Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources.

BACKGROUND: Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system. AIMS: We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia. METHODS: We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004. RESULTS: Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities. CONCLUSIONS: The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Prevalence of Mood Disorders and Associated Factors at the Time of the COVID-19 Pandemic: Potocol for a Community Survey in La Manouba Governorate, Tunisia.

Aims: The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic. Background: Mood disorders are one of the leading causes of all non-fatal burdens of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle-income countries (LMICs) and in vulnerable populations. Objective: 1/ Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders; 2/Study socio-demographic and clinical correlates of mood disorders 3/ Assess the association between mood disorders and quality of life 4/ Study the impact of the COVID-pandemic on the prevalence of mood disorders 5/ Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic. Methods: This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered. Results: Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about a headache. In addition, socio-demographic and clinical data will be collected. Conclusion: This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19-related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

Correlates of benzodiazepine dependence in patients with depression followed up in a psychiatric outpatient unit in Tunisia.

Benzodiazepines may be prescribed to manage anxiety and insomnia in patients with depression. However, as noticed during our daily practice, a considerable proportion of patients treated for depression and receiving benzodiazepines developed a dependence to these medicines. Our aims were to estimate the proportion of patients with depression who develop a benzodiazepine dependence and to identify its correlates. We conducted a comparative study in Razi Hospital's outpatient psychiatry unit (Tunisia). We included patients aged 18 to 65 years who were diagnosed with depression during the first three quarters of 2014. Included patients were prescribed benzodiazepines. Follow-up period was of 2 years. A multivariate analysis was performed to identify dependence-associated factors. We included 54 patients, and 52% developed a benzodiazepine dependence during the follow-up period. Two associated factors were identified: a daily mean benzodiazepine dose of more than 9.5 milligrams of diazepam equivalents prior to taper off (p = .001) and a benzodiazepine taper-off initiated after the fifth week of benzodiazepine intake onset (p = .007). The proportion of patients who developed a benzodiazepine dependence was high. Low doses and time-limited benzodiazepine prescription should be taken into consideration when managing patients with depression in order to prevent dependence.

The influence of primary care physicians' mental health knowledge, attitudes and self-efficacy on referrals to specialised services: findings from a longitudinal pilot trial.

BACKGROUND: Training based on the Mental Health Gap Action Programme (mhGAP) is being increasingly adopted by countries to enhance non-specialists' mental health capacities. However, the influence of these enhanced capacities on referral rates to specialised mental health services remains unknown. AIMS: We rely on findings from a longitudinal pilot trial to assess the influence of mental health knowledge, attitudes and self-efficacy on self-reported referrals from primary to specialised mental health services before, immediately after and 18 months after primary care physicians (PCPs) participated in an mhGAP-based training in the Greater Tunis area of Tunisia. METHOD: Participants included PCPs who completed questionnaires before (n = 112), immediately after (n = 88) and 18 months after (n = 59) training. Multivariable analyses with linear mixed models accounting for the correlation among participants were performed with the SAS version 9.4 PROC MIXED procedure. The significance level was α < 0.05. RESULTS: Data show a significant interaction between time and mental health attitudes on referrals to specialised mental health services per week. Higher scores on the attitude scale were associated with more referrals to specialised services before and 18 months after training, compared with immediately after training. CONCLUSION: Findings indicate that, in parallel to mental health training, considering structural/organisational supports to bring about a sustainable change in the influence of PCPs' mental health attitudes on referrals is important. Our results will inform the scale-up of an initiative to further integrate mental health into primary care settings across Tunisia, and potentially other countries with similar profiles interested in further developing task-sharing initiatives.

Reflecting on knowledge translation strategies from global health research projects in Tunisia and the Republic of Côte d'Ivoire.

OBJECTIVES: We describe the knowledge translation strategies in two projects and share lessons learned about knowledge sharing and uptake. METHODS: To generate findings for dissemination: (1) the Republic of Côte d'Ivoire (RCI) project relied on a multiple case study design to document barriers and facilitators to implementing a community-led prevention strategy targeting Ebola virus disease; and (2) the Tunisia project used several designs to assess a mental health training's effectiveness, and a case study design to explore contextual factors that may influence anticipated outcomes. RESULTS: To share findings with participants, the RCI project relied on workshops and a pamphlet, and the Tunisia project relied on a structured half-day dissemination workshop and research summary. Facilitators that may have encouraged sharing and using findings include involving champions in dissemination activities, ongoing collaboration, and developing/implementing context-specific knowledge sharing strategies. Barriers include omitting to assess strategies, limited consideration of a wider audience, and the exclusion of a knowledge translation training component. CONCLUSIONS: Our experiences might be useful to contexts involved in global and public health research that wish to address the "know-do gap."

