Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria.

PURPOSE: This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process. METHODS: This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews. RESULTS: Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers. CONCLUSIONS: Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers. TRIAL REGISTRATION: This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .

Debate: Involuntary treatment and detention are a necessary part of mental health care - a perspective from low and middle-income countries.

Mental health care is underpinned by human rights. However, certain mental health presentations can be associated with increased risk to self or others. Thus, appropriate and effective care plan to mitigate the risk may include a temporary restriction of the person's human rights. Legal frameworks are required to ensure appropriate safeguards for the affected person, and clarity about boundaries of necessity and proportionality for clinicians. The restriction needs to be proportionate, for the shortest possible period, done in a humane manner, and in a safe environment. Effective early mental interventions can reduce need for human right restrictions by preventing acute escalations in risk-related behaviours. While these principles apply across all regions, we discuss the particular circumstances in low and middle-income countries.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries.

BACKGROUND: There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES: To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS: Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS: Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS: The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Aftermath of anti-police protests in Nigeria: Burden and predictors of psychiatric morbidity among protesters and non-protesters.

OBJECTIVES: Anti-police (#EndSARS) protests took place in October 2020 across several Nigerian cities, resulting in deaths, injuries and loss of property, but the psychological sequelae of these protests have not been studied. METHOD: In a cross-sectional online survey, we collected data on psychiatric morbidity and potential risk factors from 426 Nigerian social media users, who self-identified as participants or non-participants in a recent anti-police protest. RESULTS: We found elevated rates of psychiatric morbidity, with worse outcomes for protesters compared to non-protesters (psychological distress [44.2% vs 29.8%], depression [26.0% vs 14.9%], anxiety [51.0% vs 29.8%], post-traumatic stress disorder [7.4% vs 1.8%], current substance use [11.2% vs 4.5%] and suicidal ideation [7.1% vs 4.4%], respectively). After adjusting for the effects of COVID-19 pandemic and previous mental health diagnosis, the predictors of poor mental health among non-protesters were being unmarried (odds ratio = 7.4, p = 0.01) and low resilience (odds ratio range = 4.1-5.4, p < 0.03) while for the protesters, the predictors were low resilience (odds ratio range = 2.9-4.7, p < 0.01), being from Northern Nigeria (odds ratio = 4.7, p < 0.01) or residing in Northern Nigeria (odds ratio = 2.8, p = 0.03), being under-/unemployed (odds ratio range = 2.1-2.5, p < 0.04), holding the view that the protest was caused by the state of the economy (odds ratio = 2.0, p = 0.01), belief that the protest had a direct negative impact on the protester (odds ratio = 2.3, p = 0.04) and willingness to participate in future protests (odds ratio = 4.13, p = 0.02). CONCLUSION: We conclude that participating in the #EndSARS protest was associated with significant psychiatric morbidity. There is need to recognise and address the mental health sequelae of collective actions, and invest in programmes that build resilience and address socio-political determinants of mental health, especially with a focus on youth.

Escaping social rejection, gaining total capital: the complex psychological experience of female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria.

BACKGROUND: While the deleterious effects of FGM/C on physical health are well documented, the psychological experience of this harmful practice is a neglected area of research, which limits global mental health actions. As FGM/C was a traditional practice in some areas of Nigeria, the study aimed to understand the psychological experience of FGM/C in context. METHODS: This qualitative study was completed in urban and rural Izzi communities in Southeast Nigeria where FGM/C was widely practiced. In-depth interviews were completed with 38 women of the same ethnicity using the McGill Illness Narrative Interview (MINI) to explore the collective psychological experience of FGM/C before, during and after the procedure. The MINI was successfully adapted to explore the meaning and experience of FGM/C. We completed thematic content analysis and used the concepts of total capital and habitus by Bourdieu to interpret the data. RESULTS: During the period of adolescence, Izzi young women who had not yet undergone FGM/C reported retrospectively being subjected to intense stigma, humiliation and rejection by their cut peers. Alongside the social benefits from FGM/C the ongoing psychological suffering led many to accept or request to be cut, to end their psychological torture. Virtually all women reported symptoms of severe distress before, during and after the procedure. Some expressed the emotion of relief from knowing their psychological torture would end and that they would gain social acceptance and total capital from being cut. Newly cut young women also expressed that they looked forward to harassing and stigmatizing uncut ones, therein engaging in a complex habitus that underscores their severe trauma as well as their newly acquired enhanced social status. CONCLUSION: FGM/C is profoundly embedded in the local culture, prevention strategies need to involve the whole community to develop preventive pathways in a participatory way that empowers girls and women while preventing the deleterious psychological effects of FGM/C and corresponding stigma. Results suggest the need to provide psychological support for girls and women of practicing Izzi communities of Southeast Nigeria.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

BACKGROUND: Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. AIMS: To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. METHOD: Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. RESULTS: A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. CONCLUSIONS: Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

Common mental health problems and associated factors among medical students of University of Ibadan, Nigeria.

