Adaptation of the Client Diagnostic Questionnaire for East Africa.

Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals' diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve linkage to mental healthcare, and improve outcomes. We recommend further studies to establish the psychometric properties of the translated tool.

Availability of substance use screening and treatment within HIV clinical sites across seven geographic regions within the IeDEA consortium.

BACKGROUND: Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, the extent to which alcohol use disorder (AUD) and other substance use disorders (SUD) services have been integrated within HIV clinical settings is limited. We describe AUD/SUD screening and treatment availability in HIV clinical sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS: In 2020, 223 IeDEA HIV clinical sites from 41 countries across seven geographic regions completed a survey on capacity and practices related to management of AUD/ SUD. Sites provided information on AUD and other SUD screening and treatment practices. RESULTS: Sites were from low-income countries (23%), lower-middle-income countries (38%), upper-middle income countries (17%) and high-income counties (23%). AUD and SUD screening using validated instruments were reported at 32% (n=71 located in 12 countries) and 12% (n=27 located in 6 countries) of the 223 sites from 41 countries, respectively. The North American region had the highest proportion of clinics that reported AUD screening (76%), followed by East Africa (46%); none of the sites in West or Central Africa reported AUD screening. 31% (n=69) reported both AUD screening and counseling, brief intervention, psychotherapy, or Screening, Brief Intervention, and Referral to Treatment; 8% (n=18) reported AUD screening and detox hospitalization; and 10% (n=24) reported both AUD screening and medication. While the proportion of clinics providing treatment for SUD was lower than those treating AUD, the prevalence estimates of treatment availability were similar. CONCLUSIONS: Availability of screening and treatment for AUD/SUD in HIV care settings is limited, leaving a substantial gap for integration into ongoing HIV care. A critical understanding is needed of the multilevel implementation factors or feasible implementation strategies for integrating screening and treatment of AUD/SUD into HIV care settings, particularly for resource-constrained regions.

Adapting a substance use screening and brief intervention for peer-delivery and for youth in Kenya.

Background: Substance use is a major problem among youth in sub-Saharan Africa, yet interventions that address this problem are scarce within the region. Screening and brief intervention is a cost-effective, efficacious, and easy to scale public health approach to addressing substance use problems. We conducted a pilot study to evaluate the feasibility of implementing a peer delivered screening and brief intervention program for youth in Kenya. The goal of this paper is to report on the process of adapting the Alcohol Smoking and Substance Involvement Screening Test for Youth- linked Brief Intervention (ASSIST-Y-linked BI) program for peer delivery and for the Kenyan context prior to the pilot. Methods: The adaptation process was led by a multi-disciplinary team comprised of psychiatrists, pediatricians, and psychologists. We utilized the ADAPT-ITT framework to adapt the ASSIST-Y-linked BI. The ADAPT-ITT framework consists of 8 phases including Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the evidence-based intervention. Here, we report on phases 1-7 of the framework. The results of the pilot testing have been published elsewhere. Results: Overall, we made surface level adaptations to the ASSIST-Y-linked BI program such as simplifying the language to enhance understandability. We maintained the core components of the program i.e., Feedback, Responsibility, Advice, Menu of Options, Empathy, Self-efficacy (FRAMES). Conclusions: Our paper provides information which other stakeholders planning to implement the ASSIST-Y-linked BI for youth in sub-Saharan Africa, could use to adapt the intervention.

Feasibility and acceptability of a peer provider delivered substance use screening and brief intervention program for youth in Kenya.

