Association between maternity leave policies and postpartum depression: a systematic review.

PURPOSE: Working mothers are at greater risk for postpartum depression. Maternity leave characteristics, including length, wage replacement and employment protection, could have relevant implications for mothers' mental health. We propose to explore whether there is an association between maternity leave characteristics and postpartum depression. METHODS: We conducted a systematic review searching for randomized controlled trials, quasi-experimental, cohort or cross-sectional studies on five databases using search terms including maternity and parental leave and depression, as well as references in relevant articles. We identified 500 articles and included 23 of those. We used the EPHPP Quality Assessment Tool for Quantitative Studies to assess the quality of the studies. RESULTS: Paid and longer maternity leaves tend to be associated with a reduction of postpartum depression symptoms in high-income countries. No studies explored the association between employment protection and postpartum depression. The quality of studies ranged from strong to weak, mostly influenced by study design. CONCLUSION: More restrictive maternity leave policies tend to be associated with higher rates of postpartum depression, although more research needs to be conducted in the Global South.

Using Arts-Based Methodologies to Understand Adolescent and Youth Manifestations, Representations, and Potential Causes of Depression and Anxiety in Low-Income Urban Settings in Peru.

BACKGROUND: Arts-based methodologies can be beneficial to identify different representations of stigmatized topics such as mental health conditions. This study used a theater-based workshop to describe manifestations, representations, and potential causes of depression and anxiety as perceived by adolescents and young adults. METHODS: The theater company Teatro La Plaza conducted three online sessions with a group of adolescents and another with a group of young adults from Lima, Peru. The artistic outputs, which included images, similes, monologues, and narrations, were used to describe the experiences of depression and anxiety symptoms following a content analysis using posteriori categories. RESULTS: Seventeen participants joined the sessions. The artistic outputs showed: physical, behavioral, cognitive, and emotional manifestations of depression and anxiety; a perception that both disorders have a cyclical nature; and an awareness that it is often difficult to notice symptom triggers. The mandatory social isolation due to the COVID-19 pandemic was highlighted as an important symptom trigger, mostly linked to anxiety. CONCLUSIONS: The findings are consistent with the literature, especially with regard to the manifestations, representations, and potential causes that trigger depression and anxiety. Using arts-based methods allowed adolescents and young adults to expand the articulation of their representations of mental disorders.

Systematic Review of Policies and Interventions to Prevent Sexual Harassment in the Workplace in Order to Prevent Depression.

BACKGROUND: Sexual harassment in the workplace (SHWP) is highly prevalent and has a negative impact, including depression, on its victims, as well as a negative economic impact resulting from absenteeism and low productivity at work. This paper aims to outline the available evidence regarding the prevention of depressive symptoms among workers through policies and interventions that are effective in preventing SHWP. METHODS: We conducted two systematic reviews. The first focused on the association of depression and SHWP, and the second on policies and interventions to prevent SHWP. We conducted a meta-analysis and a narrative synthesis, respectively. We identified 1831 and 6107 articles for the first and second review. After screening, 24 and 16 articles were included, respectively. RESULTS: Meta-analysis results show a prevalence of depression of 26%, as well as a 2.69 increased risk of depression among workers who experience SHWP. Variables such as number of harassment experiences and exposure to harassment from coworkers and other people increase this risk. CONCLUSIONS: There is limited evidence regarding the effectiveness of policies and training to prevent SHWP, mostly focused on improvements in workers' knowledge and attitudes about SHWP. However, there is no available evidence regarding its potential impact on preventing depression.

Participants' and Nurses' Experiences With a Digital Intervention for Patients With Depressive Symptoms and Comorbid Hypertension or Diabetes in Peru: Qualitative Post-Randomized Controlled Trial Study.

BACKGROUND: Depression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users' experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention. OBJECTIVE: This study aimed to explore the RCT participants' experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them. METHODS: In 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews. RESULTS: Participants' mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions' text simple, extending the length of the intervention, and improving the training session with long explanations. CONCLUSIONS: The findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants' experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426.

Identifying resources used by young people to overcome mental distress in three Latin American cities: a qualitative study.

