Results of the Kigali Imbereheza Project: A 2-Arm Individually Randomized Trial of TI-CBT Enhanced to Address ART Adherence and Mental Health for Rwandan Youth Living With HIV.

BACKGROUND: Adolescents living with HIV have elevated mental distress and suboptimal antiretroviral therapy (ART) adherence. SETTING: Two urban clinics in Kigali, Rwanda. METHODS: A 2-arm individual randomized controlled trial compared Trauma-Informed Cognitive Behavioral Therapy enhanced to address HIV (TI-CBTe) with usual care (time-matched, long-standing, unstructured support groups) with 356 12- to 21-year-old (M = 16.78) Rwandans living with HIV. TI-CBTe included 6 group-based 2-hour sessions led by trained and supervised 21- to 25-year-old Rwandans living with HIV. Participants reported their ART adherence, depression/anxiety, and Post-Traumatic Stress Disorder symptoms at baseline, 6, 12, and 18 months. RESULTS: ART adherence was relatively high at baseline, and youth reported elevated rates of depression/anxiety and trauma symptoms. There were no differential treatment effects on adherence, but depression/anxiety improved over time. Youth with lower depression/anxiety at baseline seemed to benefit more from TI-CBTe than usual care, whereas women with high baseline distress seemed to benefit more from usual care. Youth were less likely to score in high Post-Traumatic Stress Disorder symptom categories at the follow-up, with no differential treatment effects. CONCLUSIONS: TI-CBTe did not outperform usual care on ART adherence, possibly reflecting relatively high adherence at baseline, simplified medication regimens over time, a strong comparison condition, or because youth assigned to TI-CBTe returned to their support groups after the intervention. TI-CBTe was more effective for youth with lower depression/anxiety symptoms, whereas youth with high distress benefitted more from the support groups. TI-CBTe was feasible and acceptable, and young adults living with HIV were able to deliver a mental health intervention with fidelity. The powerful nature of the comparison group, ongoing support groups, points to the potential value of locally crafted interventions in low-resource settings.

Strengthening mental health services in Sierra Leone: perspectives from within the health system.

Though mental and substance use disorders are a leading cause of disability worldwide, mental health systems are vastly under-resourced in most low- and middle-income countries and the majority of people with serious mental health needs receives no formal treatment. Despite international calls for the integration of mental health into routine care, availability of outpatient mental health services and integration of mental health into the broader healthcare system remain weak in many countries. Efforts to strengthen mental healthcare systems must be informed by the local context, with attention to key health system components. The current study is a qualitative analysis of stakeholder perspectives on mental health system strengthening in one low-income country, Sierra Leone. It utilizes locally grounded knowledge from frontline healthcare providers to identify constraints and opportunities for strengthening mental health care within each component of the health system. In-depth semi-structured interviews were conducted with 43 participants including doctors, nurses, community health workers, mental health advocates, mental health specialists, and traditional healers recruited from the Bo, Moyamba and Western Area Urban Districts. Interview transcripts were content-coded in NVivo using both a priori and emergent codes and aggregated into broader themes, utilizing the World Health Organization Health Systems Framework. Participants described an extremely limited system of mental health care, with constraints and obstacles within each health system component. Participants identified potential strategies to help overcome these constraints. Findings reinforce the importance of factors outside of the healthcare system that shape the implementation of mental health initiatives, including pervasive stigma towards mental illness, local conceptualizations of mental illness and an emphasis on traditional treatment approaches. Implications for mental health initiatives in Sierra Leone and other low-income countries include a need for investment in primary care clinics to support integrated mental health services and the importance of engaging communities to promote the utilization of mental health services.

The strength of youth voice: exploring the influence of youth strength-perspectives on desired outcomes for youth enrolled in system-of-care services.

Recent efforts to improve mental health services for young people have called for the inclusion of youth and families in service planning and delivery. When youth strengths are considered within the treatment context, many continue to prioritize adult perspectives of youth strengths. Questions remain about how and why strengths matter for youth from the perspective of youth. The present study explores the relative influence of youth and caregiver assessments of youth strengths across six strength domains to predict emotional and behavioral outcomes. Data were gathered from 49 youth (aged 10-18) and caregiver dyads upon enrollment in system-of-care services and 6 months later. Youth strength assessments predicted changes in delinquency, school attendance, activity involvement, over and above caregiver strength assessments, and 6 months after service enrollment. Results support the inclusion of youth voice in mental health service planning and delivery, and further highlight the value of understanding strengths in a domain specific way.

Local terms and understandings of mental health problems in Burundi.

A pilot study and two intensive studies were conducted to document the local vocabularies used by Burundians to describe mental health problems and their understandings about the causes. The pilot study-in which 14 different large groups of community members awaiting appointments at a village health clinic were engaged in open-ended discussions of the local terminology and causal beliefs about mental health problems-suggested three key syndromes: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In Study 1 ( N = 542), individual interviews or surveys presented participants with the names of these syndromes and asked what they considered to be the symptoms and causes of them. Study 2 ( N = 143) cross-validated these terms with a different sample (also in individual interviews/surveys), by presenting the symptom clusters and asking what each would be called and about their causes. Findings of both studies validated this set of terms and yielded a rich body of data about causal beliefs. The influence of education level and gender on familiarity with these terms was also assessed. Implications for the development of mental health services and directions for future research are discussed.

Rumination in Early Adolescent Girls: Interactive Contributions of Mother-Adolescent Relationship Quality and Maternal Coping Suggestions.

Research suggests that rumination places adolescents at risk for psychopathology. However, little is known about the association between parenting and rumination. Moreover, relevant theoretical models suggest that parents contribute to the development of rumination both explicitly through their suggestions about how to cope and implicitly through the context of the mother-adolescent relationship. However, prior work has not examined implicit and explicit factors within the same investigation, precluding exploration of their unique and interactive effects. To address these gaps, the present study examined links between mother-adolescent relationship quality, maternal coping suggestions, and adolescent rumination. Participants were early adolescent girls (M age = 12.41 years) and their primary female caregivers. Findings suggested that maternal disengagement suggestions and mother-adolescent relationship quality were each uniquely associated with adolescent rumination. Moreover, the effect of maternal disengagement suggestions depended on the level of maternal engagement suggestions and mother-adolescent relationship quality. Follow-up analyses revealed that these findings were specific to the maladaptive ruminative brooding component of rumination. Future directions for research were elaborated.