BACKGROUND: Youth in sub-Saharan Africa are at high risk of substance use yet lack access to substance use interventions. The goal of this project was to evaluate the feasibility and acceptability of a peer-delivered, single-session substance use screening and brief intervention program for youth in Kenya. METHODS: This was a convergent parallel mixed methods study utilizing both quantitative and qualitative approaches. Two trained peer providers administered the screening and brief intervention program to 100 youth aged 15-24 years. To evaluate the implementation of the intervention, we collected quantitative and qualitative data. Feasibility and acceptability were quantitatively assessed using the Dissemination and Implementation Measures. Fidelity was assessed by rating all 100 audio-recorded sessions using a checklist. To obtain qualitative feedback on the intervention, we conducted five focus group discussions with 25 youths and six semi-structured interviews with two peer providers and four clinic leaders. The semi-structured interviews were guided by the Consolidated Framework for Implementation Research. Quantitative data was analyzed via descriptive statistics using STATA. Qualitative data was analyzed using thematic analysis with NVIVO. RESULTS: The lifetime prevalence of any substance use was 50%. The mean level of acceptability of the intervention from the perspective of the youth was 3.53 (SD 0.15), meaning that the youth found the intervention to be acceptable "a lot" of the time. Mean levels of implementation outcomes (acceptability, adoption, Acceptability, Appropriateness, Feasibility, Reach/access, Organizational climate, General leadership skills, and Sustainability) as rated by peer providers and clinic staff ranged between 2.61 ("a moderate amount") and 4.0 ("a lot"). In qualitative data, youth reported that the intervention was helpful and useful in enabling them to stop or reduce substance use. The peer providers felt that the intervention was easy to implement, while the clinic leaders felt that available resources were adequate, and that the intervention aligned well with the goals of the clinic. CONCLUSION: Our findings suggest that the peer-delivered screening and brief intervention program was perceived as acceptable to the youth and feasible to implement. TRIAL REGISTRATION: NCT04998045 Registration date: 10/08/2021.

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study.

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022.

"Association between Traumatic Life Events and Psychosis: A case-control study in western Kenya".

Globally close to 70% of the general population has experienced at least one traumatic life event (TLE). Although child and adulthood exposure to TLEs is considered a risk factor for the subsequent development of psychosis, few studies have examined the association between trauma and psychosis in the African population. We sought to explore the association between TLEs and psychosis in patients with psychotic disorders (N = 254) and individuals without (N = 254). The participants were matched by age and sex. The study was conducted at a national referral hospital, the Life Events Checklist for DSM-5 (LEC-5) was used to obtain data on TLEs, and ethical approval was obtained from the ethics committee. The proportion of those who experienced TLEs was equal among the cases and controls at about 80%. However, more cases reported that the TLEs happened to them (cases 60.3, p = 0.004). After multivariate analysis, the following specific TLEs remained statistically significant.: Physical assault (aOR = 3.66, 95% CI 2.28-5.48), assaults with a weapon (aOR = 5.26, 95% CI 2.15-10.48), sexual assault (aOR = 4.55, 95% CI 1.08-10.48). The sudden death of a loved one (aOR = 2.33, 95% CI 1.15-4.70) and serious injury/harm to others (aOR = 10.53, 95% CI 1.47-89.37).

Mental healthcare services in Kenyan counties: a descriptive survey of four counties in Western Kenya.

BACKGROUND: The government of Kenya has made progressive efforts towards improving mental health services in the country. However there is little documentation of mental health services in the counties that would support actualization of the legislative frameworks in the context of a devolved healthcare system. This study sought to document existing mental health services within 4 counties in Western Kenya. METHODS: We conducted a cross sectional descriptive survey of four counties using the World Health Organization, Assessment Instrument for Mental Health Systems (WHO-AIMS). Data was collected in 2021, with 2020 being the year of reference. We collected data from the facilities offering mental healthcare within the counties as well as from County health policy makers and leaders. RESULTS: Mental healthcare was provided at higher level facilities within the counties, with minimal structures at primary care facilities. No county had a stand-alone policy on mental health services or dedicated budget for mental healthcare. The national referral hospital, within Uasin-Gishu county, had a clear mental health budget for mental health. The national facility in the region had a dedicated inpatient unit while the other three counties admitted patients in general medical wards but had mental health outpatient clinics. The national hospital had a variety of medication for mental health care while the rest of the counties had very few options with antipsychotics being the most available. All the four counties reported submitting data on mental health to Kenya health information system (KHIS). There were no clearly defined mental healthcare structures in the primary care level except for funded projects under the National referral hospital and the referral mechanism was not well defined. There was no established mental health research in the counties except that which was affiliated to the national referral hospital. CONCLUSION: In the four counties in Western Kenya, the mental health systems are limited and not well structured, are faced with limited human and financial resources and there is lack of county specific legistrative frameworks to support mental healthcare. We recommend that counties invest in structures to support provision of quality mental healthcare to the people they serve.

Social support and the effects of the COVID-19 pandemic among a cohort of people living with HIV (PLWH) in Western Kenya.