BACKGROUND: The burden of mental health problems among medical students is on the increase especially when compared with their counterparts in other disciplines. This has counterproductive impact on the society. Understanding the prevalence and predictors of common mental health problems can inform early intervention to curb this menace. AIMS: This study was conducted to determine the prevalence, pattern and correlates of common mental health problems (anxiety and depression) amongst medical students of the University of Ibadan, Nigeria. METHODOLOGY: A descriptive cross-sectional survey was conducted among 690 pre-clinical and clinical medical students of the University of Ibadan. Data were analyzed using descriptive statistics, Chi-square test and binary logistic regression at p < 0.05. RESULTS: The prevalence of anxiety and depression were 26.5% and 10.1%, respectively, with 6.8% having both. Perceived risk factors included overwhelming academic workload (65.2%) and failure to meet up with academic expectations (64.1%). The predictors of comorbid anxiety and depression were: polygamous family setting (OR 2.7: 95% CI: 1.156-6.536) and preclinical studentship (OR: 6.2; 95% CI: 2.282-16.868). CONCLUSION: This study shows that the prevalence of mental health problems is high among medical students.

Becoming a Xhosa traditional healer: The calling, illness, conflict and belonging.

BACKGROUND: Traditional healers (THs) are an important part of the healthcare system in sub-Saharan Africa. Understanding their training, experiences of becoming healers and their perceived roles in society is critical. AIM: This study aimed to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs. SETTING: This study was conducted amongst Xhosa THs in the Western Cape, South Africa. METHODS: In-depth phenomenological interviews (n = 4) were conducted with Xhosa THs and analysed using Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis. RESULTS: The experience of becoming a TH can be summarised in the context of three units of significance: (1) the gift of healing as an illness; (2) the experience of conflict (including with their families, the church and self-conflict); and (3) the experience of belonging. Familial conflict, specifically, was fuelled by the financial burden of becoming a TH and a lack of understanding of the process. CONCLUSION: To develop a workable model of collaboration in the future, it is crucial that mental healthcare providers develop a better understanding of the experiences of THs in becoming care providers. The findings highlight an appreciation of the challenging process of becoming a TH. Finally, further research and culturally appropriate psychoeducation can provide trainee THs and their family members with the skills and knowledge to support each other through a difficult process.

Treatment gap for anxiety disorders is global: Results of the World Mental Health Surveys in 21 countries.

BACKGROUND: Anxiety disorders are a major cause of burden of disease. Treatment gaps have been described, but a worldwide evaluation is lacking. We estimated, among individuals with a 12-month DSM-IV (where DSM is Diagnostic Statistical Manual) anxiety disorder in 21 countries, the proportion who (i) perceived a need for treatment; (ii) received any treatment; and (iii) received possibly adequate treatment. METHODS: Data from 23 community surveys in 21 countries of the World Mental Health (WMH) surveys. DSM-IV mental disorders were assessed (WHO Composite International Diagnostic Interview, CIDI 3.0). DSM-IV included posttraumatic stress disorder among anxiety disorders, while it is not considered so in the DSM-5. We asked if, in the previous 12 months, respondents felt they needed professional treatment and if they obtained professional treatment (specialized/general medical, complementary alternative medical, or nonmedical professional) for "problems with emotions, nerves, mental health, or use of alcohol or drugs." Possibly adequate treatment was defined as receiving pharmacotherapy (1+ months of medication and 4+ visits to a medical doctor) or psychotherapy, complementary alternative medicine or nonmedical care (8+ visits). RESULTS: Of 51,547 respondents (response = 71.3%), 9.8% had a 12-month DSM-IV anxiety disorder, 27.6% of whom received any treatment, and only 9.8% received possibly adequate treatment. Of those with 12-month anxiety only 41.3% perceived a need for care. Lower treatment levels were found for lower income countries. CONCLUSIONS: Low levels of service use and a high proportion of those receiving services not meeting adequacy standards for anxiety disorders exist worldwide. Results suggest the need for improving recognition of anxiety disorders and the quality of treatment.

