BACKGROUND: Little is currently known about how to scale up care for depression in settings where non-physician lay workers constitute the bulk of frontline providers.
Detection of perinatal depression by healthcare providers remain an important barrier to receiving treatment. This study reports on the detection of perinatal depression by frontline non-physician primary healthcare workers (PHCWs) as well as the feasibility, effectiveness and acceptability of routine screening using the 2-item patient health questionnaire (PHQ-2) during antenatal care. Twenty-seven primary healthcare facilities were assigned to screening (n = 11) and non-screening (n = 16) arms. All PHCWs in both arms were trained to diagnose and treat perinatal depression using the WHO mental health gap action intervention guide (mhGAP-IG) while those in the screening arm were trained to routinely screen with PHQ-2 first to determine need for further mhGAP-IG assessment. Perceived usefulness, feasibility and acceptability of routine screening for perinatal depression was explored in key informant interviews on a purposive sample of PHCWs (n = 20) and study participants (n = 22). In the first 6-months following training, the detection rate of perinatal depression was 4.6% at the clinics where PHCW were not routinely screening with the PHQ-2 compared to 11% at the screening clinics. Over the next six months, with refresher training for PHCW in the screening arm and the introduction of monthly supportive supervision for PHCW in both arms, detection rates increased from 4.6 to 7.6% at non-screening clinics and from 11 to 40% at the screening clinics. Over the entire study period only 81 (15.7%) out of the 517 cases of perinatal depression were detected by the PHCWs. Detection of depression by PHCWs was associated with the severity of depression symptoms and routine screening with PHQ-2. The introduction of routine screening was acceptable to both PHCWs and perinatal women. PHCWs reported that the PHQ-2 was useful, easy to administer and feasible for routine use. Improving detection and subsequently the treatment gap for perinatal depression require not just training of frontline healthcare workers but the introduction of additional measures such as universal screening along with supportive supervision. The main study from which the data for this report was extracted was retrospectively registered 03 December 2019. Registration number: ISRCTN 94,230,307.
BACKGROUND In West Africa, healers greatly outnumber trained mental health professionals. People with serious mental illness (SMI) are often seen by healers in “prayer camps” where they may also experience human rights abuses. We developed M&M, an 8-week long dual-pronged intervention involving a) a smartphone-delivered toolkit designed to expose healers to brief psychosocial interventions and to encourage them to preserve human rights (M-Healer app), and b) a visiting nurse who provides medications to their patients (Mobile Nurse). OBJECTIVE To examine the feasibility, acceptability, safety, and preliminary effectiveness of the M&M intervention in real-world prayer camp settings. METHODS We conducted a single-arm field trial of M&M with people with SMI and healers in a prayer camp in Ghana. Healers were provided with smartphones with M-Healer installed and were trained by practice facilitators to use the digital toolkit. In parallel, a study nurse visited their prayer camp to administer medications to their patients. Clinical assessors administered study measures to participants with SMI at pre-treatment (baseline), mid-treatment (4 weeks) and post-treatment (8 weeks). RESULTS Seventeen participants were enrolled in the study and most (n=15, 88.3%) were retained. Participants had an average age of 44.3 (SD: 13.9) and 59% (n=10) were male. Fourteen participants (82%) had a diagnosis of schizophrenia and two participants (18%) were diagnosed with bipolar disorder. Four healers were trained to use M-Healer. On average, they self-initiated app use 31.9 (SD: 28.9) times per week. Healers watched an average of 19.1 videos (SD: 21.2), responded to 1.5 prompts (SD: 2.4), and used the app for 5.3 days (SD: 2.7) weekly. Pre/post analyses found a statistically significant and clinically meaningful reduction in psychiatric symptom severity (Brief Psychiatric Rating Scale: 52.3 to 30.9; Brief Symptom Inventory: 76.4 to 27.9), psychological distress (Talbieh Brief Distress Inventory: 37.7 to 16.9) shame (Other as Shamer Scale: 41.9 to 28.5), and stigma (Brief Internalized Stigma of Mental Illness Scale: 11.8 to 10.3). We recorded a significant reduction in days chained (1.6 to 0.5) and a promising trend for reduction in days of forced fasting (2.6 to 0.0, p = 0.059). We did not identify significant pre/post changes in patient-reported working alliance with healers (Working Alliance Inventory), depressive symptom severity (Patient Health Questionnaire-9), quality of life (Lehman Quality of Life Interview for the Mentally Ill), beliefs about medication (Beliefs about Medications Questionnaire – General Harm sub-scale) or other human rights abuses. No major side effects, health and safety violations, or serious adverse events occurred over the course of the trial. CONCLUSIONS The M&M intervention proved to be feasible, acceptable, safe, and clinically promising. Preliminary findings suggest the M-Healer toolkit may have shifted healer behaviors at the prayer camp so that they commit fewer human rights abuses.
