum seekers, d = 0.11, p = .001, and have experienced persecution in Uganda, d = 0.39, p < .001, and other countries that criminalize same-sex acts, d = 0.26, p < .001. More research is needed to understand clinical outcomes and implications of treatment for this population.

Social Determinants of Health and ADHD Symptoms in Preschool-Age Children.

OBJECTIVE: Attention-Deficit/Hyperactivity Disorder (ADHD) disproportionately affects socioeconomically disadvantaged children, but for unclear reasons. We examined the association between social determinants of health (SDH) and ADHD symptoms in a national sample of preschool-age children. METHODS: We conducted exploratory factor analysis (EFA) and exploratory structural equation modeling (ESEM) with a sample of 7,565 preschool-age children from the 2016 National Survey of Children's Health, to examine the association between ADHD symptoms and SDH. RESULTS: EFA indicated a one-factor structure for ADHD symptoms, and three factors for SDH (socioeconomic status, access to basic needs, and caregiver well-being). Independently, all three SDH were significantly associated with higher ADHD symptoms. However, in the ESEM model, only worse caregiver well-being (ß = .39, p < .01) was significantly associated with ADHD symptoms, and fully mediated the relationship between SDH and ADHD symptoms. CONCLUSION: Addressing caregiver well-being in preschoolers with ADHD symptoms could be an early intervention strategy.

Development of the South Sudan Mental Health Assessment Scale.

This study developed and validated a measure that captures variation in common local idioms of distress and mental health problems experienced by women in South Sudan, a country which has experienced over 50 years of violence, displacement, and political, social, and economic insecurity. This measure was developed during a randomized controlled trial of the Adolescent Girls Initiative (AGI) and used qualitative Free Listing (n = 102) and Key Informant interviews (n = 27). Internal reliability and convergent validity were assessed using data from 3,137 randomly selected women (ages 14-47) in 100 communities in South Sudan. Test-retest and inter-rater reliability were assessed using responses from 180 women (ages 15-58) who completed the measure once, and 129 of whom repeated the measure an average of 12 days (SD = 8.3) later. Concurrent validity was assessed through the ratings of 22 AGI leaders about the presence or absence of mental health symptoms in the 180 women in the test-retest sample. The study resulted in the development of the South Sudan Mental Health Assessment Scale, a 24-item measure assessing six idioms of distress. The scale consisted of one factor and had excellent internal, test-retest, and interrater reliability. The scale also demonstrated good convergent and concurrent validity and performed well psychometrically. Moreover, its development provides an example for other organizations, working in environments where mental health measures have not yet been developed and validated, to create and validate measures relevant to their populations. In this way, the role of mental health in development settings can be more rapidly assessed.

A culturally adapted brief intervention for post-traumatic stress disorder in people with severe mental illness in Botswana: protocol for a randomised feasibility trial.

BACKGROUND: Research consistently reports elevated rates of exposure to traumatic events and post-traumatic stress disorder (PTSD) in people with severe mental illness (SMI). PTSD may be adequately managed with psychotherapy; however, there is a gap when it comes to management in culturally diverse settings like Botswana. This paper describes a study protocol whose aim is to culturally adapt the BREATHE intervention, a brief psychological intervention for people living with comorbid PTSD and SMI that was developed and tested in the USA; assess the feasibility and acceptability of the adapted BREATHE intervention and explore its efficacy. METHODS: The study will be conducted in three phases using a mixed methods approach. The first phase will identify and describe the most common traumatic experiences and responses to traumatic experiences, amongst patients with SMI, and patients' and mental health care providers' perceptions about suitable PTSD interventions for Botswana. The second phase will entail cultural adaption of the intervention using findings from phase 1, and the third phase will be a pilot trial to assess the feasibility and acceptability of the culturally adapted intervention and explore its efficacy. Quantitative and qualitative data will be analysed using basic descriptive statistics and thematic analysis, respectively. DISCUSSION: Literature highlights cultural variations in the expression and management of mental illness suggesting the need for culturally adapted interventions. The findings of this feasibility study will be used to inform the design of a larger trial to assess the efficacy of an adapted brief intervention for PTSD in patients with SMI in Botswana. TRIAL REGISTRATION: Clinicaltrials.gov registration: NCT04426448 . Date of registration: June 7, 2020.

Psychotherapy in a resource-constrained setting: Understanding context for adapting and integrating a brief psychological intervention into primary care.

