Evaluating clinical outcomes of routinely delivered task-shared care for depression in rural Haiti.

BACKGROUND: There is a growing literature in support of the effectiveness of task-shared mental health interventions in resource-limited settings globally. However, despite evidence that effect sizes are greater in research studies than actual care, the literature is sparse on the impact of such interventions as delivered in routine care. In this paper, we examine the clinical outcomes of routine depression care in a task-shared mental health system established in rural Haiti by the international health care organization Partners In Health, in collaboration with the Haitian Ministry of Health, following the 2010 earthquake. METHODS: For patients seeking depression care betw|een January 2016 and December 2019, we conducted mixed-effects longitudinal regression to quantify the effect of depression visit dose on symptoms, incorporating interaction effects to examine the relationship between baseline severity and dose. RESULTS: 306 patients attended 2052 visits. Each visit was associated with an average reduction of 1.11 in depression score (range 0-39), controlling for sex, age, and days in treatment (95% CI -1.478 to -0.91; p < 0.001). Patients with more severe symptoms experienced greater improvement as a function of visits (p = 0.04). Psychotherapy was provided less frequently and medication more often than expected for patients with moderate symptoms. CONCLUSIONS: Our findings support the potential positive impact of scaling up routine mental health services in low- and middle-income countries, despite greater than expected variability in service provision, as well as the importance of understanding potential barriers and facilitators to care as they occur in resource-limited settings.

A validation study of the Zanmi Lasante Depression Symptom Inventory (ZLDSI) in a school-based study population of transitional age youth in Haiti.

BACKGROUND: The Zanmi Lasante Depression Symptom Inventory (ZLDSI) is a screening tool for major depression used in 12 primary care clinics in Haiti's Central Plateau. Although previously validated in a clinic-based sample, the present study is the first to evaluate the validity and clinical utility of the ZLDSI for depression screening in a school-based population in central Haiti. METHODS: We assessed depressive symptoms in a school-based sample of transitional age youth (18-22 years; n = 120) with the ZLDSI. Other mental health-related assessments included a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) for current Major Depressive Episode, the Center for Epidemiologic Studies Depression Scale, and selected items adapted from the Global School-Based Health Survey mental health module. Diagnostic assignments of major depressive episode (MDE) were based on modified SCID interviews. RESULTS: The ZLDSI demonstrated good overall accuracy in identifying current MDE (Area under the Curve = .92, 95% CI = .86, .98, p < .001). We ascertained ≥12 as the optimal cut-off point to screen for depression with a sensitivity of 100% and a specificity of 73.9%. In addition, the ZLDSI was associated with other measures of depressive symptoms, suggesting that it demonstrates construct validity. CONCLUSIONS: Study findings support that the ZLDSI has clinical utility for screening for depression among school-going transitional age youth.

Prevalence of stressful life events and their association with post-traumatic stress disorder among youth attending secondary school in Haiti.

The association between earthquakes and youth post-traumatic stress disorder (PTSD) has been well described, but little is known about the relationship between other stressful life events (SLEs) and PTSD among earthquake-affected youth. This study examines a variety of SLEs, including earthquake, and their association with PTSD among school-going Haitian youth following a major earthquake in 2010. In 2013, we assessed 120 students ages 18-22 for PTSD and other SLEs using a modified Structured Clinical Interview for DSM-IV (SCID)-based interview and the Stressful Life Events Checklist (SLE Checklist). Only 51.7% of participants on the SLE Checklist and 31.7% in the interview endorsed being affected by the earthquake or another disaster. Sexual assault showed the strongest association with PTSD in multivariable logistic regression. Contrary to our hypothesis, exposure to earthquake or another disaster was not significantly associated with current PTSD. In this population, exposure to interpersonal violence may have had a greater impact on PTSD risk than exposure to natural disaster. These data underscore the need to examine and reduce both acute and chronic stressors among disaster-affected youth.

A mobile clinic approach to the delivery of community-based mental health services in rural Haiti.

This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic's first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic's lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.

Formative research on a teacher accompaniment model to promote youth mental health in Haiti: Relevance to mental health task-sharing in low-resource school settings.

BACKGROUND: Task-sharing with teachers to promote youth mental health is a promising but underdeveloped strategy in improving care access in low-income countries. AIMS: To assess feasibility, acceptability and utility of the teacher accompaniment phase of a school-based Teacher- Accompagnateur Pilot Study (TAPS) in Haiti. METHODS: We assigned student participants, aged 18-22 years ( n = 120), to teacher participants ( n = 22) within four Haitian schools; we instructed participants to arrange meetings with their assigned counterparts to discuss mental health treatment, academic skills, and/or well-being. We measured student and teacher perceived feasibility, acceptability and utility of meetings with self-report Likert-style questions. We examined overall program feasibility by the percentage of students with a documented meeting, acceptability by a composite measure of student satisfaction and utility by the percentage with identified mental health need who discussed treatment with a teacher. RESULTS: Favorable ratings support feasibility, acceptability and utility of teacher- accompagnateur meetings with students. The majority of students (54%) met with a teacher. Among students with an identified mental disorder, 43.2% discussed treatment during a meeting. CONCLUSION: This accompaniment approach to mental health task-sharing with teachers provided a school-based opportunity for students with mental health need to discuss treatment and has potential relevance to other low-income settings.

High burden of mental illness and low utilization of care among school-going youth in Central Haiti: A window into the youth mental health treatment gap in a low-income country.

BACKGROUND: The mental health treatment gap for youth in low- and middle-income countries (LMICs) is substantial; strategies for redress are urgently needed to mitigate the serious health and social consequences of untreated mental illness in youth. AIMS: To estimate the burden of major depressive episode (MDE) and posttraumatic stress disorder (PTSD) as well as utilization of care among Haitian youth in order to describe the mental health treatment gap in a LMIC setting. METHODS: We estimated the point prevalence of MDE, PTSD, and subthreshold variants in a school-based sample of youth ( n = 120, ages 18-22 years) using a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID)-based interview and examined treatment utilization among those receiving one of these diagnoses. We assessed additional psychopathology with self-report measures to examine validity of study diagnostic assignments. RESULTS: The combined prevalence of full-syndrome or subthreshold MDE or PTSD was high (36.7%). A large majority of affected individuals (88.6%) had accessed no mental health services in the health sector, and 36.4% had accessed no care of any kind in either the health or folk sectors in the past year. CONCLUSION: Findings demonstrate a high mental health burden among Haiti's youth and that many youth with MDE and PTSD are not accessing mental health care.