Abstract Background. Depression is a common and severe disorder among low-income adolescent mothers in low-and middle-income countries where resources for treatment are limited. We wished to identify factors influencing health service utilization for adolescent perinatal depression in Nigeria to inform new strategies of care delivery. Methods . Focus Group Discussions (FGDs) were conducted among purposively selected low-income young mothers (with medical histories of adolescent perinatal depression), and separately with primary care clinicians treating this condition in Ibadan, Nigeria. Participants from this community-based study were from the database of respondents who participated in a previous randomized control trial (RCT) conducted between 2014 and 2016 in 28 primary health care facilities in the 11 Local government areas in Ibadan. A semi-structured interview guide was designed according to the themes of the Behavioral Model for Vulnerable Populations to obtain views of participants on the factors that promote or hinder help-seeking and engagement. FGDs were conducted, and saturation of themes was achieved after discussions with six groups. Transcripts were analyzed using content analysis framework. Results . A total of 42 participants, 17 mothers (who were adolescents at the time of the RCT), and 25 care providers participated in 6 FGDs. The availability of care for PD at the primary care level was an important enabling factor in healthcare utilization for the adolescents. Perceived health benefits of treatment received for perinatal depression were strong motivation for service use. Significant stigma and negative stereotypes expressed by care providers towards adolescent pregnancy and perinatal depression were potential obstacles to care. However, individual patient resilience was a major enabling factor, facilitating service engagement. Providers trained in the management of perinatal depression were perceived to deliver more tolerant and supportive care that adolescent mothers valued. Conclusions. Participants identified an unsupportive and stigmatizing clinic environment as a significant potential barrier to accessing available care. Interventions to reduce stigma among healthcare providers may improve services for this vulnerable population.
We thank Oladayo Afolabi and colleagues for their comments on our trial.1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Afolabi and colleagues highlight two main points: the use of the term ‘lay health workers’ to describe nurses is incorrect and might be considered disrespectful and derogatory and the ambiguity regarding the definitions used to describe personnel involved in our study might have limited the impact of our findings on policy. We are delighted that the comments provide us with an opportunity to clarify this aspect of our trial. Although our aim was to train a cross-section of frontline health providers (nurses, community health officers, and community health extension workers [CHEWs]), the workers who actually received training and subsequently delivered the intervention were all community health officers and CHEWs. These workers constitute more than 90% of the workforce at the primary health-care level in Nigeria. These individuals are, as per their job description, expected to spend a substantial proportion of their working hours in the community. As Afolabi and colleagues noted, the terms ‘community health workers’ and ‘lay health workers’ have often been used interchangeably. Although these workers do deliver general health care routinely, they are not qualified to provide mental health care, and thus require additional training. It is in this context that we chose to use the term lay health workers in the title of our trial. In most countries in sub-Saharan Africa, lay health workers constitute the bulk of frontline health providers at the primary care level.2Munetsi E Simms V Dzapasi L et al.Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study.BMC Public Health. 2018; 18: 227Crossref PubMed Scopus (11) Google Scholar Such workers have a variety of designations across the world.3Nkonki L Cliff J Sanders D Lay health worker attrition: important but often ignored.Bull World Health Organ. 