The last decade has witnessed an exponential growth of evidence-based care packages for mental, neurological, and substance use disorders (MNS) aimed at primary care populations; however, few have ...been taken to scale. Several barriers to successful integration and scale-up, such as low acceptability, poor clinical engagement process, lack of targeted resources, and poor stakeholder and policy support have been cited. This review describes and highlights common features of some of the promising programmes that deliver mental health services through primary health clinics, communities, and digital platforms, with an emphasis on those that show some evidence of complete or partial scale-up. Three distinct overarching themes and initiatives are discussed in relation to the above; primary health facilities, community (outside of primary healthcare), and digital/internet-based platforms, with a focus on how the three may interact synergistically to enhance successful integration and scale-up.
...depression is a heterogeneous entity experienced with various combinations of signs and symptoms, severity levels, and longitudinal trajectories. ...core features of the condition have been ...described over thousands of years, long before the advent of contemporary classifications, and in diverse communities and cultures. More efficient prevention of depression is likely to have powerful impacts on the Sustainable Development Goals for a country and the health of individuals and families. 5 The experiences of depression and recovery are unique for each individual Depression is the result of a set of factors, typically the interaction of proximal adversities with genetic, social, environmental, and developmental risk and resilience factors. Empowering individuals, families, and communities to work with professionals who can learn from their experiences and help demand the implementation of known preventive and therapeutic strategies and to hold health-care systems and decision makers accountable is vital. 7 A formulation is needed to personalise care Detection and diagnosis of depression on the basis of symptoms, function, and duration should be accompanied by a clinical review or formulation for each person, which takes into account individual values and preferences, life stories, and circumstances.
Sub‐Saharan Africa (SSA) has the fastest growing adolescent population in the world. In addition to developmental changes, adolescents in SSA face health and socioeconomic challenges that increase ...their vulnerability to mental ill‐health. This paper is a narrative review of adolescent mental health (AMH) in SSA with a focus on past achievements, current developments, and future directions in the areas of research, practice and policy in the region. We describe the status of AMH in the region, critical factors that negatively impact AMH, and the ways in which research, practice and policy have responded to this need. Depression, anxiety and post‐traumatic stress disorders are the most common mental health problems among adolescents in SSA. Intervention development has largely been focused on HIV/AIDS service delivery in school or community programs by non‐specialist health workers. There is a severe shortage of specialised AMH services, poor integration of services into primary health care, lack of a coordinated inter‐sectoral collaboration, and the absence of clear referral pathways. Policies for the promotion of AMH have been given less attention by policymakers, due to stigma attached to mental health problems, and an insufficient understanding of the link between mental health and social determinants, such as poverty. Given these gaps, traditional healers are the most accessible care available to help‐seeking adolescents. Sustained AMH research with a focus on the socioeconomic benefits of implementing evidence‐based, contextually adapted psychosocial interventions might prove useful in advocating for much needed policies to improve AMH in SSA.
There is a dearth of validated tools measuring posttraumatic stress disorder (PTSD) in low and middle-income countries in sub-Saharan Africa. We validated the Shona version of the PTSD Checklist for ...DSM-5 (PCL-5) in a primary health care clinic in Harare, Zimbabwe.
Adults aged 18 and above attending the clinic were enrolled over a two-week period in June 2016. After obtaining written consent, trained research assistants administered the tool to eligible participants. Study participants were then interviewed independently using the Clinician Administered PTSD Scale (CAPS-5) as the gold standard by one of five doctors with training in mental health.
A total of 204 participants were assessed. Of these, 91 (44.6%) were HIV positive, 100 (49%) were HIV negative, while 13 (6.4%) did not know their HIV status. PTSD was diagnosed in 40 (19.6%) participants using the gold standard procedure. Using the PCL-5 cut-off of ≥33, sensitivity and specificity were 74.5% (95%CI: 60.4-85.7); 70.6% (95%CI: 62.7-77.7), respectively. The area under the ROC curve was 0.78 (95%CI: 0.72-0.83). The Shona version of the PCL-5 demonstrated good internal consistency (Cronbach's alpha = 0.92).
The PCL-5 performed well in this population with a high prevalence of HIV. There is need to explore ways of integrating screening tools for PTSD in interventions delivered by lay health workers in low and middle-income countries (LMIC).
Adolescents and young people globally are highly vulnerable to poor mental health especially depression, and they account for 36% of new HIV infections in Eastern and Southern Africa. HIV services ...remain inadequate for this population and their adherence to ART is low. The Friendship Bench (FB), an evidence-based model developed in Zimbabwe to bridge the mental health gap, is a brief psychological intervention delivered on benches in primary care facilities by lay health workers ("grandmothers") trained in problem-solving therapy. This study explored the experience of young people living with HIV attending FB, and their perception of how problem-solving therapy impacted their adherence to ART.
Semi-structured interviews were conducted in July 2019 with 10 young people living with HIV aged 18-24 years, who had recently completed FB counselling in Harare. Participants were purposively sampled and recruited from three primary care facilities. Interviews were conducted in Shona, audio-recorded, transcribed verbatim and translated into English. Transcripts were analysed in NVivo12 using inductive thematic analysis.
