Epidemiological features of depression and anxiety among homeless adults with healthcare access problems in London, UK: descriptive cross-sectional analysis.

BACKGROUND: In England in 2021, an estimated 274 000 people were homeless on a given night. It has long been recognised that physical and mental health of people who are homeless is poorer than for people who are housed. There are few peer-reviewed studies to inform health and social care for depression or anxiety among homeless adults in this setting. AIMS: To measure the symptoms of depression and anxiety among adults who are homeless and who have difficulty accessing healthcare, and to describe distribution of symptoms across sociodemographic, social vulnerability and health-related characteristics. METHOD: We completed structured questionnaires with 311 adults who were homeless and who had difficulty accessing healthcare in London, UK, between August and December 2021. We measured anxiety and depression symptoms using the 4-item Patient Health Questionnaire (PHQ-4) score. We compared median PHQ-4 scores across strata of the sociodemographic, social vulnerability and health-related characteristics, and tested for associations using the Kruskal-Wallis test. RESULTS: The median PHQ-4 score was 8 out of 12, and 40.2% had scores suggesting high clinical need. Although PHQ-4 scores were consistently high across a range of socioeconomic, social vulnerability and health-related characteristics, they were positively associated with: young age; food insecurity; recent and historic abuse; joint, bone or muscle problems; and frequency of marijuana use. The most common (60%) barrier to accessing healthcare related to transportation. CONCLUSIONS: Adults who are homeless and have difficulty accessing healthcare have high levels of depression and anxiety symptoms. Our findings support consideration of population-level, multisectoral intervention.

The effect of different types of migration on symptoms of anxiety or depression and experience of violence among people who use or inject drugs in Kachin State, Myanmar.

BACKGROUND: Evidence on the social determinants of mental health conditions and violence among people who inject or use drugs (PWUD) is limited, particularly in conflict-affected countries. We estimated the prevalence of symptoms of anxiety or depression and experience of emotional or physical violence among PWUD in Kachin State in Myanmar and examined their association with structural determinants, focusing on types of past migration (migration for any reason, economic or forced displacement). MATERIALS: A cross-sectional survey was conducted among PWUD attending a harm reduction centre between July and November 2021 in Kachin State, Myanmar. We used logistic regression models to measure associations between past migration, economic migration and forced displacement on two outcomes (1) symptoms of anxiety or depression (Patient Health Questionnaire-4) and (2) physical or emotional violence (last 12 months), adjusted for key confounders. RESULTS: A total of 406, predominantly male (96.8%), PWUD were recruited. The median age (IQR) was 30 (25, 37) years, most injected drugs (81.5%) and more commonly opioid substances such as heroin or opium (85%). Symptoms of anxiety or depression (PHQ4 ≥ 6) were high (32.8%) as was physical or emotional violence in the last 12 months (61.8%). Almost one-third (28.3%) had not lived in Waingmaw for their whole life (migration for any reason), 77.9% had left home for work at some point (economic migration) and 19.5% had been forced to leave home due to war or armed conflict (forced displacement). A third were in unstable housing in the last 3 months (30.1%) and reported going hungry in the last 12 months (27.7%). Only forced displacement was associated with symptoms of anxiety or depression [adjusted odds ratio, aOR 2.33 (95% confidence interval, CI 1.32-4.11)] and recent experience of violence [aOR 2.18 (95% CI 1.15-4.15)]. CONCLUSION: Findings highlight the importance of mental health services integrated into existing harm reduction services to address high levels of anxiety or depression among PWUD, particularly among those who have been displaced through armed conflict or war. Findings reinforce the need to address broader social determinants, in the form of food poverty, unstable housing and stigma, in order to reduce mental health and violence.

Severe Mental Illness Among Adults with Atopic Eczema or Psoriasis: Population-Based Matched Cohort Studies within UK Primary Care.