Low- and middle-income countries have few mental health professionals, and efforts to increase access to treatment are a global priority. A key gap is the lack of integration of psychotherapy interventions as a part of accessible evidence-based care. Current recommendations suggest that the integration of mental health treatments, including psychotherapy, into existing primary care pathways may serve as a means to address this disparity. Understanding the cultural and contextual factors that affect this process is a critical step in identifying necessary adaptations. The aim of this qualitative study was to identify contextual factors associated with integrating psychotherapy in primary care in a predominantly rural district in south-central Ethiopia. Purposive sampling was used to recruit 48 mental health service users, caregivers, health care providers, and community leaders. Semistructured interviews were conducted, recorded, and transcribed in Amharic and translated into English. Although challenges (e.g., stigma, job strain, lack of belief in formal treatments) are present, other existing strengths (e.g., openness to seeking treatment, increasing knowledge about mental health treatment, familiarity with practices similar to therapy) support subsequent psychotherapy adaptation and implementation. These findings suggest possible mechanisms to improve delivery and adaptation in the effort to lower the existing global treatment gap. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Posttraumatic stress disorder intervention for people with severe mental illness in a low-income country primary care setting: a randomized feasibility trial protocol.

BACKGROUND: In this protocol, we outline a mixed-methods randomized feasibility trial of Brief Relaxation, Education and Trauma Healing (BREATHE) Ethiopia. BREATHE Ethiopia is a culturally and contextually adapted intervention for PTSD in participants with severe mental illness. BREATHE Ethiopia maps onto the World Health Organization's guidelines for posttraumatic stress disorder (PTSD) treatment in low- and middle-income country primary care settings. METHODS: Specifically, this study includes a non-randomized pre-pilot (n = 5) and a randomized feasibility trial comparing BREATHE Ethiopia to Treatment as Usual (n = 40) to assess trial procedures, acceptability, and feasibility of intervention delivery, and investigate potential effectiveness and implementation. In a process evaluation, we will collect data that will be critical for a future fully randomized controlled trial, including the numbers of participants who are eligible, who consent, who engage in treatment, and who complete the assessments, as well as the feasibility and acceptability of assessments and the intervention. Qualitative data on facilitators and barriers to intervention delivery and quantitative data on provider fidelity to the intervention and participant and provider satisfaction will also be collected. Quantitative assessments at baseline, post-treatment, 1-month follow-up, and 3-month follow-up will assess change in mental health symptoms and functional impairment and hypothesized intervention mechanisms, including knowledge about PTSD, stigma, trauma-related cognitions, and physiological arousal. DISCUSSION: Findings from this study will inform a future fully-powered randomized controlled trial, and if found to be effective, the intervention has the potential to be integrated into mental healthcare scale-up efforts in other low-resource settings. TRIAL REGISTRATION: Registered with ClinicalTrials.gov (NCT04385498) first posted May 13th, 2020; https://www.clinicaltrials.gov/ct2/show/NCT04385498?term=ethiopia&cond=PTSD&draw=2&rank=1 .

Traumatic events and posttraumatic stress disorder in individuals with severe mental illness in a non-western setting: Data from rural Ethiopia.

Traumatic events and ensuing stress are not widely studied in individuals with severe mental illness (SMI) despite their increased vulnerability to both. Far less is known about traumatic events and posttrauma reactions in people with SMI in low-resourced settings. OBJECTIVE: To address this gap in knowledge, our study focused on trauma and its effects for individuals with SMI and their caregivers in rural Ethiopia. Study aims were to identify events that were considered traumatic by stakeholders; characterize the mental health effects of such events; and discern events and posttrauma symptoms most relevant for SMI. METHOD: Qualitative interviews were gathered from 48 participants in Ethiopia who included individuals with SMI, their caregivers, health care providers, and community and religious leaders. RESULTS: Based on a combined emic and etic approach, major traumatic events included those commonly experienced in rural Ethiopia (e.g., lost property, forced marriage) and endorsed by individuals with SMI (e.g., restraining or chaining, SMI illness in a low-resourced setting). In addition, traumatic events were identified consistent with Western medical criteria (e.g., physical assault, sexual assault). Posttrauma symptoms that were commonly reported included emotions like anger and sadness; thinking too much; crying; and somatic (e.g., burning sensation) and physiological (e.g., shortness of breath) symptoms. As for symptoms consistent with the Diagnostic and Statistical Manual, we found the presence of all four symptom clusters. CONCLUSIONS: Overall, results point to the common occurrence of traumatic events and trauma-linked symptoms for individuals with SMI and their caregivers, including as a result of SMI. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations.

Integrated behavioral health care (IBHC) models in primary care are positioned to address the unmet needs of traditional behavioral health models. However, research support is limited to specific populations, settings, and behavioral health conditions. Empirical evidence is lacking for expansion to larger health systems and diverse behavioral health conditions. This study examines perspectives on IBHC implementation in a large medical center. Semi-structured interviews were conducted with 24 health providers and administrators in two primary care clinics with IBHC. Thematic analysis demonstrated that participants had an overall favorable perception of IBHC, but also perceived implementation challenges, including difficulties with access, underutilization, team dynamics, and financial and interdepartmental issues. The findings suggest that IBHC implementation barriers in existing large health systems risk diminishing potential benefits and successful adoption. These barriers can be combated by incorporating systems change strategies into implementation frameworks, with a focus on barrier prevention and detection and long-term sustainability.