OBJECTIVE: To explore which resources and activities help young people living in deprived urban environments in Latin America to recover from depression and/or anxiety. DESIGN: A multimethod, qualitative study with 18 online focus groups and 12 online structured group conversations embedded into arts workshops. SETTING: This study was conducted in Bogotá (Colombia), Buenos Aires (Argentina) and Lima (Peru). PARTICIPANTS: Adolescents (15-16 years old) and young adults (20-24 years old) with capacity to provide assent/consent and professionals (older than 18 years of age) that had experience of professionally working with young people were willing to share personal experience within a group, and had capacity to provide consent. RESULTS: A total of 185 participants took part in this study: 111 participants (36 adolescents, 35 young adults and 40 professionals) attended the 18 focus groups and 74 young people (29 adolescents and 45 young adults) took part in the 12 arts workshops. Eight categories captured the resources and activities that were reported by young people as helpful to overcome mental distress: (1) personal resources, (2) personal development, (3) spirituality and religion, (4) social resources, (5) social media, (6) community resources, (7) activities (subcategorised into artistic, leisure, sports and outdoor activities) and (8) mental health professionals. Personal and social resources as well as artistic activities and sports were the most common resources identified that help adolescents and young adults to overcome depression and anxiety. CONCLUSION: Despite the different contexts of the three cities, young people appear to use similar resources to overcome mental distress. Policies to improve the mental health of young people in deprived urban settings should address the need of community spaces, where young people can play sports, meet and engage in groups, and support community organisations that can enable and facilitate a range of social activities.

A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru.

BACKGROUND: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. OBJECTIVE: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. METHODS: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top-down and bottom-up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. RESULTS: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. CONCLUSIONS: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26164.

Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials.

Importance: Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective: To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants: Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions: An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures: The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results: Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance: In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration: ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).

[Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in PeruEstudo qualitativo sobre a implementação do Programa de Continuidade de Cuidados e Rehabilitação para pessoas com transtornos mentais graves no Peru]. / Estudio cualitativo sobre la implementación del Programa de continuidad de cuidados y rehabilitación para personas con trastornos mentales graves en el Perú.

OBJECTIVE: Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. METHODS: Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. RESULTS: The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. CONCLUSIONS: The PCC-R is a flagship program for the CSMCs and for the mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

OBJETIVO: Descrever a implementação do Programa de Continuidade de Cuidados e Reabilitação (PCC-R) em centros de saúde mental comunitária (CSMCs) do Peru. MÉTODOS: Estudo qualitativo sobre a implementação do PCC-R em quatro CSMCs em Lima e La Libertad, no Peru. Realizamos 42 entrevistas semiestruturadas individuais e um grupo focal com cinco participantes, com um total de 47 participantes, entre usuários, familiares e profissionais envolvidos na elaboração, implementação e monitoramento do PCC-R. RESULTADOS: O PCC-R é um programa central dos serviços de saúde mental comunitária no Peru, conta com ampla aceitabilidade e os prestadores e usuários dizem estar satisfeitos com seus resultados. No entanto, o programa não possui um documento normativo que detalhe os seus objetivos, organização e atividades, o que pode explicar a variabilidade em sua aplicação. Existem limitações na gestão dos recursos financeiros e humanos do PCC-R e necessidades de capacitação e supervisão, que devem ser melhoradas. Há consenso sobre a necessidade, utilidade e viabilidade de se desenvolver um sistema de monitoramento do PCC-R. Apresentamos aqui um conjunto de boas práticas e sugestões para enfrentar esses desafios. CONCLUSÕES: O PCC-R é um programa emblemático dos CSMCs e da reforma da saúde mental no Peru, tendo obtido ampla aceitação entre prestadores e usuários. A sua implementação combina acertos e dificuldades e revela tarefas pendentes, tais como o desenvolvimento de um documento normativo, uma melhor gestão de recursos, o reforço da capacitação e supervisão e a aplicação de um sistema de monitoramento para fomentar a melhoria contínua do programa.

Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in Peru

[ABSTRACT]. Objective. Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. Methods. Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. Results. The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. Conclusions. The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

