Cross-cultural equivalence of the Kessler Psychological Distress Scale (K10) across four African countries in a multi-national study of adults.

The Kessler Psychological Distress Scale (K10) has been widely used to screen psychological distress across many countries. However, its performance has not been extensively studied in Africa. The present study sought to evaluate and compare measurement properties of the K10 across four African countries: Ethiopia, Kenya, Uganda, and South Africa. Our hypothesis is that the measure will show equivalence across all. Data are drawn from a neuropsychiatric genetic study among adult participants (N = 9179) from general medical settings in Ethiopia (n = 1928), Kenya (n = 2556), Uganda (n = 2104), and South Africa (n = 2591). A unidimensional model with correlated errors was tested for equivalence across study countries using confirmatory factor analyses and the alignment optimization method. Results displayed 30 % noninvariance (i.e., variation) for both intercepts and factor loadings across all countries. Monte Carlo simulations showed a correlation of 0.998, a good replication of population values, indicating minimal noninvariance, or variation. Items "so nervous," "lack of energy/effortful tasks," and "tired" were consistently equivalent for intercepts and factor loadings, respectively. However, items "depressed" and "so depressed" consistently differed across study countries (R2 = 0) for intercepts and factor loadings for both items. The K10 scale likely functions equivalently across the four countries for most items, except "depressed" and "so depressed." Differences in K10 items were more common in Kenya and Ethiopia, suggesting cultural context may influence the interpretation of some items and the potential need for cultural adaptations in these countries.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia.

BACKGROUND: The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage. AIMS: To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia. METHOD: The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention. RESULTS: A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app. CONCLUSIONS: This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

Magnitude of paternal postpartum psychological distress and associated factors in Addis Ababa, Ethiopia: a facility-based cross-sectional study.

BACKGROUND: The psychological distress of fathers in the postpartum period can have adverse effects on the well-being of the family and the newborn's development in particular. However, fathers' mental health throughout the postpartum has remained understudied and clinically overlooked in many developing countries, including Ethiopia. This study aims to assess the prevalence of psychological distress among fathers in the postpartum period and to examine the associated factors in an Ethiopian population. METHODS: A facility-based, cross-sectional study was conducted at Tikur Anbessa Specialized Hospital (TASH) and Gandhi Memorial Hospital (GMH) in Addis Ababa, Ethiopia. A systematic sampling method was employed to include 280 fathers whose partners gave birth 6 to 8 weeks before the interview. Psychological distress was assessed using a validated Amharic version of the Kessler Psychological Distress Scale (K10) through a telephone interview. The collected data was analyzed using SPSS version 26. Descriptive statistics were used to summarize the data. Multivariable logistic regression was run to determine the variables associated with paternal postpartum psychological distress (K10 total score ≥ 7, a validated cut-off score in an urban Ethiopian setting), and odds ratio with 95% confidence intervals were obtained. A two-tailed p-value < 0.05 was considered for statistical significance. RESULTS: About one-fifth of the fathers endorsed having distress symptoms during the postpartum period. Those with lower income (AOR = 11.31, 95% CI:  4.10, 31.15), unintended pregnancy (AOR = 3.96, 95% CI: 1.02, 15.46), poor social support (AOR =3.28 95% CI: 1.43, 7.50), poor infantile health (AOR = 8.20, 95% CI: 2.35, 28.66)  and maternal postpartum distress (AOR = 12.10,  95% CI: 3.15, 46.48) had significantly higher odds of having paternal postpartum distress. CONCLUSIONS: Paternal postpartum distress was present in one-fifth of the fathers included in this study. This calls for due attention and efforts for early detection of those at risk of paternal distress and the development of interventions that consider their specific needs.

Understandings of depression among community members and primary healthcare attendees in rural Ethiopia: A qualitative study.