Suicidal thoughts and behaviors among college students and same-aged peers: results from the World Health Organization World Mental Health Surveys.

PURPOSE: The primary aims are to (1) obtain representative prevalence estimates of suicidal thoughts and behaviors (STB) among college students worldwide and (2) investigate whether STB is related to matriculation to and attrition from college. METHODS: Data from the WHO World Mental Health Surveys were analyzed, which include face-to-face interviews with 5750 young adults aged 18-22 spanning 21 countries (weighted mean response rate = 71.4%). Standardized STB prevalence estimates were calculated for four well-defined groups of same-aged peers: college students, college attriters (i.e., dropouts), secondary school graduates who never entered college, and secondary school non-graduates. Logistic regression assessed the association between STB and college entrance as well as attrition from college. RESULTS: Twelve-month STB in college students was 1.9%, a rate significantly lower than same-aged peers not in college (3.4%; OR 0.5; p < 0.01). Lifetime prevalence of STB with onset prior to age 18 among college entrants (i.e., college students or attriters) was 7.2%, a rate significantly lower than among non-college attenders (i.e., secondary school graduates or non-graduates; 8.2%; OR 0.7; p = 0.03). Pre-matriculation onset STB (but not post-matriculation onset STB) increased the odds of college attrition (OR 1.7; p < 0.01). CONCLUSION: STB with onset prior to age 18 is associated with reduced likelihood of college entrance as well as greater attrition from college. Future prospective research should investigate the causality of these associations and determine whether targeting onset and persistence of childhood-adolescent onset STB leads to improved educational attainment.

Quality of perinatal depression care in primary care setting in Nigeria.

BACKGROUND: Even though integrating mental health into maternal and child health (MCH) is widely accepted as a means of closing the treatment gap for maternal mental health conditions in low- and middle-income countries (LMIC), there are not many studies on the quality of the currently available mental health care for mothers in these countries. This study assessed the existing organization of service for maternal mental health, the actual care delivered for perinatal depression, as well as the quality of the care received by affected women presenting to primary care clinics in Ibadan, Nigeria. METHODS: The Assessment of Chronic Illness Care (ACIC) tool was administered to the staff in 23 primary maternal care clinics and key informant interviews were conducted with 20 facility managers to explore organizational and administrative features relevant to the delivery of maternal mental health care in the facilities. Detection rate of perinatal depression by maternal care providers was assessed by determining the proportion of depressed antenatal women identified by the providers. The women were then followed up from the antenatal period up until 6 months after childbirth to track their experience with care received. RESULTS: All the facilities had ACIC domain scores indicating poor capacity to offer quality chronic care. Emerging themes from the interviews included severe manpower shortage and absence of administrative and clinical support for manpower training and care provision. Only 31 of the 218 depressed women had been identified by the maternal care providers as having a psychological problem throughout the follow-up period. In spite of the objective evidence of inadequate care, most of the perinatal women rated the service provided in the facilities as being of good quality (96%) and reported being satisfied with the care received (98%). CONCLUSION: There are major inadequacies in the organisational and administrative profile of these primary maternal care facilities that militate against the provision of quality chronic care. These inadequacies translate to a large treatment gap for women with perinatal depression. Lack of awareness by service users of what constitutes good quality care, indicative of low service expectation, may hamper user-driven demand for quality improvement.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries.

PURPOSE: There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes. METHODS: This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models. RESULTS: A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio. CONCLUSION: Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Building the capacity of policy-makers and planners to strengthen mental health systems in low- and middle-income countries: a systematic review.