[RESUMEN]. Objetivo. Describir la implementación del Programa de continuidad de cuidados y rehabilitación (PCC-R) en centros de salud mental comunitaria (CSMC) del Perú. Métodos. Estudio cualitativo sobre la implementación del PCC-R en cuatro CSMC de Lima y La Libertad, Perú. Se realizaron 42 entrevistas semiestructuradas individuales y un grupo focal con cinco participantes, para un total de 47 informantes entre usuarios, familiares y profesionales vinculados al diseño, la implementación y el monitoreo del PCC-R. Resultados. El PCC-R es un programa central de los servicios de salud mental comunitaria en Perú, goza de amplia aceptación y los prestadores y usuarios refieren estar satisfechos con sus resultados. Sin embargo, el programa carece de un documento normativo que detalle sus objetivos, organización y actividades, lo que explicaría la variabilidad en su aplicación. Existen limitaciones en la gestión de recursos financieros y humanos del PCC-R y necesidades de capacitación y supervisión, que deben ser mejoradas. Existe consenso sobre la necesidad, la utilidad y la viabilidad de desarrollar un sistema de monitoreo del PCC-R. Se recogen buenas prácticas y sugerencias para enfrentar estos retos. Conclusiones. El PCC-R es un programa insignia de los CSMC y de la reforma de la salud mental en Perú, y ha logrado amplia aceptación entre los prestadores y usuarios. Su implementación combina aciertos y dificultades, y revela tareas pendientes como desarrollar un documento normativo, mejorar la gestión de recursos, fortalecer la capacitación y acompañamiento, y aplicar un sistema de monitoreo para favorecer la mejora continua del programa.

[RESUMO]. Objetivo. Descrever a implementação do Programa de Continuidade de Cuidados e Reabilitação (PCC-R) em centros de saúde mental comunitária (CSMCs) do Peru. Métodos. Estudo qualitativo sobre a implementação do PCC-R em quatro CSMCs em Lima e La Libertad, no Peru. Realizamos 42 entrevistas semiestruturadas individuais e um grupo focal com cinco participantes, com um total de 47 participantes, entre usuários, familiares e profissionais envolvidos na elaboração, implementação e monitoramento do PCC-R. Resultados. O PCC-R é um programa central dos serviços de saúde mental comunitária no Peru, conta com ampla aceitabilidade e os prestadores e usuários dizem estar satisfeitos com seus resultados. No entanto, o programa não possui um documento normativo que detalhe os seus objetivos, organização e atividades, o que pode explicar a variabilidade em sua aplicação. Existem limitações na gestão dos recursos financeiros e humanos do PCC-R e necessidades de capacitação e supervisão, que devem ser melhoradas. Há consenso sobre a necessidade, utilidade e viabilidade de se desenvolver um sistema de monitoramento do PCC-R. Apresentamos aqui um conjunto de boas práticas e sugestões para enfrentar esses desafios. Conclusões. O PCC-R é um programa emblemático dos CSMCs e da reforma da saúde mental no Peru, tendo obtido ampla aceitação entre prestadores e usuários. A sua implementação combina acertos e dificuldades e revela tarefas pendentes, tais como o desenvolvimento de um documento normativo, uma melhor gestão de recursos, o reforço da capacitação e supervisão e a aplicação de um sistema de monitoramento para fomentar a melhoria contínua do programa.

Estudio cualitativo sobre la implementación del Programa de continuidad de cuidados y rehabilitación para personas con trastornos mentales graves en el Perú

[RESUMEN]. Objetivo. Describir la implementación del Programa de continuidad de cuidados y rehabilitación (PCC-R) en centros de salud mental comunitaria (CSMC) del Perú. Métodos. Estudio cualitativo sobre la implementación del PCC-R en cuatro CSMC de Lima y La Libertad, Perú. Se realizaron 42 entrevistas semiestructuradas individuales y un grupo focal con cinco participantes, para un total de 47 informantes entre usuarios, familiares y profesionales vinculados al diseño, la implementación y el monitoreo del PCC-R. Resultados. El PCC-R es un programa central de los servicios de salud mental comunitaria en Perú, goza de amplia aceptación y los prestadores y usuarios refieren estar satisfechos con sus resultados. Sin embargo, el programa carece de un documento normativo que detalle sus objetivos, organización y actividades, lo que explicaría la variabilidad en su aplicación. Existen limitaciones en la gestión de recursos financieros y humanos del PCC-R y necesidades de capacitación y supervisión, que deben ser mejoradas. Existe consenso sobre la necesidad, la utilidad y la viabilidad de desarrollar un sistema de monitoreo del PCC-R. Se recogen buenas prácticas y sugerencias para enfrentar estos retos. Conclusiones. El PCC-R es un programa insignia de los CSMC y de la reforma de la salud mental en Perú, y ha logrado amplia aceptación entre los prestadores y usuarios. Su implementación combina aciertos y dificultades, y revela tareas pendientes como desarrollar un documento normativo, mejorar la gestión de recursos, fortalecer la capacitación y acompañamiento, y aplicar un sistema de monitoreo para favorecer la mejora continua del programa.

