The “treatment gap” in global mental health reconsidered: sociotherapy for collective trauma in Rwanda

Background: The “treatment gap” (TG) for mental disorders refers to the difference that exists between the number of people who need care and those who receive care. The concept is strongly promoted by the World Health Organization and widely used in the context of low- and middle-income countries. Although accepting the many demonstrable benefits that flow from this approach, it is important to critically reflect on the limitations of the concept of the TG and its implications for building capacity for mental health services in Rwanda. Objective: The article highlights concerns that the evidence base for mental health interventions is not globally valid, and problematizes the preponderance of psychiatric approaches in international guidelines for mental health. Specifically, the risk of medicalization of social problems and the limited way in which “community” has been conceptualized in global mental health discourses are addressed. Rather than being used as a method for increasing economic efficiency (i.e., reducing healthcare costs), “community” should be promoted as a means of harnessing collective strengths and resources to help promote mental well-being. This may be particularly beneficial for contexts, like Rwanda, where community life has been disrupted by collective violence, and the resulting social isolation constitutes an important determinant of mental distress. Conclusions: Moving forward there is a need to consider alternative paradigms where individual distress is understood as a symptom of social distress, which extends beyond the more individually oriented TG paradigm. Sociotherapy, an intervention used in Rwanda over the past 10 years, is presented as an example of how communities of support can be built to promote mental health and psychosocial well-being

Anxiety and depression among cancer patients: prevalence and associated factors at a Rwandan referral hospital

Background: Cancer patients frequently experience psychological problems related to reactions of cancer diagnosis, cancer type, treatment effects, recurrence, fear of end-of-life, survivorship, and financial burden. Psychological assessment has been integrated into cancer care in some countries, but there is limited knowledge about the practice in Rwanda.Objective: To assess the prevalence and associated factors of anxiety and depression among patients with cancer attending a private referral hospital in Rwanda.Methods: A descriptive cross-sectional study design was used with the Hospital Anxiety and Depression Scale (HADS) instrument to assess cancer patients. A probability systematic random sampling technique was used to recruit 96 patients. Data were analysed using descriptive statistics to determine the association of variables with anxiety and depression.Results: The majority of cancer patients had depression (67.7%) and anxiety (52.1%). Anxiety was associated with employment status (p=0.02), cancer stage (p=0.02), weight loss (p=0.00) and depression (p=0.00). Depression was associated with cancer stage (p=0.02), pain (p=0.03), weight loss (p= 0.03), cancer treatment (p=0.02) and anxiety (p=0.001).Conclusion: Anxiety and depression were reported in over half of the study population indicating a need to create and integrate psycho-oncology into standard oncology care.Keywords: Cancer, anxiety, depression, prevalence, associated factor

The significance of HIV and non-communicable diseases in Africa

No AbstractKeywords: Human Immunodeficiency Virus, communicable diseases, non-communicable diseases, Rwanda, sub-Saharan Afric

Violence politique, traumatisme et (re)création des métiers cliniques:Pour une clinique de la responsabilité sociale à partir des traumatismes psychosociaux.

Les situations de violence politique provoquent des traumatismes psychiques et sociaux d’immense ampleur et sur le long terme. Ces traumatismes psychosociaux mettent à mal les métiers qui prennent en charge les souffrances psychiques et sociales d’autrui. Ils obligent à la (re)mobilisation voire à la (re)création de ces métiers cliniques. Les auteurs illustrent et développent ces propos en s’appuyant sur deux recherches cliniques menées respectivement au Chili et au Rwanda dans les suites de la dictature (1973-1990) et du génocide (1994). De telles recherches contribuent à l’élaboration d’une clinique de la responsabilité sociale qui s’attache à restaurer les possibilités sociales et psychiques de répondre d’Autrui après qu’on ait tenté, d’une manière ou d’une autre, de le réduire à néant. L’article analyse et articule les processus d’emprise et d’expropriation à l’œuvre entre soi et autrui dans les phénomènes de violence politique étudiés. Il invite à leur mise en dialogue avec les formes diverses et multiples d’atteintes à la responsabilité sociale qui appellent ensemble à leur reconnaissance et leur prise en charge clinique, politique et épistémologique

Addressing the mental health needs of children affected by HIV in Rwanda: validation of a rapid depression screening tool for children 7–14 years old