Available evidence in Africa suggests that the prevalence of depression in primary care settings is high but it often goes unrecognized. In this study, we explored how depression is conceptualized and communicated among community members and primary care attendees diagnosed with depression in rural Ethiopia with the view to informing the development of interventions to improve detection. We conducted individual interviews with purposively selected primary care attendees with depression (n = 28; 16 females and 12 males) and focus group discussions (FGDs) with males, females, and priests (n = 21) selected based on their knowledge of their community. Data were analyzed using thematic analysis. None of the community members identified depression as a mental illness. They considered depressive symptoms presented in a vignette as part of a normal reaction to the stresses of life. They considered medical intervention only when the woman's condition in the vignette deteriorated and "affected her mind." In contrast, participants with depression talked about their condition as illness. Symptoms spontaneously reported by these participants only partially matched symptoms listed in the current diagnostic criteria for depressive disorders. In all participants' accounts, spiritual explanations and traditional healing were prominent. The severity of symptoms mediates the decision to seek medical help. Improved detection may require an understanding of local conceptualizations in order to negotiate an intervention that is acceptable to affected people.

Under detection of depression in primary care settings in low and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Depression is one of the commonest mental disorders in primary care but is poorly identified. The objective of this review was to determine the level of detection of depression by primary care clinicians and its determinants in studies from low- to middle-income countries (LMICs). METHODS: A systematic review and meta-analysis was conducted using PubMed, PsycINFO, MEDLINE, EMBASE, LILAC, and AJOL with no restriction of year of publication. Risk of bias within studies was evaluated with the Effective Public Health Practice Project (EPHPP). "Gold standard" diagnosis for the purposes of this review was based on the 9-item Patient Health Questionnaire (PHQ-9; cutoff scores of 5 and 10), other standard questionnaires and interview scales or expert diagnosis. Meta-analysis was conducted excluding studies on special populations. Analyses of pooled data were stratified by diagnostic approaches. RESULTS: A total of 3159 non-duplicate publications were screened. Nine publications, 2 multi-country studies, and 7 single-country studies, making 12 country-level reports, were included. Overall methodological quality of the studies was good. Depression detection was 0.0% in four of the twelve reports and < 12% in another five. PHQ-9 was the main tool used: the pooled detection in two reports that used PHQ-9 at a cutoff point of 5 (combined sample size = 1426) was 3.9% (95% CI = 2.3%, 5.5%); in four reports that used PHQ-9 cutoff score of 10 (combined sample size = 5481), the pooled detection was 7.0% (95% CI = 3.9%, 10.2%). Severity of depression and suicidality were significantly associated with detection. CONCLUSIONS: While the use of screening tools is an important limitation, the extremely low detection of depression by primary care clinicians poses a serious threat to scaling up mental healthcare in LMICs. Interventions to improve detection should be prioritized. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016039704 .

Psychometric properties and factor structure of the Kessler-10 among Ethiopian adults.

BACKGROUND: Many common mental disorders are underdiagnosed and undertreated in low-resource countries. The ten-item Kessler Psychological Distress Scale (K10) is a brief screening tool widely used to assess psychological distress. We evaluated the K10's performance in an Ethiopian population by assessing internal consistency and construct validity through factor structure. METHODS: K10 survey responses and sociodemographic data were collected from 1928 adults, including patients and caregivers from a general medical setting, who served as controls of a large epidemiological study. RESULTS: The K10 had good internal consistency, with a Cronbach's alpha of 0.83. Results from exploratory factor analyses showed that the K10 had a two-factor solution that accounted for approximately 66% of the variance. Confirmatory factor analyses demonstrated that a unidimensional model with correlated errors, informed by a theoretical model, was the best fitting model for the setting (comparative fit index of 0.90 and root mean square error of approximation of 0.10). LIMITATIONS: We did not assess the K10's test-retest reliability or its criterion validity (i.e., agreement with a reference measure). CONCLUSIONS: Based on internal consistency and construct validity, the K10 can effectively assess psychological distress among Ethiopian adults for population-based research and potentially clinical screening, consistent with previous findings in this setting. Further studies are needed to test its criterion validity against a reference measure of psychological distress.