[ABSTRACT]. Objective. Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. Methods. Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. Results. The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. Conclusions. The PCC-R is a flagship program for the CSMCs and for the mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

[RESUMO]. Objetivo. Descrever a implementação do Programa de Continuidade de Cuidados e Reabilitação (PCC-R) em centros de saúde mental comunitária (CSMCs) do Peru. Métodos. Estudo qualitativo sobre a implementação do PCC-R em quatro CSMCs em Lima e La Libertad, no Peru. Realizamos 42 entrevistas semiestruturadas individuais e um grupo focal com cinco participantes, com um total de 47 participantes, entre usuários, familiares e profissionais envolvidos na elaboração, implementação e monitoramento do PCC-R. Resultados. O PCC-R é um programa central dos serviços de saúde mental comunitária no Peru, conta com ampla aceitabilidade e os prestadores e usuários dizem estar satisfeitos com seus resultados. No entanto, o programa não possui um documento normativo que detalhe os seus objetivos, organização e atividades, o que pode explicar a variabilidade em sua aplicação. Existem limitações na gestão dos recursos financeiros e humanos do PCC-R e necessidades de capacitação e supervisão, que devem ser melhoradas. Há consenso sobre a necessidade, utilidade e viabilidade de se desenvolver um sistema de monitoramento do PCC-R. Apresentamos aqui um conjunto de boas práticas e sugestões para enfrentar esses desafios. Conclusões. O PCC-R é um programa emblemático dos CSMCs e da reforma da saúde mental no Peru, tendo obtido ampla aceitação entre prestadores e usuários. A sua implementação combina acertos e dificuldades e revela tarefas pendentes, tais como o desenvolvimento de um documento normativo, uma melhor gestão de recursos, o reforço da capacitação e supervisão e a aplicação de um sistema de monitoramento para fomentar a melhoria contínua do programa.

Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in Peru.

OBJECTIVE: Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. METHODS: Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. RESULTS: The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. CONCLUSIONS: The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

Provision of mental health care within primary care in Peru: A qualitative study exploring the perspectives of psychologists, primary health care providers, and patients.

Background: This study aimed to understand the offer of mental health care at the primary care level, collecting the views of psychologists, primary health care providers (PHCPs), and patients, with a focus on health services in which patients attend regularly and who present a higher prevalence of mental disorders. Methods: A qualitative study was conducted in antenatal care, tuberculosis, HIV/AIDS, and chronic diseases services from six primary health care centers. Semi-structured interviews were conducted with psychologists, PHCPs, and patients working in or attending the selected facilities.  Results: A total of 4 psychologists, 22 PHCPs, and 37 patients were interviewed. A high perceived need for mental health care was noted. PHCPs acknowledged the emotional impact physical health conditions have on their patients and mentioned that referral to psychologists was reserved only for serious problems. Their approach to emotional problems was providing emotional support (includes listening, talk about their patients' feelings, provide advice). PHCPs identified system-level barriers about the specialized mental health care, including a shortage of psychologists and an overwhelming demand, which results in brief consultations and lack in continuity of care. Psychologists focus their work on individual consultations; however, consultations were brief, did not follow a standardized model of care, and most patients attend only once. Psychologists also mentioned the lack of collaborative work among other healthcare providers. Despite these limitations, interviewed patients declared that they were willing to seek specialized care if advised and considered the psychologist's care provided as helpful; however, they recognized the stigmatization related to seeking mental health care. Conclusions: There is a perceived need of mental health care for primary care patients. To attend these needs, PHCPs provide emotional support and refer to psychology the most severe cases, while psychologists provide one-to-one consultations. Significant limitations in the care provided are discussed.

Integration of a Technology-Based Mental Health Screening Program Into Routine Practices of Primary Health Care Services in Peru (The Allillanchu Project): Development and Implementation.