BACKGROUND: Little is known about the interventions required to build the capacity of mental health policy-makers and planners in low- and middle-income countries (LMICs). We conducted a systematic review with the primary aim of identifying and synthesizing the evidence base for building the capacity of policy-makers and planners to strengthen mental health systems in LMICs. METHODS: We searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, ScieELO, Google Scholar and Cochrane databases for studies reporting evidence, experience or evaluation of capacity-building of policy-makers, service planners or managers in mental health system strengthening in LMICs. Reports in English, Spanish, Portuguese, French or German were included. Additional papers were identified by hand-searching references and contacting experts and key informants. Database searches yielded 2922 abstracts and 28 additional papers were identified. Following screening, 409 full papers were reviewed, of which 14 fulfilled inclusion criteria for the review. Data were extracted from all included papers and synthesized into a narrative review. RESULTS: Only a small number of mental health system-related capacity-building interventions for policy-makers and planners in LMICs were described. Most models of capacity-building combined brief training with longer term mentorship, dialogue and/or the establishment of networks of support. However, rigorous research and evaluation methods were largely absent, with studies being of low quality, limiting the potential to separate mental health system strengthening outcomes from the effects of associated contextual factors. CONCLUSIONS: This review demonstrates the need for partnership approaches to building the capacity of mental health policy-makers and planners in LMICs, assessed rigorously against pre-specified conceptual frameworks and hypotheses, utilising longitudinal evaluation and mixed quantitative and qualitative approaches.

Gender-Based Violence following Social Media Acquaintance in Nigeria.

In Nigeria, the growth in mobile phone use has provided the opportunity for increased access to the internet, and through this, the social media. The social media in turn offers tremendous communication benefits but also results in some undesirable consequences. One of such is the experience of Gender-Based Violence (GBV). Internet searches using Google Search and Google Scholar in addition to information available to the authors from news media is reported in this study. Five cases were selected for reporting. All cases selected had first contact with their perpetrator(s) on Facebook. The perpetrators were usually men, older than the victims (24-34 years for perpetrators compared with 17-25 years for the victims). The victims experienced physical, psychological, sexual and economic violence from their aggressors. One case resulted in the death of the victim, while two required hospitalization following severe trauma. Three of the victims were raped, while rape was attempted for the other two cases. GBV associated with acquaintances made on social media channels is emerging as a new social problem in Nigeria. Interventions to educate female social media users about this potential danger are urgently necessary.

Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide.

BACKGROUND: The World Mental Health Surveys conducted by the World Health Organization (WHO) have shown that huge treatment gaps for severe mental disorders exist in both developed and developing countries. This gap is greatest in low and middle income countries (LMICs). Efforts to scale up mental health services in LMICs have to contend with the paucity of mental health professionals and health facilities providing specialist services for mental, neurological and substance use (MNS) disorders. A pragmatic solution is to improve access to care through the facilities that exist closest to the community, via a task-shifting strategy. This study describes a pilot implementation program to integrate mental health services into primary health care in Nigeria. METHODS: The program was implemented over 18 months in 8 selected local government areas (LGAs) in Osun state of Nigeria, using the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), which had been contextualized for the local setting. A well supervised cascade training model was utilized, with Master Trainers providing training for the Facilitators, who in turn conducted several rounds of training for front-line primary health care workers. The first set of trainings by the Facilitators was supervised and mentored by the Master Trainers and refresher trainings were provided after 9 months. RESULTS: A total of 198 primary care workers, from 68 primary care clinics, drawn from 8 LGAs with a combined population of 966,714 were trained in the detection and management of four MNS conditions: moderate to severe major depression, psychosis, epilepsy, and alcohol use disorders, using the mhGAP-IG. Following training, there was a marked improvement in the knowledge and skills of the health workers and there was also a significant increase in the numbers of persons identified and treated for MNS disorders, and in the number of referrals. Even though substantial retention of gained knowledge was observed nine months after the initial training, some level of decay had occurred supporting the need for a refresher training. CONCLUSION: It is feasible to scale up mental health services in primary care settings in Nigeria, using the mhGAP-IG and a well-supervised cascade-training model. This format of training is pragmatic, cost-effective and holds promise, especially in settings where there are few specialists.

Pattern of experienced and anticipated discrimination among people with depression in Nigeria: a cross-sectional study.