Background: Existing research exploring associations between atopic eczema (AE) or psoriasis, and severe mental illness (SMI - ie, schizophrenia, bipolar disorder, other psychoses) is limited, with longitudinal evidence particularly scarce. Therefore, temporal directions of associations are unclear. We aimed to investigate associations between AE or psoriasis and incident SMI among adults. Methods: We conducted matched cohort studies using primary care electronic health records (January 1997 to January 2020) from the UK Clinical Practice Research Datalink GOLD. We identified two cohorts: 1) adults (≥18 years) with and without AE and 2) adults with and without psoriasis. We matched (on age, sex, general practice) adults with AE or psoriasis with up to five adults without. We used Cox regression, stratified by matched set, to estimate hazard ratios (HRs) comparing incident SMI among adults with and without AE or psoriasis. Results: We identified 1,023,232 adults with AE and 4,908,059 without, and 363,210 with psoriasis and 1,801,875 without. After adjusting for matching variables (age, sex, general practice) and potential confounders (deprivation, calendar period) both AE and psoriasis were associated with at least a 17% increased hazard of SMI (AE: HR=1.17,95% CI=1.12-1.22; psoriasis: HR=1.26,95% CI=1.18-1.35). After additionally adjusting for potential mediators (comorbidity burden, harmful alcohol use, smoking status, body mass index, and, in AE only, sleep problems and high-dose glucocorticoids), associations with SMI did not persist for AE (HR=0.98,95% CI=0.93-1.04), and were attenuated for psoriasis (HR=1.14,95% CI=1.05-1.23). Conclusion: Our findings suggest adults with AE or psoriasis are at increased risk of SMI compared to matched comparators. After adjusting for potential mediators, associations with SMI did not persist for AE, and were attenuated for psoriasis, suggesting that the increased risk may be explained by mediating factors (eg, sleep problems). Our research highlights the importance of monitoring mental health in adults with AE or psoriasis.

'Progression capitals': How homeless health peer advocacy impacts peer advocates.

This article presents analysis from a qualitative evaluation of a homeless health peer advocacy (HHPA) service in London, United Kingdom. Whilst evidence is growing for the impact of peer programming on clients, understanding of the impact on peers themselves is limited in the context of homelessness. Research here is vital for supporting sustainable and effective programmes. Analysis of interview data with 14 current and former peer advocates, 2 members of staff and 3 external stakeholders suggests peer advocacy and its organizational setting can generate social, human, cultural and physical resources to help peer advocates fulfil their own life goals. We explore these with reference to 'recovery capital', reframed as 'progression capitals' to reflect its relevance for pursuits unrelated to clinical understandings of recovery. Progression capitals can be defined as resources to pursue individually determined goals relating to self-fulfilment. We find engagement with, and benefits from, a peer advocacy service is most feasible among individuals already possessing some 'progression capital'. We discuss the value of progression capitals for peers alongside the implications of the role being unsalaried within a neoliberal political economy, and comment on the value that the progression capitals framework offers for the development and assessment of peer interventions more broadly.

Why were COVID-19 infections lower than expected amongst people who are homeless in London, UK in 2020? Exploring community perspectives and the multiple pathways of health inequalities in pandemics.

High rates of COVID-19 infections and deaths amongst people who are homeless in London, UK were feared. Rates however stayed much lower than expected throughout 2020; an experience that compares to other settings globally. This study sought a community level perspective to explore this rate of infections, and through this explore relationships between COVID-19 and existing health inequalities. Analyses are reported from ongoing qualitative studies on COVID-19 and homeless health service evaluation in London, UK. Repeated in-depth telephone interviews were implemented with people experiencing homelessness in London (n=17; 32 interviews in total) as well as street outreach workers, nurses and hostel staff (n=10) from September 2020 to early 2021. Thematic analysis generated three themes to explore peoples' experiences of, and perspectives on, low infections: people experiencing homelessness following, creating and breaking social distancing and hygiene measures; social distancing in the form of social exclusion as a long-running feature of life; and a narrative of 'street immunity' resulting from harsh living conditions. Further study is needed to understand how these factors combine to prevent COVID-19 and how they relate to different experiences of homelessness. This community perspective can ensure that emerging narratives of COVID-19 prevention success don't ignore longer running causes of homelessness and reinforce stigmatising notions of people who are homeless as lacking agency. Our findings aid theorisation of how health inequalities shape pandemic progression: severe exclusion may substantially delay epidemics in some communities, although with considerable other non-COVID-19 impacts.

First 1,000 days: enough for mothers but not for children? Long-term outcomes of an early intervention on maternal depressed mood and child cognitive development: follow-up of a randomised controlled trial.