2011; 89: 919-923Crossref PubMed Scopus (69) Google Scholar In Nigeria, lay health workers are mainly community health officers and CHEWs. Our study was designed to assess whether these workers, with appropriate training and supervision, could deliver effective care for individuals presenting with depression in primary care settings. We therefore do not agree that our approach is likely to limit the relevance of our findings with regard to policy. The use of other categories of health workers who provide services in primary health care settings in Nigeria, including nurses and physicians, but who do not constitute the main frontline providers, would have produced findings less likely to be of relevance for policy. At present, the Nigerian Government is working on how to implement a programme of task-shifting that is essentially designed around the training of community health officers and CHEWs to deliver frontline services for mental health conditions, with support and supervision provided by nurses, physicians, and mental health specialists, as appropriate and available. We declare no competing interests. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trialFor patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. Full-Text PDF Open AccessTask-shifting must recognise the professional role of nursesThe Nursing Now campaign and the designation of 2020 as the “Year of the Nurse and Midwife” by WHO highlights the need to acknowledge the competence, increase the influence, and maximise the contribution of nursing to the achievement of universal health coverage. However, poor perceptions and misrepresentation of the professional role of nurses persists. The cluster-randomised controlled trial by Oye Gureje and colleagues (April, 2019)1 published in The Lancet Global Health, which assessed the effectiveness of task-shifting and stepped care in the management of major depressive disorder at the primary health-care level in Nigeria, and the associated commentary by Bolanle Adeyemi Ola and colleagues,2 provide examples of how nurses are misrepresented and the need for the Nursing Now campaign. Full-Text PDF Open Access
Perinatal depression is more common and is associated with greater negative consequences among adolescents than adults. Psychosocial interventions designed for adults may be inadequate at addressing the unique features of adolescent perinatal depression.In a two-arm parallel cluster randomized trial conducted in thirty primary maternal care clinics in Ibadan, Nigeria (15-intervention and 15-control) we compared age-appropriate intervention consisting of problem-solving therapy, behavioral activation, parenting skills training, and parenting support from a self-identified adult to care as usual. Pregnant adolescents (aged <20 years) at fetal gestational age16-36 weeks with moderate to severe depression were recruited. Primary outcomes were depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and parenting practices (Infant-Toddler version of the Home Inventory for Measurement of the Environment, HOME-IT) at six-months postnatal.There were 242 participants (intervention arm: 141; Control arm: 101), with a mean age of 18∙0 (SD-1∙2). Baseline mean EPDS score was 14∙2 (SD-2.1); 80∙1 % completed the six-month postnatal follow-up. The intervention group had lower level of depressive symptoms than the control group, mean EPDS scores: 5∙5 (SD-3∙6) versus 7∙2 (SD-4∙0) (adjusted mean difference -1∙84 (95%CI- 3∙06 to -0∙62; p = 0∙003) and better parenting practices, mean total HOME-IT scores: 29∙8 (SD-4∙4) versus 26∙4 (SD-4∙2) (adjusted mean difference 3∙4 (95%Cl- 2∙12 to 4∙69, p = 0∙001).This study explored the effect of complex interventions making it difficult to know precisely what aspects produced the outcomes.An age-appropriate psychosocial intervention package holds promise for scaling up care for adolescents with perinatal depression especially in resource-constrained settings.ISRCTN16775958. Registered on 30 April 2019.
Psychotic disorders are a group of severe mental disorders that cause considerable disability to sufferers and a high level of burden to families. In many low- and middle-income countries (LMIC), traditional and faith healers are the main providers of care to affected persons. Even though frequently canvassed as desirable for improved care delivery, collaboration between these complementary alternative health providers (CAPs) and conventional health providers has yet to be rigorously tested for feasibility and effectiveness on patient outcomes. COSIMPO is a single-blind, cluster randomized controlled trial (RCT) being conducted in Nigeria and Ghana to compare the effectiveness of a collaborative shared care (CSC) intervention program implemented by CAPs and primary health care providers (PHCPs) with care as usual (CAU) at improving the outcome of patients with psychosis. The study is designed to test the hypotheses that patients receiving CSC will have a better clinical outcome and experience fewer harmful treatment practices from the CAPs than patients receiving CAU at 6 months