As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world implemented various prevention strategies, such as banning of public and social gatherings, restriction in movement, etc. These efforts may have had a deleterious effect on already vulnerable populations, including people living with HIV (PLWH). PLWH were concerned about contracting COVID-19, the impact of COVID-19 on their social networks that provide social support, and the continued availability of antiretroviral medications during the pandemic. In addition, their mental health may have been exacerbated by the pandemic. The purpose of this study was to explore pandemic-related concerns among a cohort of PLWH in Kenya and investigate social support factors associated with symptoms of depression and anxiety. This study is part of a larger cohort study that recruited from two clinics in Western Kenya. Data are drawn from 130 PLWH who participated in two phone surveys about experiences during the pandemic in 2020 and 2021. Participants reported a variety of concerns over the course of the pandemic and we documented statistically significant increases in symptoms of depression and anxiety over time, which affected some participants' ability to adhere to their antiretroviral medication. However, a small but statistically significant group of participants reached out to expand their networks and mobilize support in the context of experiencing mental health and adherence challenges, speaking to the importance of social support as a coping strategy during times of stress. Our findings call for holistic approaches to HIV care that consider the broader political, economic, and social contexts that shape its effectiveness.

Intravenous ketamine for severe alcohol use disorder at Moi Teaching & Referral Hospital, Kenya: a case report.

BACKGROUND: Alcohol use disorder is prevalent globally and in Kenya, and is associated with significant health and socio-economic consequences. Despite this, available pharmacological treatment options are limited. Recent evidence indicates that intravenous (IV) ketamine can be beneficial for the treatment of alcohol use disorder, but is yet to be approved for this indication. Further, little has been done to describe the use of IV ketamine for alcohol use disorder in Africa. The goal of this paper, is to: 1) describe the steps we took to obtain approval and prepare for off-label use of IV ketamine for patients with alcohol use disorder at the second largest hospital in Kenya, and 2) describe the presentation and outcomes of the first patient who received IV ketamine for severe alcohol use disorder at the hospital. CASE PRESENTATION: In preparing for the off-label use of ketamine for alcohol use disorder, we brought together a multi-disciplinary team of clinicians including psychiatrists, pharmacists, ethicists, anesthetists, and members of the drug and therapeutics committee, to spearhead the process. The team developed a protocol for administering IV ketamine for alcohol use disorder that took into account ethical and safety issues. The national drug regulatory authority, the Pharmacy and Poison's Board, reviewed and approved the protocol. Our first patient was a 39-year-old African male with severe alcohol use disorder and comorbid tobacco use disorder and bipolar disorder. The patient had attended in-patient treatment for alcohol use disorder six times and each time had relapsed between one to four months after discharge. On two occasions, the patient had relapsed while on optimal doses of oral and implant naltrexone. The patient received IV ketamine infusion at a dose of 0.71 mg/kg. The patient relapsed within one week of receiving IV ketamine while on naltrexone, mood stabilizers, and nicotine replacement therapy. DISCUSSION & CONCLUSIONS: This case report describes for the first time the use of IV ketamine for alcohol use disorder in Africa. Findings will be useful in informing future research and in guiding other clinicians interested in administering IV ketamine for patients with alcohol use disorder.

Patient perceptions of facilitators and barriers to reducing hazardous alcohol use among people living with HIV in East Africa.

BACKGROUND: Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use. METHODS: We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 - 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time. RESULTS: People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers' recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social environment, alcohol accessibility and alcohol dependency. CONCLUSIONS: Interventions that capacity-build professional and lay health care workers with the skills and resources to decrease problematic alcohol use, along with alcohol cessation in peer support structures, should be explored.

Factor structure and item response of psychosis symptoms among Kenyan adults.

