Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial.

BACKGROUND: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. OBJECTIVE: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. METHODS: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. RESULTS: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005). CONCLUSIONS: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance. TRIAL REGISTRATION: ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-016-1511-1.

Development of mental health and psychosocial support (MHPSS) guidelines for deaf and hard of hearing children in the Gaza Strip.

Deaf and hard of hearing children in the Gaza Strip may be at risk of mental health conditions and psychological distress, as a result of social exclusion and limited accessible communication. This article presents the process and research methods used to develop guidelines for schools in the Gaza Strip on mental health and psychosocial support for deaf and hard of hearing children. The process was guided by the GIN-McMaster guideline development checklist across four steps: (1) priority settings; (2) searching for evidence; (3) developing recommendations; (4) evaluation. Priority setting was spearheaded by local and international researchers, and a local steering committee comprised of deaf and hard of hearing representatives, school administration and staff, mental health specialists, family members and government officials. In searching for evidence, and in order to generate evidence-based recommendations for the guidelines, we utilised a scoping review of global mental health support for deaf and hard of hearing children and qualitative research with deaf and hard of hearing children and adults, families and teachers. Two pilot studies were conducted in mainstream and specialist educational settings as way of evaluation. The scoping review and qualitative research identified various content for the guidelines, including the importance of information on disability and deafness, promoting social inclusion and self-esteem, and accessible learning environments. The pilot studies demonstrated feasibility and acceptability among teachers and deaf and hard of hearing children, although teachers need sufficient support and resources to implement. Now finalised, the guidelines are being distributed to schools in the Gaza Strip to support the mental health and wellbeing of deaf and hard of hearing children.

Lessons from the development process of the Afghanistan integrated package of essential health services.

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

Communication, inclusion and psychological wellbeing among deaf and hard of hearing children: A qualitative study in the Gaza Strip.

Deaf and hard of hearing children are at risk of exclusion from community life and education, which may increase their risk of mental health conditions. This study explores the experience of deaf and hard of hearing children in the Gaza Strip, with particular focus on the factors that contribute to psychological wellbeing and distress. In-depth interviews were conducted with 17 deaf and hard of hearing children, 10 caregivers of deaf and hard of hearing children and eight teachers of deaf and hard of hearing children in mainstream and special schools, across the Gaza Strip. Further, three focus group discussions were held with deaf and hard of hearing adults and disability leaders, mental health specialists and other teachers of deaf and hard of hearing children. Data collection was completed in August 2020. Key themes identified in the analysis included lack of accessible communication, community exclusion, negative attitudes towards hearing impairment and deafness and the impact on deaf and hard of hearing children's sense of self, and limited family knowledge on hearing impairment and deafness. Further findings focused on strategies to improve the inclusion of deaf and hard of hearing children and how to promote wellbeing. In conclusion, participants in this study believed that deaf and hard of hearing children in the Gaza Strip are at increased risk of mental health conditions. Changes are needed across community and government structures, including education systems, to promote the inclusion of deaf and hard of hearing children and to support their psychological wellbeing. Recommendations from the findings include increasing efforts to improve awareness and reduce stigma, providing better access to sign language for deaf and hard of hearing children, and offering training for teachers of deaf and hard of hearing children, especially in mainstream environments.

Practitioners' experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators.

BACKGROUND: Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists' experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme. AIMS: To investigate psychological well-being practitioners' (PWPs') experiences of the working alliance in a trial of blended cognitive-behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725. METHOD: Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data. RESULTS: Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients' needs and lack of confidence in delivering b-CBT. CONCLUSIONS: Our study is the first specifically to investigate practitioners' perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs' experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.

Listening to the Shenzhen Primary Healthcare Context to Adapt the mhGAP-IG.v2 for the Assessment of Depression: Qualitative Workshops with Primary Healthcare Leaders.

In Shenzhen, despite recent primary and mental healthcare reform, Primary healthcare doctors (PHC) have limited access to diagnostic tools and a significant mental health treatment gap presides. The World Health Organization's (WHO) mental health gap intervention guide (mhGAP-IG.v2) offers a non-specialist and evidence-based guide for the assessment of depression however requires adaptation to the context of use. Bilingual (Mandarin and English) qualitative research was undertaken with 30 PHC leaders from Shenzhen to compare their assessment approach for depression against the mhGAP-IG.v2 in order to identify context-specific modifications for a local guide. Local assessment differentiators included: a need for culturally sensitive translation of depression symptoms; a preference for a broad, non-hierarchical symptom presentation (including somatic, behavioural and anxiety items); national prioritisation of suicide patients; the integration of family into the cycle of care; limited primary care awareness of a depressive episode in Bipolar Disorder; and China's specialist-led diagnostic approach. Contextual modification of mhGAP-IG.v2 is recommended to take account of China's unique cultural and primary health system response to depression. Ongoing mental health training is required to develop professional confidence in the recognition of mental disorders.

Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study.

BACKGROUND: Primary care doctors in Shenzhen, China are increasingly expected to identify and prevent depressive disorder; however, they have received limited mental health training and community healthcare centres (CHC) do not provide standardised protocols for the diagnosis and care of depressive disorder. The World Health Organization's mental health gap intervention guide, version 2 (mhGAP-IG.v2) is a decision support tool for non-specialists for the assessment, management and follow-up of mental, neurological and substance use disorders (including depressive disorder). Given that mhGAP-IG.v2 is a generic tool, it requires adaptation to take account of cultural differences in depression presentation and unique characteristics of China's emergent mental health system. METHODS: A two-round, web-based, Delphi survey was conducted. A panel of primary care doctors from Shenzhen, were invited to score their level of agreement with 199 statements (arranged across 10 domains) proposing changes to the content and structure of mhGAP-IG.v2 for use in Shenzhen. Consensus was predefined as 80% panelists providing a rating of either "somewhat agree/definitely agree", or "definitely disagree/somewhat disagree" on a five-point scale for agreement. RESULTS: 79% of statements received consensus with a mean score of 4.26 (i.e. "somewhat agree"). Agreed adaptations for mhGAP-IG.v2 included:- an assessment approach which considers a broader spectrum of depression symptoms and reflects the life course of disease; incorporating guidance for screening tool usage; clarifying physicians' roles and including referral pathways for intersectorial care with strong family involvement; aligning drug treatment with national formularies; stronger emphasis of suicide prevention throughout all sections of the guide; contextualizing health education; reflecting a person-centred approach to care. Panelists chose to maintain diagnostic and treatment advice for bipolar patients experiencing a depressive episode as in the current guide. CONCLUSIONS: An adapted mhGAP-IG.v2 for depression recognises China's cultural and contextual needs for assessment guidance; unique primary healthcare system organization, priorities and treatment availability; and diverse psychosocial educational needs. An adapted mhGAP-IG.v2 could both inform the future training programs for primary care in Shenzhen and also offer an additional mental health resource for non-specialists in other countries.

Gender, mental health and resilience in armed conflict: listening to life stories of internally displaced women in Colombia.

For over 60 years, Colombia has endured violent civil conflict forcibly displacing more than 8 million people. Recent efforts have begun to explore mental health consequences of these contexts, with an emphasis on national surveys. To date few Colombian studies explore mental health and well-being from a lived experience perspective. Those that do, overlook processes that enable survival. In response to this gap, we conducted a life history study of seven internally displaced Colombian women in the Cundinamarca department, analysing 18 interview sessions and 36 hours of transcripts. A thematic network analysis, informed by Latin-American perspectives on gender and critical resilience frameworks, explored women's coping strategies in response to conflict-driven hardships related to mental well-being. Analysis illuminated that: (1) the gendered impacts of the armed conflict on women's emotional well-being work through exacerbating historical gendered violence and inequality, intensifying existing emotional health challenges, and (2) coping strategies reflect women's ability to mobilise cognitive, bodied, social, material and symbolic power and resources. Our findings highlight that the sociopolitical contexts of women's lives are inseparable from their efforts to achieve mental well-being, and the value of deep narrative and historical work to capturing the complexity of women's experiences within conflict settings. We suggest the importance of social interventions to support the mental health of women in conflict settings, in order to centre the social and political contexts faced by such marginalised groups within efforts to improve mental health.

Towards a conceptual framework of the working alliance in a blended low-intensity cognitive behavioural therapy intervention for depression in primary mental health care: a qualitative study.