BACKGROUND: Child cognitive development is often compromised in contexts of poverty and adversity, and these deficits tend to endure and affect the child across the life course. In the conditions of poverty and violence that characterise many low- and middle-income countries (LMIC), the capacity of parents to provide the kind of care that promotes good child development may be severely compromised, especially where caregivers suffer from depression. One avenue of early intervention focuses on the quality of the early mother-infant relationship. The aim of this study was to examine the long-term impact of an early intervention to improve the mother-infant relationship quality on child cognitive outcomes at 13 years of age. We also estimated the current costs to replicate the intervention. METHOD: We re-recruited 333 children from an early childhood maternal-infant attachment intervention, 'Thula Sana', when the children were 13 years old, to assess whether there were impacts of the intervention on child cognitive outcomes, and maternal mood. We used the Kaufman Assessment Battery to assess the child cognitive development and the Patient Health Questionnaire (PHQ-9) and the Self-Reporting Questionnaire (SRQ-20) to assess maternal mental health. RESULTS: Effect estimates indicated a pattern of null findings for the impact of the intervention on child cognitive development. However, the intervention had an effect on caregiver psychological distress (PHQ-9, ES = -0.17 [CI: -1.95, 0.05] and SRQ-20, ES = -0.30 [CI: -2.41, -0.19]), but not anxiety. The annual cost per mother-child pair to replicate the Thula Sana intervention in 2019 was estimated at ZAR13,365 ($780). CONCLUSION: In a socio-economically deprived peri-urban settlement in South Africa, a home visiting intervention, delivered by community workers to mothers in pregnancy and the first six postpartum months, had no overall effect on child cognitive development at 13 years of age. However, those caregivers who were part of the original intervention showed lasting improvements in depressed mood. Despite the fact that there was no intervention effect on long-term child outcomes, the improvements in maternal mood are important.

Experiences of a 'screen and treat' cervical cancer prevention programme among brothel-based female sex workers in Bangladesh: A qualitative interview study.

OBJECTIVES: Little is known about sex workers' experiences of cervical cryotherapy. We sought to understand sex workers' perspectives of 'screen and treat' programmes and their management of the World Health Organization post-treatment guidance to abstain from sex or use condoms consistently for 4 weeks. We explored contraceptive preferences and use of menstrual regulation services. METHODS: We conducted semi-structured interviews with 16 sex workers and six brothel leaders in an urban brothel complex in Bangladesh between October and November 2018. All had undergone cryotherapy. We conducted a thematic analysis using deductive coding, informed by a priori themes, and inductive data-driven coding. RESULTS: Most sex workers could not abstain from sex during the healing period. Consistent condom use was challenging due to economic incentives attached to condomless sex and coercive behaviours of clients. The implications of non-adherence among high-risk groups such as sex workers are not known. Use of short-acting methods of contraception was common, and discontinuation was high due to side effects and other perceived health concerns. The majority of sex workers and brothel leaders had utilized menstrual regulation services. Barriers to accessing timely menstrual regulation and other sexual and reproductive health services included limited mobility, economic costs, and discriminatory attitudes of health care workers. CONCLUSION: Service innovations are required to enable sex workers to abstain or use condoms consistently in the post-cryotherapy healing phase and to address sex workers' broader sexual and reproductive health needs. Further research is required to assess the risk of HIV and other sexually transmitted infection transmission following cryotherapy among high-risk groups.

Peer advocacy and access to healthcare for people who are homeless in London, UK: a mixed method impact, economic and process evaluation protocol.

INTRODUCTION: People who are homeless experience higher morbidity and mortality than the general population. These outcomes are exacerbated by inequitable access to healthcare. Emerging evidence suggests a role for peer advocates-that is, trained volunteers with lived experience-to support people who are homeless to access healthcare. METHODS AND ANALYSIS: We plan to conduct a mixed methods evaluation to assess the effects (qualitative, cohort and economic studies); processes and contexts (qualitative study); fidelity; and acceptability and reach (process study) of Peer Advocacy on people who are homeless and on peers themselves in London, UK. People with lived experience of homelessness are partners in the design, execution, analysis and dissemination of the evaluation. ETHICS AND DISSEMINATION: Ethics approval for all study designs has been granted by the National Health Service London-Dulwich Research Ethics Committee (UK) and the London School of Hygiene and Tropical Medicine's Ethics Committee (UK). We plan to disseminate study progress and outputs via a website, conference presentations, community meetings and peer-reviewed journal articles.

Risk and Protective Factors for Difficulty Controlling Violent Behavior in National Guard and Reserve Service Members.