BACKGROUND: The aim of this study was to evaluate the construct validity of the psychosis module of the Mini International Neuropsychiatric Interview version 7.0.2 (MINI-7). METHOD: We utilized data collected from 2738 participants with a primary psychotic or bipolar disorder. Participants were drawn from two Kenyan sites of a large multi-center neuropsychiatric genetic study. The factor structure of the MINI-7 psychosis items were explored using confirmatory factor analyses (CFA) and Item Response Theory approach, for the full sample and by gender. RESULTS: The CFA revealed that a 1-factor model provided adequate fit for the MINI-7 psychosis items for the full sample (x2 = 397.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.90) as well as for the female (x2 = 185.16.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.93; TLI = 0.91) and male groups (x2 = 242.09, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.89). Item thresholds for the full sample, and female and male groups were highest for 'odd beliefs' (-1.42, -1.33, and -1.51 respectively) and lowest for 'visual hallucinations' (-0.03, -0.04, and -0.01 respectively). LIMITATIONS: Our study used a hospital-based population, which may have excluded patients with milder psychotic symptoms. Findings may therefore not be generalizable to the community setting. CONCLUSIONS: Our findings indicate good construct validity of the MINI-7 psychosis module, and provides support for use of the tool in diagnosing psychotic disorders in clinical settings in Kenya.

A systematic review of substance use and substance use disorder research in Kenya.

OBJECTIVES: The burden of substance use in Kenya is significant. The objective of this study was to systematically summarize existing literature on substance use in Kenya, identify research gaps, and provide directions for future research. METHODS: This systematic review was conducted in line with the PRISMA guidelines. We conducted a search of 5 bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) from inception until 20 August 2020. In addition, we searched all the volumes of the official journal of the National Authority for the Campaign Against Alcohol & Drug Abuse (the African Journal of Alcohol and Drug Abuse). The results of eligible studies have been summarized descriptively and organized by three broad categories including: studies evaluating the epidemiology of substance use, studies evaluating interventions and programs, and qualitative studies exploring various themes on substance use other than interventions. The quality of the included studies was assessed with the Quality Assessment Tool for Studies with Diverse Designs. RESULTS: Of the 185 studies that were eligible for inclusion, 144 investigated the epidemiology of substance use, 23 qualitatively explored various substance use related themes, and 18 evaluated substance use interventions and programs. Key evidence gaps emerged. Few studies had explored the epidemiology of hallucinogen, prescription medication, ecstasy, injecting drug use, and emerging substance use. Vulnerable populations such as pregnant women, and persons with physical disability had been under-represented within the epidemiological and qualitative work. No intervention study had been conducted among children and adolescents. Most interventions had focused on alcohol to the exclusion of other prevalent substances such as tobacco and cannabis. Little had been done to evaluate digital and population-level interventions. CONCLUSION: The results of this systematic review provide important directions for future substance use research in Kenya. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42020203717.

Harmful Alcohol Use Among Healthcare Workers at the Beginning of the COVID-19 Pandemic in Kenya.

Background: Healthcare workers play a key role in responding to pandemics like the on-going COVID-19 one. Harmful alcohol use among them could result in inefficiencies in health service delivery. This is particularly concerning in sub-Saharan Africa where the health workforce is already constrained. The aim of this study is to document the burden and correlates of harmful alcohol use among healthcare workers at the beginning of the COVID-19 pandemic in Kenya with the aim of informing policy and practice. Methods: This study was a cross-sectional analysis of data obtained from a parent online survey that investigated the burden and factors associated with mental disorders among healthcare workers during the COVID-19 pandemic in Kenya. We analyzed data obtained from a sub-population of 887 participants who completed the Alcohol Use Disorder Identification Test questionnaire. We used descriptive statistics to summarize the socio-demographic characteristics of the participants and multivariate analysis to determine the factors associated with harmful alcohol use. Results: Three hundred and eighty nine (43.9%) participants reported harmful alcohol use. The factors significantly associated with increased odds of endorsing harmful alcohol use were: being male (AOR = 1.56; 95% CI = 1.14, 2.14; p = 0.006), being unmarried (AOR = 2.06; 95% CI = 1.48, 2.89; p < 0.001), having 11-20 years of experience as compared to having 20+ years of experience (AOR = 1.91; 95% CI = 1.18, 3.12; p = 0.009), and being a specialist (AOR = 2.78; CI = 1.64, 4.78; p = < 0.001) or doctor (AOR = 2.82; 95% CI = 1.74, 4.63; p < 0.001) as compared to being a nurse. Conclusions: A high proportion of healthcare workers reported harmful alcohol use at the beginning of the COVID-19 pandemic in Kenya. Males, the unmarried, those with 11-20 years of experience in the health field, doctors and specialists, were more likely to report harmful alcohol use. These findings highlight the need to institute interventions for harmful alcohol use targeting these groups of healthcare workers in Kenya during the COVID-19 pandemic in order to optimize functioning of the available workforce.