BACKGROUND: Despite their high prevalence and significant burden, mental disorders such as depression remain largely underdiagnosed and undertreated. OBJECTIVE: The aim of the Allillanchu Project was to design, develop, and test an intervention to promote early detection, opportune referral, and access to treatment of patients with mental disorders attending public primary health care (PHC) services in Lima, Peru. METHODS: The project had a multiphase design: formative study, development of intervention components, and implementation. The intervention combined three strategies: training of PHC providers (PHCPs), task shifting the detection and referral of mental disorders, and a mobile health (mHealth) component comprising a screening app followed by motivational and reminder short message service (SMS) to identify at-risk patients. The intervention was implemented by 22 PHCPs from five health centers, working in antenatal care, tuberculosis, chronic diseases, and HIV or AIDS services. RESULTS: Over a period of 9 weeks, from September 2015 to November 2015, 733 patients were screened by the 22 PHCPs during routine consultations, and 762 screening were completed in total. The chronic diseases (49.9%, 380/762) and antenatal care services (36.7%, 380/762) had the higher number of screenings. Time constraints and workload were the main barriers to implementing the screening, whereas the use of technology, training, and supervision of the PHCPs by the research team were identified as facilitators. Of the 733 patients, 21.7% (159/733) screened positively and were advised to seek specialized care. Out of the 159 patients with a positive screening result, 127 had a follow-up interview, 72.4% (92/127) reported seeking specialized care, and 55.1% (70/127) stated seeing a specialist. Both patients and PHCPs recognized the utility of the screening and identified some key challenges to its wider implementation. CONCLUSIONS: The use of a screening app supported by training and supervision is feasible and uncovers a high prevalence of unidentified psychological symptoms in primary care. To increase its sustainability and utility, this procedure can be incorporated into the routine practices of existing health care services, following tailoring to the resources and features of each service. The early detection of psychological symptoms by a PHCP within a regular consultation, followed by adequate advice and support, can lead to a significant percentage of patients accessing specialized care and reducing the treatment gap of mental disorders.

Peruvian Mental Health Reform: A Framework for Scaling-up Mental Health Services.

BACKGROUND: Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face. METHODS: Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up. RESULTS: Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru. CONCLUSION: Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services.

[Integration of mental health and chronic non-communicable diseases in Peru: challenges and opportunities for primary care settings]. / Atendiendo la salud mental de las personas con enfermedades crónicas no transmisibles en el Perú: retos y oportunidades para la integración de cuidados en el primer nivel de atención.

In this article, the relationship between mental health and chronic non-communicable diseases is discussed as well as the possibility to address them in a comprehensive manner in the Peruvian health system. First, the prevalence estimates and the burden of chronic non-communicable diseases and mental disorders worldwide and in Peru are reviewed. Then, the detrimental impact of depression in the early stages as well as the progress of diabetes and cardiovascular diseases is described. Additionally, the gap between access to mental health care in Peru is analyzed. Lastly, the alternatives to reduce the gap are explored. Of these alternatives, the integration of mental health into primary care services is emphasized; as a feasible way to meet the care needs of the general population, and people with chronic diseases in particular, in the Peruvian context.

Atendiendo la salud mental de las personas con enfermedades crónicas no transmisibles en el Perú: retos y oportunidades para la integración de cuidados en el primer nivel de atención / Integration of mental health and chronic non-communicable diseases in Peru: challenges and opportunities for primary care settings

En este artículo se discute la relación entre la salud mental y las enfermedades crónicas no transmisibles; así como la posibilidad de atenderlas de manera integral en el sistema de salud peruano. En primer lugar se revisan los estimados de prevalencia y carga de enfermedad de enfermedades crónicas no transmisibles y desórdenes mentales a nivel mundial y en el Perú. Luego, se describe el impacto perjudicial de la depresión en la etiología así como en la progresión de la diabetes y las enfermedades cardiovasculares. Posteriormente, se analiza la brecha en el acceso a la atención de la salud mental en el Perú y, finalmente, se exploran las alternativas para reducirla. De estas alternativas se enfatiza la integración de la salud mental en servicios de atención primaria como una forma viable de responder a las necesidades de atención de la población en general, y de las personas con enfermedades crónicas, en particular, en el contexto peruano.

In this article, the relationship between mental health and chronic non-communicable diseases is discussed as well as the possibility to address them in a comprehensive manner in the Peruvian health system. First, the prevalence estimates and the burden of chronic non-communicable diseases and mental disorders worldwide and in Peru are reviewed. Then, the detrimental impact of depression in the early stages as well as the progress of diabetes and cardiovascular diseases is described. Additionally, the gap between access to mental health care in Peru is analyzed. Lastly, the alternatives to reduce the gap are explored. Of these alternatives, the integration of mental health into primary care services is emphasized; as a feasible way to meet the care needs of the general population, and people with chronic diseases in particular, in the Peruvian context.