Correction: National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis.

[This corrects the article DOI: 10.1371/journal.pmed.1003090.].

National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: People living in sub-Saharan Africa (SSA) are disproportionately exposed to trauma and may be at increased risk for posttraumatic stress disorder (PTSD). However, a dearth of population-level representative data from SSA is a barrier to assessing PTSD. This manuscript sought to calculate pooled PTSD prevalence estimates from nationally and regionally representative surveys in SSA. METHODS AND FINDINGS: The search was conducted in PubMed, Embase, PsycINFO, and PTSDpubs and was last run between October 18, 2019, and November 11, 2019. We included studies that were published in peer-reviewed journals; used probabilistic sampling methods and systematic PTSD assessments; and included ≥ 450 participants who were current residents of an SSA country, at least 50% of whom were aged between 15 and 65 years. The primary outcomes were point prevalence estimates of PTSD across all studies, and then within subgroups. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016029441). Out of 2,825 unique articles reviewed, 25 studies including a total of 58,887 eligible participants (54% female) in 10 out of the 48 countries in SSA were identified. Most studies enrolled any adult aged 18 years or older. However, some studies only enrolled specific age brackets or persons as young as 15 years old. Six studies were national surveys, and 19 were regional. There were 4 key findings in the meta-analysis: (1) the overall pooled prevalence of probable PTSD was 22% (95% CI 13%-32%), while the current prevalence-defined as 1 week to 1 month-was 25% (95% CI 16%-36%); (2) prevalence estimates were highly variable, ranging from 0% (95% CI 0%-0%) to 74% (95% CI 72%-76%); (3) conflict-unexposed regions had a pooled prevalence of probable PTSD of 8% (95% CI 3%-15%), while conflict-exposed regions had a pooled prevalence of probable PTSD of 30% (95% CI 21%-40%; p < 0.001); and (4) there was no significant difference in the pooled prevalence of PTSD for men and women. The primary limitations of our methodology are our exclusion of the following study types: those published in languages other than English, French, and Portuguese; smaller studies; those that focused on key populations; those that reported only on continuous measures of PTSD symptoms; and unpublished or non-peer-reviewed studies. CONCLUSIONS: In this study, PTSD symptoms consistent with a probable diagnosis were found to be common in SSA, especially in regions exposed to armed conflict. However, these studies only represent data from 10 of the 48 SSA countries, and only 6 studies provided national-level data. Given the enormous heterogeneity expected across the continent, and also within countries and regions, this review cannot speak to rates of PTSD in any regions not included in this review. Thus, substantial gaps in our knowledge of PTSD prevalence in SSA remain. More research on population-level prevalence is needed to determine the burden of trauma symptoms and PTSD in SSA and to identify acceptable and feasible approaches to address this burden given limited mental healthcare resources.

Trauma exposure, depression, suicidal ideation, and alcohol use in people with severe mental disorder in Ethiopia.

PURPOSE: To investigate exposure to traumatic and stressful events and their association with depression, suicidal ideation, and alcohol abuse in people with severe mental disorder (SMD) in Ethiopia. METHODS: As part of the Programme for Improving Mental health carE, 300 people with SMD (84% primary psychosis, 11% bipolar disorder, and 16% depression with psychotic features) in a rural district were identified by psychiatric nurses. A cross-sectional assessment included clinical characteristics, experience of being restrained, exposure to stressful events as measured by an adapted version of the List of Threatening Experiences scale, traumatic events as measured by endorsement of 13 locally relevant potentially traumatic events that occurred since the onset of the participant's mental illness, depression symptoms measured by the Patient Health Questionnaire, the Suicidal Behavior Module of the Composite International Diagnostic Interview, and hazardous drinking which was calculated as a sum score of eight or higher on the Alcohol Use Disorders Identification Test. RESULTS: Almost half of participants reported being restrained since becoming ill, which was associated with more suicidal ideation and less hazardous drinking. More than one-third experienced traumatic events since becoming ill, including being assaulted, beaten, or raped. Exposure to traumatic events was associated with hazardous drinking. CONCLUSIONS: In this rural Ethiopian setting, people with SMD experienced high levels of traumatic and stressful events which were associated with co-morbid conditions. Greater attention needs to be given to trauma prevention and integration of treatment for trauma sequelae in efforts to expand integrated mental health care.