Traumatic experiences assessed with the life events checklist for Kenyan adults.

BACKGROUND: Life Events Checklist (LEC-5) has been widely used to assess for exposure to potentially traumatic life events (PTEs), but its psychometric properties have not been evaluated in Kenya. The objectives of this study were to determine the frequency and types of PTEs within this setting and to examine the construct validity of LEC-5 in Kenya. METHODS: The LEC-5 was administered to 5316 participants in the ongoing multisite case-control study of Neuropsychiatric Genetics of African Populations-Psychosis. We used exploratory factor analysis to assess LEC-5 structure, and conducted confirmatory factor analyses to compare these results with two other models: a six-factor model based on the only prior EFA of the LEC and a theoretical seven-factor model. RESULTS: The majority (63.4% overall and 64.4% of cases and 62.4% of controls) of participants had experienced at least one PTE in their lifetime. Results of the exploratory factor analyses for LEC-5 yielded a seven-factor solution with eigenvalues greater than one, accounting for 55.3% of the common variance. Based on confirmatory factor analyses, all three models had good fit for our sample, but the theoretical seven-factor model had the best fit. LIMITATIONS: The study did not assess if the participants perceived experiences as traumatic, we did not carry out test retest reliability or and we did not consider cultural variations in perception of trauma. CONCLUSION: This study provides evidence of a high prevalence of traumatic life events and for the construct validity of LEC-5 in assessing PTE exposures in a Kenyan setting.

Mental Disorders Among Health Care Workers at the Early Phase of COVID-19 Pandemic in Kenya; Findings of an Online Descriptive Survey.

Background: Healthcare workers responding to the Corona Virus Pandemic (COVID-19) are at risk of mental illness. Data is scanty on the burden of mental disorders among Kenyan healthcare workers responding to the pandemic that can inform mental health and psychosocial support. The purpose of this study was to establish the frequency and associated factors of worry, generalized anxiety disorder, depression, posttraumatic stress disorder and poor quality of sleep among Kenyan health care workers at the beginning of COVID-19 pandemic. Methods: We conducted an online survey among 1,259 health care workers in Kenya. A researcher developed social demographic questionnaire and several standardized tools were used for data collection. Standardized tools were programmed into Redcap, (Research Electronic Data Capture) and data analysis was performed using R Core Team. In all analysis a p-value < 0.05 was considered significant. Results: 66% of the participants reported experiencing worry related to COVID-19. 32.1% had depression, 36% had generalized anxiety, 24.2% had insomnia and 64.7% scored positively for probable Post Traumatic Stress Disorder (PTSD). Depression was higher among females compared to men (36.5 vs. 26.9%, p = 0.003), workers <35 years old compared to older ones (38.1 vs. 26.4%, p < 0.001), and those who were not married compared to those who were married (40.6 vs. 27.6%, p < 0.001). Generalized anxiety was commoner among workers aged <35 years (43.5 vs. 29.3%, p < 0.001), females (41.7 vs. 29.2%, p < 0.001), those who mere not married compared to the married (45.2 vs. 31.2%, p < 0.001) and those with <10 years working experience (41.6 to 20.5%, p < 0.001). Younger health care professional had a higher proportion of insomnia compared to the older ones (30.3 vs. 18.6%, p < 0.001). Insomnia was higher among those with <10 years' experience compared to those with more than 20 years' experience(27.3 vs. 17.6%, p = 0.043) Conclusion: Many Kenyan healthcare workers in the early phase of COVID-19 pandemic suffered from various common mental disorders with young, female professionals who are not married bearing the bigger burden. This data is useful in informing interventions to promote mental and psychosocial wellbeing among Kenyan healthcare workers responding to the pandemic.

Sudden Death After Electroconvulsive Therapy in the Context of Coronavirus Disease 2019.

CONCLUSIONS: Although ECT is a safe procedure, caution should be exercised in the context of COVID-19, as it is now clear that patients who recovered from COVID-19 might have an undetected venous thromboembolism that can cause untoward outcomes. ETHICAL CONSIDERATION: A written consent was obtained from the sister to the deceased patient.