OBJECTIVES: To examine and adapt a conceptual framework of the working alliance (WA) in the context of a low-intensity blended (psychological well-being practitioner (PWP) plus computerised program) cognitive behavioural therapy intervention (b-CBT) for depression. DESIGN: Patient involvement was enlisted to collaboratively shape the design of the project from the onset, before data collection. In-depth semi-structured interviews were carried out with participants who experienced b-CBT as part of the E-compared trial. A thematic analysis was conducted using a constant comparative method informed by grounded theory. SETTING: Recruitment was carried out in four psychological primary care services across the UK. PARTICIPANTS: Nineteen trial participants with major depressive disorder who completed at least one computerised program and face-to-face session with a PWP in the b-CBT arm were recruited to the study. RESULTS: Qualitative interviews that were guided by WA theory and patient involvement, revealed four themes: (1) a healthcare provider (PWP and computerised program) with good interpersonal competencies for building a working relationship with the client ('bond'); (2) collaborative efforts between the client and the provider to appropriately identify what the client hopes to achieve through therapy ('goals'); (3) the selection of acceptable therapeutic activities that address client goals and the availability of responsive support ('task') and (4) the promotion of active engagement and autonomous problem solving ('usability heuristics'). Participants described how the PWP and computerised program uniquely and collectively contributed to different WA needs. CONCLUSIONS: This study is the first to offer a preliminary conceptual framework of WA in b-CBT for depression, and how such demands can be addressed through blended PWP-computerised program delivery. These findings can be used to promote WA in technological design and clinical practice, thereby promoting engagement to b-CBT interventions and effective deployment of practitioner and program resources. TRIAL REGISTRATION NUMBER: ISRCTN12388725.

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study.

BACKGROUND: Policies and programmes in Mexico promote the integration of mental health services into primary health care (PHC), however these services remain largely unavailable in the country. Since 2014 a non-governmental organisation has delivered a mental health programme at PHC clinics in the state of Chiapas, in partnership with the local Ministry of Health (MoH). The programme provides mental health services based on the mhGAP guidelines through multiple implementation strategies, including programme financing, infrastructure strengthening, high-intensity training, and supervision. This study aimed to examine the implementation process and outcomes of this mental health programme to understand the extent to which mental health care integration has been achieved and to identify the successes and remaining challenges in order to inform the development and implementation of similar programmes. METHODS: We used a mixed-methods convergent design. Quantitative data for the period between December 2016 and December 2017 were extracted from the organisation's health information system to capture process indicators, including the amount (dose) and quality (fidelity) of services delivered. We conducted two focus groups and 24 semi-structured interviews with health providers and managers to ascertain implementation outcome data: penetration, fidelity, acceptability, appropriateness and feasibility. Quantitative and qualitative data were analysed using descriptive and framework analyses, respectively. RESULTS: During the study period, health providers delivered mental health consultations to 486 adults diagnosed with a mood or anxiety disorder. Programme fidelity was limited given that talk-based interventions, which are required in all consultations according to programme guidelines, were only provided in 24% of consultations. Only 42% of service users attended more than 50% of scheduled mental health follow-up consultations, which also hindered fidelity. Low attendance is partially attributed to limited programme appropriateness, given that interventions to address social risk factors are not available. High levels of acceptability and feasibility enabled through strong support from the organisation were key programme strengths. CONCLUSIONS: Mental health programmes at PHC can be implemented when adequate support and supervision structures are in place, and key resources are available. There is an urgent need for health systems strengthening to support efforts to provide mental health care, and to link PHC with locally-relevant social interventions.

Service user and family participation in mental health policy making in Timor-Leste: a qualitative study with multiple stakeholders.

BACKGROUND: Participation in mental health system strengthening by people with mental health problems and their families is a cornerstone of people-centred mental health care, yet there is a dearth of research about participation from low- and middle-income countries (LMICs), particularly from the Asia Pacific region. Hence, this study aimed to assess the current situation, challenges, enabling factors and future actions for service user and family participation in mental health policy making in Timor-Leste. METHODS: In-depth interviews were conducted with 85 adults (≥18 years) who were: (1) mental health service users (n = 20) and their families (n = 10); (2) government decision makers (n = 10); (3) mental health and social service providers (n = 23); (4) civil society (n = 9); and (5) other groups (n = 13). Interview data was analysed using framework analysis. RESULTS: There was limited service user, family and community participation in mental health policy making in Timor-Leste. Perceptions that policy making is a technical exercise and that people with mental health problems lack cognitive capacity, and a lack of supportive mechanisms challenged participation. Enabling factors were a strong focus on human rights within the social sector, and existing mechanisms for advocacy and representation of people with disabilities in social policy making. Participants suggested bolstering civil society representation of people with mental health problems, and increasing mental health awareness and literacy, including government competencies to facilitate service user participation. CONCLUSION: The findings highlight the need for theoretical and practical focus on the role of family within mental health system development in LMICs. Global mental health research and practice should adopt a critical approach to mental health service user and family participation to ensure that the concept and strategies to achieve this are embedded in LMIC knowledge.

Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries.

Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.

Intersectoral collaboration for people-centred mental health care in Timor-Leste: a mixed-methods study using qualitative and social network analysis.

BACKGROUND: Intersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle-income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system. METHODS: This study employed a mixed-methods convergent design. Qualitative data elicited from in-depth interviews with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system. RESULTS: There was consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density = 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, the mixed-methods data sources identified a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation = 0.28 and 0.47 for information and resource sharing, respectively). CONCLUSIONS: Overall, the findings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste.

Are people-centred mental health services acceptable and feasible in Timor-Leste? A qualitative study.

People-centred mental healthcare is an influential concept for health system strengthening and sustainable development that has been developed and promoted primarily in Western contexts. It characterizes service users, families and communities as active participants in health system development. However, we have limited understanding of how well people-centred mental healthcare aligns with the multiplicity of peoples, cultures, languages and contexts in low- and middle-income countries (LMICs). Timor-Leste, a lower-middle income country in South-East Asia, is in the process of strengthening its National Mental Health Strategy 2018-22 to align with people-centred mental healthcare. To support the implementation of this Strategy, this study investigated the acceptability and feasibility of people-centred mental health services in Timor-Leste. In-depth semi-structured individual (n = 57) and group interviews (n = 15 groups) were conducted with 85 adults (≥18 years). Participants were service users, families, decision-makers, service providers and members of civil society and multilateral organizations across national and sub-national sites. Government and non-government mental health and social care was also observed. Framework analysis was used to analyse interview transcripts and observation notes. The study found that the ecology of mental healthcare in Timor-Leste is family-centred and that government mental health services are largely biomedically oriented. It identified the following major challenges for people-centred mental health services in Timor-Leste: different sociocultural perceptions of (in)dividual personhood, including a diminished status of people with mental illness; challenges in negotiating individual and family needs; a reliance on and demand for biomedical interventions; and barriers to health service access and availability. Opportunities for people-centred mental healthcare are better available within the social and disability sectors, which focus on social inclusion, human rights and peer support. Accounting for local cultural knowledge and understandings will strengthen design and implementation of people-centred mental healthcare in LMIC settings.

Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders.

BACKGROUND: The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community. METHODS: Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations. RESULTS: Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital. CONCLUSIONS: Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence.

Resolving the paradox of increased mental health expenditure and stable prevalence.

A doubling of Australian expenditure on mental health services over two decades, inflation-adjusted, has reduced prevalence of neither psychological distress nor mental disorders. Low rates of help-seeking, and inadequate and inequitable delivery of effective care may explain this partially, but not fully. Focusing on depressive disorders, drawing initially on ideas from the work of philosopher and socio-cultural critic Ivan Illich, we use evidence-based medicine statistics and simulation modelling approaches to develop testable hypotheses as to how iatrogenic influences on the course of depression may help explain this seeming paradox. Combined psychological treatment and antidepressant medication may be available, and beneficial, for depressed people in socioeconomically advantaged areas. But more Australians with depression live in disadvantaged areas where antidepressant medication provision without formal psychotherapy is more typical; there also are urban/non-urban disparities. Depressed people often engage in self-help strategies consistent with psychological treatments, probably often with some benefit to these people. We propose then, if people are encouraged to rely heavily on antidepressant medication only, and if they consequently reduce spontaneous self-help activity, that the benefits of the antidepressant medication may be more than offset by reductions in beneficial effects as a consequence of reduced self-help activity. While in advantaged areas, more comprehensive service delivery may result in observed prevalence lower than it would be without services, in less well-serviced areas, observed prevalence may be higher than it would otherwise be. Overall, then, we see no change. If the hypotheses receive support from the proposed research, then implications for service prioritisation and delivery could include a case for wider application of recovery-oriented practice. Critically, it would strengthen the case for action to correct inequities in the delivery of psychological treatments for depression in Australia so that combined psychological therapy and antidepressant medication, accessible and administered within an empowering framework, should be a nationally implemented standard.

Social inclusion and exclusion of people with mental illness in Timor-Leste: a qualitative investigation with multiple stakeholders.

BACKGROUND: Social inclusion is a human right for all people, including people with mental illness. It is also an important part of recovery from mental illness. In Timor-Leste, no research has investigated the social experiences of people with mental illness and their families. To fill this knowledge gap and inform ongoing mental health system strengthening, we investigated the experiences of social inclusion and exclusion of people with mental illness and their families in Timor-Leste. METHODS: Eighty-five participants from the following stakeholder groups across multiple locations in Timor-Leste were interviewed: (1) people with mental illness and their families; (2) mental health and social service providers; (3) government decision makers; (4) civil society members; and (5) other community members. Framework analysis was used to analyse interview transcripts. RESULTS: People with mental illness in Timor-Leste were found to face widespread, multi-faceted sociocultural, economic and political exclusion. People with mental illness were stigmatised as a consequence of beliefs that they were dangerous and lacked capacity, and experienced instances of bullying, physical and sexual violence, and confinement. Several barriers to formal employment, educational, social protection and legal systems were identified. Experiences of social inclusion for people with mental illness were also described at family and community levels. People with mental illness were included through family and community structures that promoted unity and acceptance. They also had opportunities to participate in activities surrounding family life and livelihoods that contributed to intergenerational well-being. Some, but not all, Timorese people with mental illness benefited from disability-inclusive programming and policies, including the disability pension, training programs and peer support. CONCLUSIONS: These findings highlight the need to combat social exclusion of people with mental illness and their families by harnessing local Timorese sociocultural strengths. Such an approach could centre around people with mental illness and their families to: increase population mental health awareness; bolster rights-based and culturally-grounded mental health services; and promote inclusive and accessible services and systems across sectors.

Personal attributes and competencies required by community health workers for a role in integrated mental health care for perinatal depression: voices of primary health care stakeholders from Surabaya, Indonesia.

BACKGROUND: Non-professional community health workers have been widely reported as possibly having a role in mental health. In Indonesia, their role is currently being introduced in the national health system for perinatal depression. Prior publications have shown that it is generally considered feasible and acceptable by key stakeholders for community health workers to identify and refer women experiencing mental health issues during their perinatal phase to primary care. However, characteristics and competencies required for these workers have not yet been identified. METHODS: 62 participants from four groups of stakeholders in primary health care in Surabaya were interviewed, including program managers, health workers, community health workers (CHWs), mental health specialists, and pregnant and postpartum women. Semi-structured questions were used to explore participants' views about characteristics and competencies required by CHWs to identify and refer perinatal depression. RESULTS: Literacy and social skills were seen as basic characteristics required for CHWs to contribute to perinatal identification, together with willingness to volunteer and time availability. Participants identified females in the age range 30-50 years who have experienced pregnancy as being preferable. To ensure competency, training addressing knowledge about maternal life and depression, and communication skills are regarded as prerequisites for the role. CONCLUSIONS: The results are consistent with WHO guidelines for informal workers working with people with mental disorders in non-specialised settings. The results provide a rationale for the criteria to be met when informal workers are to be involved in primary care mental health area and provide information for the development of training in the identification of perinatal depression.

The feasibility of a role for community health workers in integrated mental health care for perinatal depression: a qualitative study from Surabaya, Indonesia.

BACKGROUND: Indonesian maternal health policies state that community health workers (CHWs) are responsible for detection and referral of pregnant women and postpartum mothers who might suffer from mental health problems (task-sharing). The documents have been published for a while, however reports on the implementation are hardly found which possibly resulted from feasibility issue within the health system. AIMS: To examine the feasibility of task-sharing in integrated mental health care to identify perinatal depression in Surabaya, Indonesia. METHODS: Semi-structured interviews were conducted with 62 participants representing four stakeholder groups in primary health care: program managers from the health office and the community, health workers and CHWs, mental health specialists, and service users. Questions on the feasibility were supported by vignettes about perinatal depression. WHO's health systems framework was applied to analyse the data using framework analysis. RESULTS: Findings indicated the policy initiative is feasible to the district health system. A strong basis within the health system for task-sharing in maternal mental health rests on health leadership and governance that open an opportunity for training and supervision, financing, and intersectoral collaboration. The infrastructure and resources in the city provide potential for a continuity of care. Nevertheless, feasibility is challenged by gaps between policy and practices, inadequate support system in technologies and information system, assigning the workforce and strategies to be applied, and the lack of practical guidelines to guide the implementation. CONCLUSION: The health system and resources in Surabaya provide opportunities for task-sharing to detect and refer cases of perinatal depression in an integrated mental health care system. Participation of informal workforce might facilitate in closing the gap in the provision of information on perinatal mental health.