after study entry. An estimated sample of 296 participants will be recruited from across 51 clusters, with a cluster consisting of a primary care clinic and its neighboring CAP facilities. CSC is a manualized intervention package consisting of regular and scheduled visits of PHCPs to CAP facilities to assist with the management of trial participants. Assistance includes the administration of antipsychotic medications, management of comorbid physical condition, assisting the CAP to avoid harmful treatment practices, and engaging with CAPs, caregivers and participants in planning discharge and rehabilitation. The primary outcome, assessed at 6 months following trial entry, is improvement on the Positive and Negative Symptom Scale (PANSS). Secondary outcomes, assessed at 3 and 6 months, consist of levels of disability, experience of harmful treatment practices and of victimization, and levels of perceived stigma and of caregivers' burden. Information about whether collaboration between orthodox and complementary health providers is feasible and can lead to improved outcome for patients is important to formulating policies designed to formally engage the services of traditional and faith healers within the public health system. National Institutes of Health Clinical Trial registry, ID: NCT02895269 . Registered on 30 July 2016
List of abstract titles and authors:1. Antipsychotics across the spectrum: An overview of their mechanisms of actionAnissa Abi-Dargham2. Recent advances in the treatment of common anxiety disordersChrister Allgulander3. Psychiatry in Africa: The myths, the realities and the exoticO Gureje4. Mental Health policy developmet in Kenya and Tanznia - A DFID funded projectRachel Jenkins, David Kima, Joseph Mbatia, Frank Njenga5. Vascular factors in Alzheimer's diseaseR N Kalaria6. Depression as an immunologically based Neurodegenerative disorderBrian Leonard7. Eight years of progress in Arican PsychiatryF Njenga8. Treatment of Depression: Present and futureDr R.M. Pinder9. Imaging the Serotinergic system in impulsive aggressive personality disorder patientsLarry J Siever, Antonia S. New, Mari Goodman, Monte Buchsbaum, Erin Hazlett, Karen O'Flynn, Anissa Abi-argham, Marc Lauelle10. Mode of action of Atypical antipsychotic rugs: Focus on A2 AdrnoceptorsT.H. SvenssonNeuroscience: Selected Abstracts11. Chemical odulato of Fronto-execuitive functions: Neropsychiatric implicationsTrevor W Robbins12. Neural mechanisms of recognition memory and of social atacntProf. G Horn13. Estrogen signling after estrogen receptor ß (ERß)Jan-Ake Gustafsson14. Getting Lost: Hippocampal contributions to agerelated memory dysfunctionCarol BarnesMetals and the brain: Selected abstracts15. Modeling the contributin of iron mismanagement to Neurological disordersProf. J R C Connor16. Aluminium-triggered fibrillogenesis of B-AmyloidsProf. PZ Zatta, Dr D Drago, Mr G Tognon, Dr F RicchelliPsychiatry in Africa:17. Psychosocal aspects of Khat use among the youth of NairobiMs T M Khamis18. PTSD among motor vehicle accident survivors, KenyaDr F A Ongecha19. Psychiatric relities within African context - The Kenyan case StudyProf. D M N Ndetei20. Adolescent-parenta interactions from infancy, Nairobi KenyaDr L K Ksakhala, Prof. D M N Ndetei21. Alcohol use ong young persons: A focus group study in Southwest NigeriaO A Obeijide22. Personality disorders and personality traits among tyoe 2 Diabetic patientsProf. O El Rufaie, Dr M Sabosy, Dr M S Abuzeid23. Association of traumatic experiences with depression among Nigerian adolescentsDr O Omigbodun, Dr K BakareMs O B Yusuf, Dr O Esan24. Prevalence of depression among women attending outpatient clinics in MalawiDr M Tugumisirize, Prof. Agn, Dr Musisi25. Non-fatal suicidalbehaviour at the Johannesburg General HospitalDr M Y H Moosa, Prof. F Y Jeenah, Dr A Pillay, Pof. M Vorstere, Dr R Liebenberg26. Integrating mental health into general primary health care - Uganda's experienceDr N Kigozi27. Depression among Nigerian survivors of stroke:Prevalance and associated factorsDr F.O Fatoye Dr M A Komolafe, Dr A. O Adewuya, Dr B.A. Eegunranti Prof. M.A. Lawal28. NGO Involvement mental health care -The way forwardDr Basangwa29. Prevalen of Attenton Deficit Hyperactivity sorder among African school childrenDr E KashalaProf. T Tylleskar, Dr I Elgen, Dr K Sommerfelt30. Barriers to effective mental health care in NigeriaMs L. Kola31. Quay of life evaluation in patients with HIV-I infection with respect to the impact of Phyttherapy (Traditional Herb in Zimbabwe)M B Sebit, S K Chandiwaa, A S Latif, E Gomo, S W Acuda, F Makoni, J Vushe
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