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial.

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

"We find what we look for, and we look for what we know": factors interacting with a mental health training program to influence its expected outcomes in Tunisia.

BACKGROUND: Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists' mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper's objective is to fill that lack. METHODS: We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis. RESULTS: Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training's expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions. CONCLUSIONS: Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.

Mental health knowledge, attitudes, and self-efficacy among primary care physicians working in the Greater Tunis area of Tunisia.

BACKGROUND: Non-specialists' involvement in mental health care is encouraged in the field of global mental health to address the treatment gap caused by mental illness, especially in low- and middle-income countries. While primary care physicians (PCPs) are involved in mental health care in Tunisia, a lower-middle-income country in North Africa, it is unclear to what extent they are prepared and willing to address mental health problems, substance use disorders, and suicide/self-harm. In this context, we aim (1) to report on mental health knowledge, attitudes, and self-efficacy among a sample of PCPs working in the Greater Tunis area, prior to the implementation of a mental health training program developed by the World Health Organization; and (2) to identify what characteristics are associated with these competencies. METHODS: In total, 112 PCPs completed questionnaires related to their socio-demographic and practice characteristics, as well as their mental health knowledge, attitudes, and self-efficacy. Descriptive analyses and regression models were performed. FINDINGS: PCPs had more knowledge about depression, symptoms related to psychosis, and best practices after a suicide attempt; had favourable attitudes about distinctions between physical and mental health, learning about mental health, and the acceptance of colleagues with mental health issues; and believed most in their capabilities related to depression and anxiety. However, most PCPs had less knowledge about substance use disorders and myths about suicide attempts; had unfavorable attitudes about the dangerousness of people with mental health problems, personal disclosure of mental illness, non-specialists' role in assessing mental health problems, and personal recovery; and believed the least in their capabilities related to substance use disorders, suicide/self-harm, and psychosis. Participation in previous mental health training, weekly hours (and weekly hours dedicated to mental health), weekly provision of psychoeducation, and certain work locations were associated with better mental health competencies, whereas mental health knowledge was negatively associated with weekly referrals to specialized services. CONCLUSIONS: Findings suggest that PCPs in our sample engage in mental health care, but with some gaps in competencies. Mental health training and increased interactions/involvement with people consulting for mental health issues may help further develop non-specialists' mental health competencies, and integrate mental health into primary care settings.

Tailoring a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) to Tunisia: process and relevant adaptations.

BACKGROUND: In order to make mental health services more accessible, the Tunisian Ministry of Health, in collaboration with the School of Public Health at the University of Montreal, the World Health Organization office in Tunisia and the Montreal World Health Organization-Pan American Health Organization Collaborating Center for Research and Training in Mental Health, implemented a training programme based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) (version 1.0), developed by the World Health Organization. This article describes the phase prior to the implementation of the training, which was offered to general practitioners working in primary care settings in the Greater Tunis area of Tunisia. METHODS: The phase prior to implementation consisted of adapting the standard mhGAP-IG (version 1.0) to the local primary healthcare context. This adaptation process, an essential step before piloting the training, involved discussions with stakeholder groups, as well as field observations. RESULTS: Through the adaptation process, we were able to make changes to the standard training format and material. In addition, the process helped uncover systemic barriers to effective mental health care. CONCLUSIONS: Targeting these barriers in addition to implementing a training programme may help reduce the mental health treatment gap, and promote implementation that is successful and sustainable.

Building system capacity for the integration of mental health at the level of primary care in Tunisia: a study protocol in global mental health.