Measuring Traumatic Experiences in a Sample of Ethiopian Adults: Psychometric Properties of the Life Events Checklist-5.

Background: Traumatic events. e.g., road traffic accidents, violent conflicts, natural and human-made disasters, are common in sub-Saharan Africa. However, validated trauma screening tools to assess trauma at the individual level are lacking in many sub-Saharan African countries, such as Ethiopia, which limits accurate diagnosis and effective care provision. Objective: We sought to measure trauma exposure among cases and controls and evaluate the psychometric properties of the Life Event Checklist for DSM-5 (LEC-5) among Ethiopian adults. Method: This study included 4,183 participants (2,255 cases with a clinical diagnosis of psychosis and 1,928 controls without a history of psychosis) from the Neuropsychiatric Genetics of African Populations-Psychosis (NeuroGAP-Psychosis) study. We conducted exploratory factor analysis (EFA) to group the items into factors/subscales, and confirmatory factor analysis (CFA) to investigate the best model fit in Ethiopia. Result: 48.7% of participants reported exposure to at least one traumatic event. Physical assault (19.6%), sudden violent death (12.0%), and sudden accidental death (10.9%) were the three most common traumatic experiences. Cases were twice as likely to report experiences of traumatic events compared to controls (p<0.001). EFA revealed a four-factor/subscale model. CFA results indicated a theoretically-driven seven-factor model to be the preferred model by the goodness of fit (comparative fit index of 0.965 and Tucker-Lewis index of 0.951) and accuracy (root mean square error of approximation of 0.019). Conclusion: Exposure to traumatic events was common in Ethiopia, even more so for individuals with a diagnosis of psychotic disorders. The LEC-5 demonstrated good construct validity for measuring traumatic events among Ethiopian adults. Future studies that examine criterion validity and test-retest reliability of the LEC-5 in Ethiopia are warranted.

"Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia.

BACKGROUND: There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries. METHODS: We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data. RESULTS: There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. CONCLUSION: It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

Movement disorders in neuroleptic-naïve patients with schizophrenia spectrum disorders.

BACKGROUND: Spontaneous Movements Disorders (SMDs) or dyskinetic movements are often seen in patients with schizophrenia and other psychotic disorders, and are widely considered to be adverse consequences of the use of antipsychotic medications. Nevertheless, SMDs are also observed in the pre-neuroleptic ear and among patients who were never exposed to antipsychotic medications. The aim of this study was to determine the extent of SMDs among antipsychotic-naïve patients in a low income setting, and to evaluate contextually relevant risk factors. METHODS: The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting treatment-naïve patients with a diagnosis of schizophrenia, schizoaffective disorder and schizophreniform disorder contacting services for the first time were assessed using the Simpson-Angus Rating Scale (SAS) and the Abnormal Involuntary Movement Scale (AIMS) to evaluate the presence of SMDS. Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS) were administered to evaluate negative and positive symptom profiles respectively. Body mass index (BMI) was used as a proxy measure for nutritional status. RESULT: Sixty-four patients, 67.2% male (n = 43), with first contact psychosis who met the DSM-IV-TR criteria for schizophrenia (n = 47), schizophreniform disorder (n= 5), and schizoaffective disorder (n = 12) were assessed over a two month study period. Seven patients (10.9%) had SMDs. BMI (OR = 0.6, 95% CI = 0.40, 0.89; p = 0.011) and increasing age (OR = 1.10; 95% CI = 1.02, 1.20; p = 0.017) were associated with SMD. CONCLUSIONS: This finding supports previous suggestions that abnormal involuntary movements in schizophrenia and other psychotic disorders may be related to the pathophysiology of psychotic disorders and therefore cannot be attributed entirely to the adverse effects of neuroleptic medication.