Violent behavior is an important problem for military service members and veterans. A representative cohort of U.S. Reserve and National Guard personnel (N = 1,293) were interviewed to assess self-reported problems controlling violent behavior, deployment traumas, posttraumatic stress disorder (PTSD), alcohol abuse, and social support. Poisson regression models were used to estimate the associations of violent behavior with risk and protective factors. Problems controlling violent behavior were uncommon among male (3.3%) and female (1.7%) service members. Adjusted prevalence ratios (aPR) showed associations between violent behavior and deployment traumas (aPR = 1.67, 95% confidence interval [CI] = [1.34, 2.08]), PTSD (aPR = 9.95, 95% CI = [5.09, 19.48]), and PTSD symptom severity (aPR for each additional PTSD symptom = 1.07, 95% CI = [1.06, 1.09]). Social support was associated with lower prevalence of violent behavior (aPR = 0.62, 95% CI = [0.52, 0.76]). The association between violent behavior and alcohol abuse was not statistically significant (aPR = 1.94, 95% CI = [0.92, 4.09]). Results were consistent when the population was restricted to personnel who had deployed to a war zone. Problems controlling violent behavior were less common in this cohort than has been documented in other studies. Associations of violent behavior with risk and protective factors are consistent with prior research.

Correction to: Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol.

An amendment to this paper has been published and can be accessed via the original article.

Health care use and treatment-seeking for depression symptoms in rural India: an exploratory cross-sectional analysis.

BACKGROUND: There is a large "treatment gap" for depression worldwide. This study aimed to better understand the treatment gap in rural India by describing health care use and treatment-seeking for depression. METHODS: Data were analysed from a two round cross-sectional community survey conducted in rural Madhya Pradesh between May 2013 and December 2016. We examined the proportion of individuals who screened positive for depression (≥10) on the Patient Health Questionnaire (PHQ-9) who sought treatment in different sectors, for depression symptoms and for any reason, and compared the latter with health service use by screen-negative individuals. We analysed the frequency with which barriers to healthcare utilisation were reported by screen-positive adults. We also analysed the association between seeking treatment for depression and various predisposing, enabling and need factors using univariable regression. RESULTS: 86% of screen-positive adults reported seeking no depression treatment. However, 66% had used health services for any reason in the past 3 months, compared to 46% of screen-negative individuals (p < 0.0001). Private providers were most frequently consulted by screen-positive adults (32%), while only 19% consulted traditional providers. Structural barriers to healthcare use such as cost and distance to services were frequently reported (54 and 52%, respectively) but were not associated with treatment-seeking for depression. The following factors were found to be positively associated with treatment-seeking for depression: higher symptom severity; lack of energy, lack of interest/pleasure, low self-esteem, or slow movements/restlessness on more than 7 days in the past 2 weeks; being married; having discussed depression symptoms; and reporting problems with medication availability and supply as a barrier to healthcare. No evidence was found for an association between treatment-seeking for depression and most socio-economic, demographic or attitudinal factors. CONCLUSIONS: These findings suggest that the majority of adults who screen positive for depression seek healthcare, although not primarily for depression symptoms, indicating the need to improve detection of depression during consultations about other complaints. Private providers may need to be considered in programmes to improve depression treatment in this setting. Further research should test the hypotheses generated in this descriptive study, such as the potential role of marriage in facilitating treatment-seeking.

Health service costs and their association with functional impairment among adults receiving integrated mental health care in five low- and middle-income countries: the PRIME cohort study.

This study examines the level and distribution of service costs-and their association with functional impairment at baseline and over time-for persons with mental disorder receiving integrated primary mental health care. The study was conducted over a 12-month follow-up period in five low- and middle-income countries participating in the Programme for Improving Mental health carE study (Ethiopia, India, Nepal, South Africa and Uganda). Data were drawn from a multi-country intervention cohort study, made up of adults identified by primary care providers as having alcohol use disorders, depression, psychosis and, in the three low-income countries, epilepsy. Health service, travel and time costs, including any out-of-pocket (OOP) expenditures by households, were calculated (in US dollars for the year 2015) and assessed at baseline as well as prospectively using linear regression for their association with functional impairment. Cohort samples were characterized by low levels of educational attainment (Ethiopia and Uganda) and/or high levels of unemployment (Nepal, South Africa and Uganda). Total health service costs per case for the 3 months preceding baseline assessment averaged more than US$20 in South Africa, $10 in Nepal and US$3-7 in Ethiopia, India and Uganda; OOP expenditures ranged from $2 per case in India to $16 in Ethiopia. Higher service costs and OOP expenditure were found to be associated with greater functional impairment in all five sites, but differences only reached statistical significance in Ethiopia and India for service costs and India and Uganda for OOP expenditure. At the 12-month assessment, following initiation of treatment, service costs and OOP expenditure were found to be lower in Ethiopia, South Africa and Uganda, but higher in India and Nepal. There was a pattern of greater reduction in service costs and OOP spending for those whose functional status had improved in all five sites, but this was only statistically significant in Nepal.