Background: Depression in children presents a significant health burden to society and often co-exists with chronic illnesses, such as human immunodeficiency virus (HIV). Research has demonstrated that 10–37% of children and adolescents living with HIV also suffer from depression. Low-and-middle income countries (LMICs) shoulder a disproportionate burden of HIV among other health challenges, but reliable estimates of co-morbid depression are lacking in these settings. Prior studies in Rwanda, a LMIC of 12 million people in East Africa, found that 25% of children living with HIV met criteria for depression. Though depression may negatively affect adherence to HIV treatment among children and adolescents, most LMICs fail to routinely screen children for mental health problems due to a shortage of trained health care providers. While some screening tools exist, they can be costly to implement in resource-constrained settings and are often lacking a contextual appropriateness. Methods: Relying on international guidelines for diagnosing depression, Rwandan health experts developed a freely available, open-access Child Depression Screening Tool (CDST). To validate this tool in Rwanda, a sample of 296 children with a known diagnosis of HIV between ages 7–14 years were recruited as study participants. In addition to completing the CDST, all participants were evaluated by a mental health professional using a structured clinical interview. The validity of the CDST was assessed in terms of sensitivity, specificity, and a receiver operating characteristic (ROC) curve. Results: This analysis found that depression continues to be a co-morbid condition among children living with HIV in Rwanda. For identifying these at-risk children, the CDST had a sensitivity of 88.1% and specificity of 96.5% in identifying risk for depression among children living with HIV at a cutoff score of 6 points. This corresponded with an area under the ROC curve of 92.3%. Conclusions: This study provides evidence that the CDST is a valid tool for screening depression among children affected by HIV in a resource-constrained setting. As an open-access and freely available tool in LMICs, the CDST can allow any health practitioner to identify children at risk of depression and refer them in a timely manner to more specialized mental health services. Future work can show if and how this tool has the potential to be useful in screening depression in children suffering from other chronic illnesses

An International Pilot Study of Self-Reported Quality of Life in Outpatient and Inpatient Mental Health Settings

troduction: Measuring quality of life (QoL) is essential to understand how clients perceive their care. In practice, many instruments are in place to identify mental health diagnoses and measure treatment outcomes, but there are fewer standardized instruments to routinely collect information about self-reported QoL, especially across different mental health settings. Moreover, existing tools have been criticized for being built from the perspective of care professionals rather than the users' perspective. The 23-item Self-Reported interRAI-QoL Survey for Mental Health and Addictions (interRAI SQoL-MHA) tackles these issues, as it is based on self-reported measures and has proven validity across settings and countries.Objective: The aim of this study is to assess and compare QoL across settings and explore associations between dimensions of self-reported QoL and some items from the interRAI SQoL-MHA in a multinational sample.Settings: Inpatient and community mental health services.Methods: Data were collected from organizations in Belgium, Finland, Russia, Brazil, Rwanda, Canada and Hong Kong. Logistic regression models were constructed using each domain scale of the interRAI SQoL-MHA (relationship, support, hope, activities and relationship with staff) as dependent variables.Results: A total of 2,474 people (51.2% female, 56.7% of age 45 or older) were included in the study. A benchmark analysis showed the samples that performed above the benchmark line or below. The models yielded significant odds ratios among the domain scales, as well as for the items of the interRAI SQoL-MHA, with positive associations for the items “work and education opportunities” and “satisfied with services”, and inverse associations for the items “financial difficulties” and for the inpatient setting.Conclusion: The analysis of associations between the determinants offers relevant information to improve mental health care and clients' perceived quality of life. Information about the determinants can help policymakers to design interventions to improve care outcomes, as well as provide more possibilities for integration into the community. The interRAI SQoL-MHA is innovative, as it can be linked to the third generation interRAI MH and Community MH-instruments, to be used in different mental health care settings, combining the objective and subjective QoL domains.</p

Community based sociotherapy for depressive symptomatology of Congolese refugees in Rwanda and Uganda (CoSTAR): a protocol for a cluster randomised controlled trial