Study findings revealed a clear emotional denial towards HIV, particularly for young people infected perinatally, and a resulting low adherence to ART. The study also unpacked the issues of internal stigma and how young people living with perinatally acquired HIV are informed of their HIV status. Participants reported that FB had a critical role in helping them accept their HIV status. Grandmothers' empathic attitude was key during counselling on adherence to ART, to demystify the disease and treatment, normalize the reality of living with HIV, encourage young people to socialize with peers and free them of guilt. Interviewees unanimously reported improved ART adherence following FB counselling, and many described enhanced health and wellbeing.
Participants saw FB as a strong contributor to their general well-being, evident in decreased symptoms of depression and improved adherence to ART. FB problem-solving therapy should be rolled out to further support young people after post-test counselling or HIV serostatus disclosure for perinatally acquired HIV, for acceptance of HIV status and adherence to ART.
Adolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and ...increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health.
We conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18-24) from across 10 intervention districts and audio recorded 200 of the peer supporters' monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support.
A primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision.
Extending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.
Given this context, this Special Issue of the Journal of the International AIDS Society focuses on mental health and HIV, predominantly in LMIC settings with a high HIV burden, and among key ...populations at greatest risk of HIV, to highlight: (1) the linkage between mental health problems, and other psychosocial factors, which increase HIV risk; (2) the interventions and strategies to prevent HIV among people with mental health problems; (3) factors associated with common mental disorders among young people and adults living with HIV and (4) interventions to improve mental health among persons with HIV (PWH). ...we endorse WHO advice to integrate screening and treatment of depression into the HIV care cascade in prevention and healthcare settings, including community-based practices 18. ...prevention must target social determinants across the life course, particularly in adolescence where risk factors can be similar to those in adults, but even more pronounced in terms of their negative consequences. ...we need to emphasize social justice and equity to reduce disparities and inequities, for example as experienced by sexual, gender, racial and ethnic minorities.
In early development programmes in Latin America, anthropologist Paul analysed unsuccessful health programmes and attributed their failure to inadequate understanding of cultural context.3 In 1984, ...renowned medical anthropologist, Foster, evoked the urgent need for research on ethnomedical studies to inform community health interventions.4 Echoing Foster’s concerns, Airhihenbuwa proposes the centrality of culture in health programmes while critiquing the Eurocentrism of these programmes in the Global South. ...most research and interventions on newborn care in the Global South focus only on mothers of young children, thereby ignoring the structure of non-western families where caregiving is collective and intergenerational.9 A second example, related to child marriage, concerns the gap between the culturally determined role of elders in perpetuating this practice and the fact that most programmes do not actively involve them while primarily targeting girls and sometimes their biological parents.10 In both cases, programmes blatantly overlook the structure and strategies of family systems to promote the well-being of newborns and adolescents by acknowledging and building on the culturally designated roles of influential family and community members. According to her, social norms are products of those culturally constructed social contexts. According to Henrich et al,14 more collectivist cultures make up approximately 88% of the world’s population, that is, the Majority World.
In 2014 close to 10 million people living with HIV (PLWH) in sub-Saharan Africa were on highly active anti-retroviral therapy (HAART). The incidence of non-communicable diseases has increased ...markedly in PLWH as mortality is reduced due to use of HAART. Common mental disorders (CMD) are highly prevalent in PLWH. We aimed to determine factors associated with probable CMD and depression, assessed by 2 locally validated screening tools in a population with high prevalence of HIV in Harare, Zimbabwe.
We carried out a cross-sectional survey of a systematic random sample of patients utilizing the largest primary health care facility in Harare. Adults aged ≥18 years attending over a 2-week period were eligible, excluding those who were critically ill or unable to give written informed consent. Two locally validated screening tools the Shona symptom questionnaire (SSQ-14) and the Patient Health Questionnaire (PHQ-9) were administered by trained research assistants to identify probable CMD and depression.
Of the 264 participants, 165 (62.5 %) were PLWH, and 92 % of these were on HAART. The prevalence of probable CMD (SSQ14 > = 9) and depression (PHQ9 > = 11) were higher among people living with HIV than among those without HIV (67.9 and 68.5 % vs 51.4 and 47.2 % respectively). Multivariable analysis showed female gender and recent negative life events to be associated with probable CMD and depression among PLWH (gender: OR = 2.32 95 % CI:1.07-5.05; negative life events: OR = 4.14; 95 % CI 1.17-14.49) and with depression (gender: OR = 1.84 95 % CI:0.85-4.02; negative life events: OR = 4.93.; 95 % CI 1.31-18.50) CONCLUSION: Elevated scores on self-report measures for CMD and depression are highly prevalent in this high HIV prevalence population. There is need to integrate packages of care for CMD and depression in existing primary health care programs for HIV/AIDS.
There is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost ...multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale.
We trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention.
Of 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention.
We have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial.
ISRCTN: ISRCTN25476759.
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