Healthcare utilization and out-of-pocket expenditures associated with depression in adults: a cross-sectional analysis in Nepal.

BACKGROUND: Despite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal. METHODS: We analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more. RESULTS: We classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7-22%, p < 0.0001) and $9 USD increase in OOP expenditures (95% CI $2-$17; p < 0.0001). People with depression sought most healthcare from pharmacists (30.1%) but reported the greatest expenditure on specialist doctors ($36 USD). CONCLUSIONS: In this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.

"Is there a medicine for these tensions?" Barriers to treatment-seeking for depressive symptoms in rural India: A qualitative study.

Rationale and objective Fewer than 15% of adults who meet criteria for a depression diagnosis in India seek treatment for these symptoms. It is unclear whether this reflects limited supply of mental health services or lack of demand for medical intervention for these experiences. This paper aims to identify and describe self-reported barriers that contribute to this "treatment gap" in a rural district in central India, where depression treatment had recently become available in primary care facilities. METHOD: In this qualitative study we conducted in-depth interviews with 35 adults who screened positive for depression and who had not sought treatment for their condition, and 15 of their relatives. We analysed the data using the framework approach. RESULTS: A key barrier to seeking health care for psychological symptoms was lack of perceived need for treatment for these symptoms. Low perceived need for health interventions arose because participants frequently attributed depression-like symptoms to their socio-economic circumstances, or to the stress of physical illness, which conflicted with the biomedical approach associated with health services. Despite widespread recognition of the links between psychological symptoms, social circumstances and physical health, it was believed that health care providers are equipped to treat only somatic symptoms, which were commonly reported. CONCLUSIONS: Low demand for depression treatment reflected discrepancies between the community's perceived needs and a narrow biomedical model of mental health. Meeting their needs may require a radical change in approach that acknowledges the social determinants of distress, and the interactions between mental and physical health. The capabilities approach may provide a framework for more holistically conceptualising people's needs.

Peer support for frequent users of inpatient mental health care in Uganda: protocol of a quasi-experimental study.

BACKGROUND: Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated. METHODS: This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral. DISCUSSION: To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.

Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa.

BACKGROUND: The rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. The aim of this study was thus to evaluate a task shared integrated collaborative care package of care for chronic patients with co-existing depressive and alcohol use disorder (AUD) symptoms. METHODS: The complex intervention strengthened capacity of primary care nurse practitioners to identify, diagnose and review symptoms of CMDs among chronic care patients; and implemented a stepped up referral system, that included clinic-based psychosocial lay counsellors, doctors and mental health specialists. Under real world conditions, in four PHC facilities, a repeat cross-sectional Facility Detection Survey (FDS) assessed changes in capacity of nurses to correctly detect CMDs in 1310 patients before implementation and 1246 patients following implementation of the intervention at 12 months; and a non-randomly assigned comparison group cohort study comprising 373 screen positive patients with depressive symptoms using the Patient Health Questionnaire-9 (PHQ9) at baseline, evaluated responses of patients correctly identified and referred for treatment (intervention arm) or not identified and referred (control arm) at three and 12 months. RESULTS: The FDS showed a significant increase in the identification of depression and AUD from pre-implementation to 12-month post-implementation. Depression: (5.8 to 16.4%) 95% CI [2.9, 19.1]); AUD: (0 to 13.8%) 95% CI [0.6-24.9]. In the comparison group cohort study, patients with depressive symptoms having more than a 50% reduction in PHQ-9 scores were greater in the treatment group (n = 69, 55.2%) compared to the comparison group (n = 49, 23.4%) at 3 months (RR = 2.10, p < 0.001); and 12 months follow-up (intervention: n = 57, 47.9%; comparison: n = 60, 30.8%; RR = 1.52, p = 0.006). Remission (PHQ-9 ≤ 5) was greater in the intervention group (n = 32, 26.9%) than comparison group (n = 33, 16.9%) at 12 months (RR = 1.72, p = 0.016). CONCLUSION: A task shared collaborative stepped care model can improve detection of CMDs and reduce depressive symptoms among patients with chronic conditions under real world conditions.

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

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

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

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

Partnerships in a Global Mental Health Research Programme-the Example of PRIME.

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.