PURPOSE: Stigma is commonly encountered by individuals with mental illness and leads to discrimination. These phenomena restrict access to and use of mental health care services. This study evaluated the impact of stigma and discrimination among individuals with major depression in Nigeria. METHODS: A cross-sectional study was conducted across four tertiary psychiatric facilities located in different regions of Nigeria. Consenting adults attending the psychiatric units in the participating sites with a diagnosis of a major depressive disorder and having an episode within the past 12 months were recruited. Interviews were conducted using a socio-demographic questionnaire, the Discrimination and Stigma Scale, the Internalized Stigma of Mental Illness Scale, the Boston University Self Empowerment Scale, and the Rosenberg Self Esteem Scale. RESULTS: One hundred and three interviews were completed. The mean age of the participants was 35.5 years. The most frequent item for experienced discrimination was being unfairly treated in dating or intimate relationships (13.6%), while concealment of mental illness was the most common for anticipated discrimination (51.5%). Younger people (age less than 40 years) with a higher level of education appear to be at high risk for experienced discrimination. CONCLUSIONS: Important suggestions may be derived for clinicians, caregivers, and policy makers to appreciate the role of stigma in the burden, treatment, and rehabilitation of individuals with depression, especially for younger people with higher level of education.

Global prevalence of depression in chronic kidney disease: a systematic review and meta-analysis.

BACKGROUND: Chronic kidney disease (CKD) is commonly associated with psychosocial problems, especially depression, contributing to poor overall outcomes. Depression has not been given adequate priority in the management of CKD patients despite its significant adverse impact on all major outcomes. This systematic review and meta-analysis determined the pooled prevalence of clinical depression in the global CKD population and sub-populations. METHODS: PubMed, African Journals Online (AJOL), and EMBASE were systematically searched to identify published articles with relevant data. The pooled prevalence of clinical depression in the global CKD population was determined using random effects meta-analytic techniques. The study protocol was registered with PROSPERO (CRD42022382708). RESULTS: Sixty-five articles were included in this review, comprising 80,932 individuals with CKD from 27 countries. The participants' mean age ranged from 11.0 to 76.3 years. Most (70.4%) of the studies had medium methodological quality. The overall pooled prevalence of depression was 26.5% (95% CI 23.1-30.1%). Studies using the Diagnostic Statistical Manual for Mental Diseases (DSM) and International Classification of Disease (ICD) returned a pooled prevalence of 25.5% and 39.6%, respectively, p = 0.03. There was a significant difference in the pooled prevalence across regions; p = 0.002.The prevalence of depression was higher among individuals on chronic hemodialysis compared to pre-dialysis patients (29.9% versus 18.5%; p = 0.01) and among those on hemodialysis compared to peritoneal dialysis (30.6% versus 20.4%; p = 0.04). There was no significant difference between adults and children (26.8% versus 15.9%, p = 0.21). There was an increasing temporal trend in depression prevalence, though this did not achieve statistical significance (p = 0.16). CONCLUSION: Depression is common in patients with CKD. The findings of this study highlight the need for clinicians to make efforts to evaluate individuals with CKD for depression, especially those with advanced stages of the disease.

Task-sharing psychosocial interventions for the prevention of common mental disorders in the perinatal period in low- and middle-income countries: A systematic review and meta-analysis.

AIM: to assess the efficacy of psychosocial interventions delivered through task-sharing approaches for preventing perinatal common mental disorders among women in low- and middle-income countries. METHODS: We conducted a systematic review of randomized controlled trials following a prespecified protocol registered in the Open Science Framework (osf.io/qt4y3). We searched MEDLINE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL) through June 2022. Two reviewers independently extracted the data and evaluated the risk of bias of included studies using the Cochrane risk of bias tool. We performed random-effects meta-analyses and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: We included 23 studies with 24,442 participants. At post-intervention, task-shared psychosocial interventions, were effective in preventing the development of mental disorders in general (RR 0.57, 95% CI [0.35, 0.91]), and specifically depression (RR 0.51, 95% CI [0.35, 0.75]), but not anxiety disorders (RR 0.46, 95% CI [0.06, 3.33]). Similarly, psychosocial interventions reduced psychological distress (SMD -1.32, 95% CI [-2.28, -0.35]), and depressive symptoms (SMD -0.50, 95% CI [-0.80, -0.16]), and increased parenting self-efficacy (SMD -0.76, 95% CI [-1.13, -0.38]) and social support (SMD -0.72, 95% CI [-1.22, -0.22]). No effect was detected for anxiety symptoms at post-intervention. At follow-up the beneficial effects of interventions progressively decreased. CONCLUSIONS: Psychosocial interventions delivered through the task-sharing modality are effective in preventing perinatal common mental disorders and fostering positive mental health among women in low- and middle-income countries. However, our findings are tentative, due to the low number of preventative intervention strategies considering outcomes as the incidence of mental disorders, especially in the long-term. This evidence supports calls to implement and scale up psychosocial prevention interventions for perinatal common mental disorders in low- and middle-income countries.