BACKGROUND: In low- and middle-income countries (LMICs), addressing the high prevalence of mental disorders is a challenge given the limited number and unequal distribution of specialists, as well as scarce resources allocated to mental health. The Mental Health Gap Action Programme (mhGAP) and its accompanying Intervention Guide (IG), developed by the World Health Organization (WHO), aim to address this challenge by training non-specialists such as general practitioners (GPs) in mental health care. This trial aims to implement and evaluate an adapted version of the mhGAP-IG (version 1.0) offered to GPs in 2 governorates of Tunisia (i.e., Tunis and Sousse), in order to uncover important information regarding implementation process and study design before country-wide implementation and evaluation. METHODS/DESIGN: First, a systematic review will be conducted to explore types and effectiveness of mental health training programs offered to GPs around the world, with a specific focus on programs implemented and evaluated in LMICs. Second, a cluster randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of the implemented training based on the mhGAP-IG (version 1.0). Third, multiple case study design will be used to explore how contextual factors impact the successful implementation of the training and desired outcomes. DISCUSSION: In Tunisia, an important need exists to further develop proximity health services and to address the growing mental health treatment gap. One solution is to train GPs in the detection, treatment, and management of mental health problems, given their strategic role in the healthcare system. This trial thus aims to implement and evaluate an adapted version of a training based on the mhGAP-IG (version 1.0) in Tunis and Sousse before country-wide implementation and evaluation. Several contributions are envisioned: adding to the growing evidence on the mhGAP and its accompanying guide, especially in French-speaking nations; building research capacity in Tunisia and more generally in LMICs by employing rigorous designs; evaluating an adapted version of the mhGAP-IG (version 1.0) on a sample of GPs; generating important information regarding implementation process and study design before country-wide implementation; and complimenting the trial results with implementation analysis, a priority in global mental health.

[Quality of sleep in nursing home non-demented residents]. / La qualité du sommeil chez les résidents sans syndrome démentiel vivant en institution gériatrique.

PURPOSE: admission to nursing homes is often associated with major changes in the way the elderly live, possibly leading to sleep disorders. The aim of our study was to assess sleep quality in the elderly without dementia living in nursing homes, to determine the prevalence of sleep disorders, and to examine the links between sleep quality and sociodemographic features, comorbidities, and degree of dependency. METHODS: we carried out a cross-sectional survey, involving old people living in Manouba nursing home. Assessment of sleep was performed using Pittsburgh Sleep Quality Index. We excluded subjects with severe motor or sensory impairments as well as individuals with cognitive impairment. RESULTS: thirty-two patients were included in the study. The majority (68.8%) were male, institutionalized for an average period of 6.3 years. Mean age was 71.6 years. More than half of the subjects (56.3%) had depression, and 93.8% had one or more chronic conditions. About one third (37.5%) of residents were dependent in one or more activities of daily living and 25% were confined to bed or to a wheelchair. The majority of residents (73%) were identified as "poor sleepers" based on a global Pittsburgh Sleep Quality Index score >5. Sleep disorders were attributed to nocturia, nocturnal or premature awakenings and pain. We noted a fairly large percentage (18.8%) of hypnotic drugs intake among participants. Our results also showed a strong association between poor sleep quality and depression (p<0.001). CONCLUSION: early detection of sleep disorders in nursing home residents can help them to get an optimized and efficacious treatment.

[Validity and reliability of the Tunisian version of section G of the Composite International Diagnostic Interview, relative to schizophrenia]. / Validation de la section G du Composite International Diagnostic Interview relative à la schizophrénie, traduite au dialecte tunisien.

BACKGROUND: Early diagnosis of schizophrenia can improve its outcome. Hence, screening policies should be held and suitable tools must be available for general practitioners. AIM: To translate the section G (about schizophrenia) of the Composite International Diagnostic Interview to the Tunisian dialect and to check its validity and reliability. METHODS: The Arabic version of section G of the Composite International Diagnostic Interview has been translated to the Tunisian dialect by psychiatrists speaking fluently both languages. Metric features of the instrument (sensitivity, specificity and predictive values) were assessed by checking its results against those of the gold standard i.e. the expert's opinion owing to the criteria of the Diagnostical and Statistical Manual of mental disorders 3rd revised edition. Reliability has been measured by the index of observer agreement. RESULTS: The instrument showed a low sensitivity of 45% [32% - 58%] and a high specificity of 96% [93% - 99%]. It looked as a diagnostical test that can avoid wrong diagnoses of such a serious and stigmatizing illness. These values are similar or even better than those of literature. The observer agreement index was 0.83 showing a very good reliability. The interviews mean duration was 20 minutes. The instrument showed no variability towards the sex, the age or the educational level of interviewees. CONCLUSION: Even though section G of the Composite International Diagnostic Interview failed to detect most cases with schizophrenia and showed a poor sensitivity, this instrument can be useful for screening strategies carried out by lay interviewers in the general population.

[A descriptive study of the procedures of psychiatric admissions at Razi hospital]. / Etude descriptive des modalités d'hospitalisation en psychiatrie á l'hôpital Razi.