Background: Conflict in the Democratic Republic of Congo has led to large numbers of refugees fleeing to Uganda and Rwanda. Refugees experience elevated levels of adverse events and daily stressors, which are associated with common mental health difficulties such as depression. The current cluster randomised controlled trial aims to investigate whether an adapted form of Community-based Sociotherapy (aCBS) is effective and cost-effective in reducing depressive symptomatology experienced by Congolese refugees in Uganda and Rwanda. Methods: A two-arm, single-blind cluster randomised controlled trial (cRCT) will be conducted in Kyangwali settlement, Uganda and Gihembe camp, Rwanda. Sixty-four clusters will be recruited and randomly assigned to either aCBS or Enhanced Care As Usual (ECAU). aCBS, a 15-session group-based intervention, will be facilitated by two people drawn from the refugee communities. The primary outcome measure will be self-reported levels of depressive symptomatology (PHQ-9) at 18-weeks post-randomisation. Secondary outcomes will include levels of mental health difficulties, subjective wellbeing, post-displacement stress, perceived social support, social capital, quality of life, and PTSD symptoms at 18-week and 32-week post-randomisation. Cost effectiveness of aCBS will be measured in terms of health care costs (cost per Disability Adjusted Life Year, DALY) compared to ECAU. A process evaluation will be undertaken to investigate the implementation of aCBS. Conclusion: This cRCT will be the first investigating aCBS for mental health difficulties experienced by refugees and will contribute to knowledge about the use of psychosocial interventions for refugees at a time when levels of forced migration are at a record high. Trial registration: ISRCTN.org identifier: ISRCTN20474555

Crises traumatiques collectives d'ihahamuka lors des commémorations du génocide des Tutsi : aspects cliniques et perspectives thérapeutiques

In Rwanda, the annual commemorations of the genocide are associated with an increase of collective traumatic crisis whereby many people participating in commemoration activities present various symptoms, including emotional distress and re-experiencing traumatic events of 1994 genocide. These crises can affect hundreds of people at big commemoration events and are accompanied by a degree of urgency that disturbs the whole assembly. To the best of our knowledge, any study has examined this phenomenon in Rwanda. This thesis dissertation a) analyzes clinically these crises and documents one of the common clinical features of post-genocide trauma in Rwanda, b) explore the lived experience of people affected by these crises, c) depicts the content and the evolution of an emergency intervention generated by this situation during the last decade and d) finally present the results of a study on the effects of a supportive-expression group intervention in the post-crisis period for people who experienced these collective traumatic crises conducted in district hospital in Rwanda. The study compares the therapeutic progress made by a group of people who have benefited from the supportive-expression group intervention as compared to those who did not receive the intervention. The study suggests that the supportive group intervention can improve the overall psychological well-being of people who experienced collective traumatic crisis even though it was ineffective for some symptoms.(PSYE - Sciences psychologiques et de l) -- UCL, 201

Quand le corps abrite l'inconcevable. Comment dire le bouleversement dont témoignent les corps au Rwanda ?

Cet article aborde la question du corps sous l’emprise du traumatisme dans la clinique des survivants du génocide des Tutsis au Rwanda. Il est divisé en quatre parties. On part d’une situation clinique pour interroger la place du corps et les rapports corps-psyché chez une survivante qui a subi des violences sexuelles pendant le génocide. La seconde situe cette problématique du corps dans le contexte de l’après-génocide au Rwanda et des « crises traumatiques » d’allure collective qui accompagnent les commémorations annuelles du génocide. Dans la troisième, on présente les appellations créées au Rwanda pour dénommer ces crises traumatiques comme une façon singulière d’y reconnaître ce qui s’y joue. La dernière partie propose quelques pistes d’analyse de la place et du sens du corps dans ce contexte clinique et social spécifique

Supportive-Expressive Group Therapy for People Experiencing Collective Traumatic Crisis During the Genocide Commemoration Period in Rwanda: Impact and Implications

In Rwanda, the annual commemorations of the genocide are associated with an increase in the level of collective traumatic crises whereby many people participating in commemoration activities present various symptoms, including emotional distress and re-experiencing traumatic events of the 1994 genocide. These sudden crises normally last between 30 and 120 minutes and can affect hundreds of people at big commemoration events. They are accompanied by a degree of urgency that disturbs the whole assembly. This article briefly presents an overview of these crises and highlights the results of a study on the effects of a supportive-expression group intervention in the post-crisis period for people who experienced these collective traumatic crises. The study compares the therapeutic progress made by a group of people who participated in a supportive-expression group therapy program as compared to those who did not receive the intervention. The study suggests that the supportive group intervention can improve the overall psychological wellbeing of people who experienced collective traumatic crisis even though it was ineffective for some symptoms