Cascade training for scaling up care for perinatal depression in primary care in Nigeria.

BACKGROUND: Task-shared care is a demonstrated approach for integrating mental health into maternal and child healthcare (MCH) services. Training and continued support for frontline providers is key to the success of task sharing initiatives. In most settings this is provided by mental health specialists. However, in resource constrained settings where specialists are in short supply, there is a need to explore alternative models for providing training and supportive supervision to frontline maternal care providers. This paper reports on the impact of a cascade training (train-the-trainers) approach in improving the knowledge and attitudes of primary healthcare workers (PHCW) to perinatal depression. METHODS: Senior primary health care providers selected from across participating local government areas were trained to provide training to other PHCWs. The training sessions facilitated by these trainers were observed and rated for fidelity by specialist trainers, while the trainees provided their impression of and satisfaction with the training sessions using predesigned assessment forms. Training outcomes assessed included knowledge of depression (using mhGAP training questions and knowledge of depression questionnaire) and attitude towards providing care for depression (revised depression attitude questionnaire (R-DAQ)) measured pre and post training as well as six months after training. RESULTS: Trainees were 198 PHCWs (94.4% female), who routinely provide MCH services in 28 selected primary care clinics and had between 6- and 34-years' experience. Training was provided by 11 trained trainers who were general physicians or senior nurses. Training sessions were rated high in fidelity and on training style. Sessions were rated excellent by 77.8% of the trainees with the trainers described as knowledgeable, effective and engaging. Knowledge of depression mean score improved from a pre-training level of 12.3 ± 3.5 to 15.4 ± 3.7, immediately post-training and 14.7 ± 3.2, six months post-training (both comparisons: p < 0.001). The proportion of PHCW workers endorsing statements indicative of positive attitudes on the professional confidence and the generalist perspective modules of the R-DAQ also increased with training. CONCLUSION: Our findings suggest that cascade training can be an effective model for rapidly providing training and upskilling frontline PHCWs to deliver care for women with perinatal depression in resource limited settings. TRIAL REGISTRATION: This study was retrospectively registered 03 December 2019. https://doi.org/10.1186/ISRCTN 94,230,307.

Assessment of anxiety and depression, and coping mechanisms during COVID-19 lockdown among pregnant women.

Background: COVID-19 lockdown was associated with disruption of daily life, economy, essential health services including maternal health service, and psychological reflexes such as panic, sleep disorders, fear, anxiety, and depression. Aim: To assess the perception of pregnant women on the COVID-19 pandemic lockdown and the prevalence of common mental health disorders (CMHD) among pregnant women. Methods: A cross-sectional study was conducted among 380 pregnant women at the University College Hospital (UCH) Ibadan; participants were enrolled using a simple random sampling technique. Data was collected using pretested interviewer-administered questionnaire. Information obtained - sociodemographic and obstetric characteristics, perception and reaction to the COVID-19 pandemic and lockdown, effect on ANC, coping mechanisms, and presence of CMHD (anxiety and depression) were measured using Hospital Anxiety and Depression Scale (HADS). Data were analysed using STATA 16.0 Software. Descriptive and bivariate statistics were performed. The level of significance was p-value < 0.05. Results: The mean age was 32 ± 4.78 years, most respondents were <35 years (75%), married (97.1%), had a higher education (89%) and multiparous (70%). About 43.9% were worried that COVID-19 would affect pregnancy care, 42.9% reported it affected care and 81.6% were not worried it would affect the delivery care. Among respondents, 96.6% were able to cope with the effects of the pandemic and 96.8% enjoyed good social support. Respondents did not have CMHD (88.16%), 7.9% had CMHD (4.74% had depression and 3.16% had anxiety) and 3.95% had co-morbid depression and anxiety. On multinomial regression analysis, relative to anxiety or depression only, respondents with combined depression and anxiety had higher odds of having no delivery plan and thought COVID-19 may affect their delivery. Conclusion: Only a few women reported anxiety and depression symptoms during the lockdown and those with anxiety or combined symptoms of anxiety and depression had no birth plan and believed that COVID-19 would affect their delivery.