BACKGROUND: The law 92-83, has established the rights of the mentally ill to respect for individual freedom and to appropriate care. However some gaps in its implementation led to the revision by Act 2004-40. AIM: To study the evolution of the number of admissions with and without consent (hospitalizations at the request of a third party and compulsory hospitalizations), between 2000 and 2009. METHODS: Retrospective study of the archives of the mental health unit of Razi hospital. The study population included inpatients under the mode of voluntary and involuntary admission either compulsory hospitalizations or at the request of a third party. RESULTS: An increase in the number of hospitalizations without the consent from 2000 to 2009 was noted. The number of compulsory hospitalizations and the one of hospitalizations at the request of a third party rose respectively from 1,048 to 1,443 and from 22 to 1,323. So the number of free hospitalizations has decreased while the number of involuntary hospitalizations has increased, leading to a constant number of total hospitalizations. The sex ratio for compulsory hospitalizations has increased from 2.04 to 5.83 while it markedly decreased for hospitalizations at the request of a third party (from 10 to 1.7).Men, unlike women, were more likely to be hospitalized compulsorily than at the request of a third party. CONCLUSION: There is a larger use of hospital admissions under constraints than free ones; is it due to a concern for the respect of law or an abuse in the deprivation of freedom for some patients?

[Effectiveness of acupuncture in treating schizophrenia: a clinical randomized trial of 31 patients]. / Apport de l'acupuncture dans le traitement de la schizophrénie : etude randomisée en double-aveugle portant sur 31 patients

BACKGROUND: Acupuncture is one of the most popular types of complementary/alternative medicine in the world. It is sometimes used as a treatment for schizophrenia mainly in China. AIM: To assess the contribution of acupuncture in the treatment of patients treated for schizophrenia in Tunisian population. METHODS: Our study is a clinical randomized trial about 31 hospitalized patients with schizophrenia or schizo-affectif disorder (DSM IV). They were evaluated by the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS) the first and 23nd day of the study. Manual acupuncture was used for 10 sessions at the rate of three sessions per week. All patients were under drug therapy. Among them, 15 were treated by acupuncture and 16 by sham acupuncture. RESULTS: Scores of the PANSS, SAPS and SANS were similar in the two groups at the end of the study. CONCLUSION: Our study did not provide any evidence for the effectiveness of acupuncture in treating schizophrenic symptoms.

Plasma homocysteine in schizophrenia: determinants and clinical correlations in Tunisian patients free from antipsychotics.

The existence of association between hyperhomocysteinaemia (HHC) and schizophrenia has been suggested by several recent studies. This study aimed to determine the prevalence of HHC and its main determinants, and sought a correlation with clinical features in Tunisian patients with schizophrenia. Plasma homocysteine (Hcy), folate, and vitamin B12, as well as the C677T methylene tetrahydrofolate reductase (MTHFR) polymorphism, were studied in 33 patients with schizophrenia, all free from antipsychotic treatment, and 35 age- and smoking-habit-matched healthy subjects as controls. Biochemical determinations and psychometric evaluations were carried out in patients before the administration of antipsychotics. The prevalence of HHC was higher and plasma B12 vitamin was significantly lower in patients. There was no significant difference in genotypic distribution and allelic frequency of the C677T MTHFR polymorphism between groups. Hcy was significantly correlated to the 'anhedonia-asociality' subscales of the Scale for the Assessment of Negative Symptoms (SANS). This study showed an association between HHC and schizophrenia, especially with the negative symptoms of the disease. In the Tunisian population, HHC in schizophrenia seems to be linked to vitamin B12 deficiency, likely caused by a lack of dietary animal proteins.

[Validation of a school children addictive behaviors questionnaire]. / Validation d'un questionnaire d'addiction en milieu scolaire.

UNLABELLED: The aim was to develop and validate an addictive behaviors screening tool in school children. METHODOLOGY: A cross sectional study including a self administrated 223 item questionnaire developed in Arabic language. The questionnaire included identification of the student and seven life domains: school, family, addiction, relationships with peers, leisure and well being, risky behaviors and personality traits. N=854 high school children. of Monastir City. RESULTS: the questionnaire Alpha Cronbach's Coefficient ranged between 0.3 and 0.8. Only items with a coefficient higher than 0.6 were maintained in the final version. The time reliability by using the Bland and Altman method 15 days after the first measure showed a Pearson's coefficient of 0.81. Validity evaluated by principal components analysis led to 3 independent factors consisting respectively in 20, 4 and 3 well correlated items: family, school and risky behaviors. CONCLUSION: validated version of the questionnaire consisted in 102 items, easy to read and understand. This version doesn't require much time to be filled in and takes into consideration cultural particularities of the school children of Monastir. It could be considered as an interesting tool for both the assessment and the prevention of addictive behaviors in school.