A cluster randomized clinical trial of a stepped care intervention for depression in primary care (STEPCARE)--study protocol.

BACKGROUND: Depression constitutes a significant public health burden and is associated is with high level of individual suffering. Insufficient human and material resources impede the provision of adequate care for persons with the condition in low- and middle-income countries. It is commonly recognized that, to bridge this treatment gap, it is essential to integrate the treatment of depression into primary health care system. METHODS/DESIGN: STEPCARE is a two-arm parallel cluster randomized controlled trial to compare a stepped-care intervention package for depression in primary health care with care as usual in Nigeria. Randomization was conducted at the level of the participating primary health care clinics, while interventions are delivered to consenting individual participants who screen positive on the 9-item patient health questionnaire (PHQ-9 score ≥ 11) and fulfil the DSM-IV criteria for major depression. Intervention delivered by trained primary health care workers (PHCW) supported by general physicians and psychiatrists as needed is in 3 steps determined by response to treatment. Each step consists of psychological interventions (including psychoeducation, activity scheduling, social network reactivation and problem solving treatment) offered to all participants and, depending on severity and response, medication. Primary outcome, assessed at 12 months following recruitment into the trial, is recovery from depression as shown by a PHQ-9 score of less than 6. Secondary outcomes include changes in disability, quality of life and service utilization assessed at 6 and 12 months. DISCUSSION: The stepped care model examines the effectiveness of an intervention package for depression in which the intensity of treatment is determined by the clinical need of the patients. This approach is designed to make the most efficient use of available resources. TRIAL REGISTRATION: ISRCTN46754188 (ISRTCN registry at isrtcn.com; registered 23 September 2013)

How can Canadian, African and other health systems benefit from each other?

Innovating for Maternal and Child Health in Africa (IMCHA) and Dalhousie University co-hosted a virtual event which provided a platform for exchange regarding implementation research on health systems strengthening, and an opportunity for participants to reflect on research gaps. This report covers key points from the plenary sessions: Delivering integrated health services for neonates; Integrating mental health into routine maternal care in low- and middle-income countries; The importance of leadership and management; Strengthening quality through the use of health data; and, Quality of care and safety standards.Canadian Institutes of Health ResearchGlobal Affairs Canad

Stigma and utilization of treatment for adolescent perinatal depression in Ibadan Nigeria

This study identified predisposing, enabling, and hindering factors to health services utilization by adolescent mothers. Approximately 95% of all births to girls under age 18 occur in low- and middle -income countries (LMICs), where supporting infrastructure for healthcare is limited. Depression is a common and severe disorder among low-income adolescent mothers, where treatment often includes stigmatizing attitudes towards adolescent sexuality by healthcare providers. The study recognizes that it is difficult for someone young to enforce anything at home because they are not autonomous

Responding to the challenge of adolescent perinatal depression (RAPiD) : protocol for a cluster randomized hybrid trial of psychosocial intervention in primary maternal care

The project, “Responding to the challenge of adolescent perinatal depression (RAPiD)” is designed to address the need for interventions, as well as demonstrate effectiveness of interventions, for depressive disorders among adolescent mothers. The article provides a detailed proposal outline including background information and methodology of the RAPiD programme development and objectives, including conducting a comprehensive process evaluation to assess the barriers and facilitators of scaling up the intervention. Few studies have examined the effectiveness of interventions delivered to adolescents with perinatal depression. The World Health Organization estimates that up to 11% of all births worldwide are to girls aged between 15 and 19 years

High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial)

Background: Contextually appropriate interventions delivered by primary maternal care providers might be effective in reducing the treatment gap for perinatal depression.Aim: To compare a high intensity psychological intervention with a low intensity enhanced usual care in the treatment of perinatal depression.Methods: This cluster randomized clinical trial was conducted in Ibadan, Nigeria between June 18, 2013 and December 11, 2015. Twenty-nine maternal care clinics were randomized to either high intensity (HIT, n=15) or low intensity (LIT, n=14) treatment. Pregnant women, registering for antenatal care, assessed to have DSM-IV major depression, received either enhanced usual care delivered by providers using the WHO Mental Health Gap Action Programme – Intervention Guide (LIT arm) or 8 weekly structured problem solving prenatal sessions delivered within a stepped care model (HIT arm). Primary outcome was recovery from depression 6 months postpartum (score < 6 on the Edinburgh Postnatal Depression Scale, (EPDS). Results: There were 686 participants, 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed recovery rates of 70% in the HIT arm and 66% in the LIT arm: adjusted risk difference 4% (95%CI: -4·1%, 12·0%), adjusted odds ratio 1·12 (95%CI: 0·73, 1·72). HIT was more effective among women with higher baseline EPDS scores (adjusted interaction OR 2·29, 95%CI 1·01, 5·20).Conclusions: Except among more severely depressed perinatal women, we found no strong evidence to recommend high intensity in preference to low intensity psychological intervention in routine primary maternal care

A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria

Background Depression is common in primary care and is often unrecognized and untreated. Studies are needed to demonstrate the feasibility of implementing evidence-based depression care provided by primary health care workers (PHCWs) in sub-Saharan Africa. We carried out a pilot two-parallel arm cluster randomized controlled trial of a package of care for depression in primary care. Methods Six primary health care centers (PHCC) in two Local Government Areas of Oyo State, South West Nigeria were randomized into 3 intervention and 3 control clinics. Three PHCWs were selected for training from each of the participating clinics. The PHCWs from the intervention clinics were trained to deliver a manualized multicomponent stepped care intervention package for depression consisting of psychoeducation, activity scheduling, problem solving treatment and medication for severe depression. Providers from the control clinics delivered care as usual, enhanced by a refresher training on depression diagnosis and management. Outcome measures Patient’s Health Questionnaire (PHQ-9), WHO quality of Life instrument (WHOQOL-Bref) and the WHO disability assessment schedule (WHODAS) were administered in the participants’ home at baseline, 3 and 6 months. Results About 98% of the consecutive attendees to the clinics agreed to have the screening interview. Of those screened, 284 (22.7%) were positive (PHQ-9 score ≥ 8) and 234 gave consent for inclusion in the study: 165 from intervention and 69 from control clinics. The rates of eligible and consenting participants were similar in the control and intervention arms. In all 85.9% (92.8% in intervention and 83% in control) of the participants were successfully administered outcome assessments at 6 months. The PHCWs had little difficulty in delivering the intervention package. At 6 months follow up, depression symptoms had improved in 73.0% from the intervention arm compared to 51.6% control. Compared to the mean scores at baseline, there was improvement in the mean scores on all outcome measures in both arms at six months. Conclusion The results provide support for the feasibility of conducting a fully-powered randomized study in this setting and suggest that the instruments used may have the potential to detect differences between the arms

Parental psychopathology and the risk of suicidal behavior in their offspring: results from the World Mental Health surveys

Prior research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well-understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive-aggression (e,g., antisocial personality) and anxiety/agitation (e.g., panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55,299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (i.e., time-since-most-recent-episode controlling for age-of-onset and time-since-onset) of subsequent suicidal behavior (suicide ideation, plans, and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental anti-social personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt also was found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of inter-generational transmission of suicidal behavior.Psycholog

Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful