Addressing the treatment gap for perinatal depression within an integrated primary health care model: development and feasibility study in the Dr Kenneth Kaunda District, North West Province.

Doctoral Degree. University of KwaZulu-Natal, Durban.Background: Perinatal depression (PND) is a common mental disorder (CMD) with onset either during pregnancy or in the postnatal period, with potentially harmful inter-generational impacts on families, and by extension on communities. In South Africa a combination of high prevalence rates for PND, an estimated treatment gap of 75 percent for CMDs, and a large medically uninsured population poses a public health and social burden. Compounding the issue, there is a lack of awareness of and minimal attention paid to PND in scarce-resourced primary health care (PHC) settings in South Africa. Consequently, screening, referral and treatment for PND is low to absent, as are targeted pharmacological and psychosocial therapies for PND. Internationally, evidence supports the concepts of both collaborative care and task-sharing to address PND in low-and middle-income countries (LMIC). In South Africa however, despite support for the integration of mental health services into general health care, promotion of perinatal mental health care, and endorsement of task-sharing in mental health care, promoted by a national mental health policy framework, there is an absence of clear strategies to address PND in the mandated maternity care guidelines in PHC. In response to this service and evidence gap, the aim of this study was to co-develop and evaluate the feasibility of a culturally and contextually appropriate integrated model of care for PND with PHC service users and service providers. The research aimed to contribute towards the body of evidence towards the development of integrated, PHC-based, task-shared collaborative care for PND in South Africa and other LMIC. The study was guided by explanatory models of illness and the UK Medical Research Council framework for complex interventions. Methods: Set in an urban 24-hour service community health centre in the Dr Kenneth Kaunda District, North West province, and nested within the larger PRogramme for Improving Mental health CarE (PRIME) project, the study was undertaken using a phased approach. The first step was an in-depth review of the literature on task-shared care, integrated or collaborative care for PND, particularly in LMIC, and the platforms, models and cadres used in task-shared care for PND. These essential components for task-shared PND care in LMIC were identified and guided the development of the interview schedules for both service users and service providers. In-depth semi-structured interviews were conducted with 20 service users to understand their perceptions, attitudes to task-shared care and recommendations to address PND, using thematic analysis to analyse the data. This work comprised the first phase of the study. In the second phase, nurses (n=10), HIV counsellors (n=20) and operational managers (n=4) were interviewed to gauge their clinical understanding of PND, attitudes to task-shared mental health care and recommendations to address PND. This was followed by a participatory workshop which included nurses, managers and specialists to co-develop a model of care for PND. An additional six key informants were interviewed for institutional perspectives and guidance on the model. Framework analysis was used to analyse the data in this phase. In the third phase, a quasi- experimental cohort design was used to recruit perinatal care attendees (n=54) to evaluate depression outcomes, feasibility and acceptability of the model. Primary care nurses consulting women attending antenatal and postnatal services were trained to identify women with depressive symptoms using a short maternal depression screening tool, and clinical assessment. Pregnant and postnatal women (6-48 weeks postpartum) who had mild/moderate depressive symptoms were referred to an existing 9-session manualized counselling intervention addressing common triggers of depressive symptoms, based on cognitive behavioural approaches, provided by a co-located non-specialist counsellor. Women with moderate/severe depressive symptoms were referred to both the counsellor and upwards for specialist assessment and treatment. Participants were administered a questionnaire including the Patient Health Questionnaire 9 (PHQ9). Service users (n=31) identified by nurse clinicians and referred for counselling and/or further treatment were assigned to the intervention arm, and service users (n=23) not identified with PND by the nurse, but who screened positive on the PHQ-9 were assigned to the control arm. Participants were interviewed at baseline and four months after baseline to assess change in PHQ-9 scores. Qualitative process evaluations were also conducted with five service user participants and eight health workers after the four-month assessment to identify evidence of feasibility and acceptability, challenges and recommendations. Results: The qualitative results from the first phase indicated support for task-shared care and produced service-user recommendations to address the need for psychoeducation, support groups and counselling, either at community or facility-levels for PND. The second phase service provider engagement (participatory workshop) culminated in the co- development of a task-shared, collaborative care model for PND, with strengthened referral pathways, based on the nurse clinician screening, diagnosing, and referring onward to either a facility-based non-specialist counsellor, a doctor or a mental health specialist. In the third phase, an evaluation of the task-shared, collaborative care model with strengthened referral pathways to a co-located psychosocial intervention delivered by non-professional mental health workers at PHC level, indicated a clinically significant decline in depression scores (10- point reduction) in the intervention arm from baseline (M=14.3, SD 2.9), and at four- month follow-up (M=4.3, SD 4.5). Qualitative data indicated that participants experienced the counselling intervention as beneficial and acceptable. The non-specialist, co-located counselling was viewed by most nurses as beneficial although there were recommendations to streamline the screening and diagnosis process. Process indicators suggest that the model is feasible and acceptable. Conclusion and recommendations: This study has contributed new applied knowledge regarding the development and evaluation of a task-shared, integrated, collaborative care model for PND at PHC level in South Africa, providing evidence of feasibility and acceptability of the model of care. The favourable results suggest the potential for a larger effectiveness study, based on the recommendations and lessons garnered from this study. At the time of this report, the policy developments within the mental health landscape demonstrate a level of awareness among a minority of policy-makers, researchers and health care providers of the need to promote perinatal mental health. However, the lessons from this study suggest that key policy level changes are required which include but are not confined to the adoption and reporting of mental health data elements and indicators for PND, and adaptations to the maternity guidelines to include detection in the form of brief screening, assessment, diagnosis and referral for PND. With reference to task-shared mental health care, the inclusion of social workers in counselling treatment plans, and the identification of appropriate cadres, trainers, training, and supervision for non-specialist mental health counsellors are critical factors that require concerted political will and effort.Author's Dedication on page 3

Experiences of South African Indian women screened for postpartum depression.

Thesis (M.Soc.Sc.)-University of KwaZulu-Natal, Durban, 2010.Postpartum depression is a debilitating condition that has been researched in different populations. A surge in prevalence has been noted in non-western cultures and extremely high prevalence has been recorded in some South African studies. There is a dearth of literature on prevalence or experiences of postpartum depression in South African Indian women. AIMS: This study sought to understand the causes and experiences of South African Indian women potentially suffering from postpartum depression with a view to making recommendations for prevention and care of postpartum depression. METHOD: Low-income South African Indian women were screened for postpartum depression at primary health care clinics at two locations in KwaZulu-Natal. The Edinburgh Postnatal Depression Scale was used to screen women for postpartum depression. A semi-structured interview was then carried out to determine eight women’s levels of coping. These included individual, interpersonal, community, societal and cultural coping mechanisms and support systems. RESULTS: In line with other studies on postpartum depression, the study revealed that interpersonal issues, abusive relationships, economic hardships and a lack of adequate social support precipitated or aggravated depressive feelings in the postpartum period. CONCLUSION: A number of recommendations for prevention and treatment of postpartum depression were identified and include Routine Screening, Psycho-education, Interpersonal Therapy, Task-shifting to Community Health Workers to aid in prevention and treatment and increased maternity and paternity leave

Stakeholder analysis of the Programme for Improving Mental health carE (PRIME): baseline findings

Background: The knowledge generated from evidence-based interventions in mental health systems research is sel-dom translated into policy and practice in low and middle-income countries (LMIC). Stakeholder analysis is a poten-tially useful tool in health policy and systems research to improve understanding of policy stakeholders and increase the likelihood of knowledge translation into policy and practice. The aim of this study was to conduct stakeholder analyses in the five countries participating in the Programme for Improving Mental health carE (PRIME); evaluate a template used for cross-country comparison of stakeholder analyses; and assess the utility of stakeholder analysis for future use in mental health policy and systems research in LMIC

Characteristics and correlates of alcohol consumption among adult chronic care patients in North West Province, South Africa.

BACKGROUND: Alcohol consumption patterns in South Africa (SA) tend to be characterised by risky patterns of drinking. Taken together with the large burden of disease associated with HIV and tuberculosis (TB), heavy alcohol consumption patterns with these chronic conditions has the potential to compromise the efficacy of treatment efforts among such patients. OBJECTIVE: To explore the characteristics, correlates and diagnoses of alcohol use disorders among chronic care patients in SA. METHOD: A cross-sectional survey was conducted in three public health clinic facilities in the North West Province of SA. A total of 1 322 patients were recruited from non-emergency waiting areas. RESULTS: Proportions of patients with abstinence, hazardous, harmful and dependent consumption were determined using logistic regression. Of the patients screened, nearly half (45%) drank alcohol and, of these, 10% were classified as hazardous drinkers, 1.7% as harmful drinkers, and 1.6% as dependent drinkers (overall 3% alcohol use disorder). Abstinence proportions were 60% and 38% among women and men, respectively. Alcohol Use Disorders Identification Test scores for men were 63% higher than for women. The lowest patient abstinence proportion (47%) and highest dependent drinking (10%) was for TB. The highest abstinence proportion was for diabetes (65%), and the highest hazardous and harmful drinking was among TB (14%) and HIV (7%) patients. CONCLUSIONS: The high levels of risky drinking among chronic care patients, particularly among patients receiving treatment for HIV and TB, are concerning. Instituting appropriate screening measures and referral to treatment would be an important first step in mitigating the effects of risky alcohol use among chronic care patients

Characteristics and correlates of alcohol consumption among adult chronic care patients in North West Province, South Africa

Background. Alcohol consumption patterns in South Africa (SA) tend to be characterised by risky patterns of drinking. Taken together with the large burden of disease associated with HIV and tuberculosis (TB), heavy alcohol consumption patterns with these chronic conditions has the potential to compromise the efficacy of treatment efforts among such patients.Objective. To explore the characteristics, correlates and diagnoses of alcohol use disorders among chronic care patients in SA.Method. A cross-sectional survey was conducted in three public health clinic facilities in the North West Province of SA. A total of 1 322 patients were recruited from non-emergency waiting areas. Results. Proportions of patients with abstinence, hazardous, harmful and dependent consumption were determined using logistic regression. Of the patients screened, nearly half (45%) drank alcohol and, of these, 10% were classified as hazardous drinkers, 1.7% as harmful drinkers, and 1.6% as dependent drinkers (overall 3% alcohol use disorder). Abstinence proportions were 60% and 38% among women and men, respectively. Alcohol Use Disorders Identification Test scores for men were 63% higher than for women. The lowest patient abstinence proportion (47%) and highest dependent drinking (10%) was for TB. The highest abstinence proportion was for diabetes (65%), and the highest hazardous and harmful drinking was among TB (14%) and HIV (7%) patients. Conclusions. The high levels of risky drinking among chronic care patients, particularly among patients receiving treatment for HIV and TB, are concerning. Instituting appropriate screening measures and referral to treatment would be an important first step in mitigating the effects of risky alcohol use among chronic care patients

Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low-and middle-income countries

BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care

Management of depression in chronic care patients using a task‑sharing approach in a real‑world primary health care setting in South Africa: Outcomes of a cohort study

Depressive symptoms are common in South African primary care patients with chronic medical conditions, but are usually unrecognised and untreated. This study evaluated an integrated, task-sharing collaborative approach to management of depression comorbid with chronic diseases in primary health care (PHC) patients in a real-world setting. Existing HIV clinic counsellors provided a manualised depression counselling intervention with stepped-up referral pathways to PHC doctors for initiation of anti-depressant medication and/ or referral to specialist mental health services. Using a comparative group cohort design, adult PHC patients in 10 PHC facilities were screened with the Patient Health Questionnaire-9 with those scoring above the validated cut-off enrolled. PHC nurses independently assessed, diagnosed and referred patients. Referral for treatment was independently associated with substantial improvements in depression symptoms three months later. The study confirms the viability of task-shared stepped-up collaborative care for depression treatment using co-located counselling in underserved real-world PHC settings

Maternal mental health in primary care in five low- and middle-income countries: a situational analysis.

BACKGROUND: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. METHODS: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. RESULTS: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. CONCLUSIONS: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services

Health service costs and their association with functional impairment among adults receiving integrated mental health care in five low- And middle-income countries- And PRIME cohort study:the PRIME cohort study

This study examines the level and distribution of service costs-and their association with functional impairment at baseline and over time-for persons with mental disorder receiving integrated primary mental health care. The study was conducted over a 12-month follow-up period in five low- and middle-income countries participating in the Programme for Improving Mental health carE study (Ethiopia, India, Nepal, South Africa and Uganda). Data were drawn from a multi-country intervention cohort study, made up of adults identified by primary care providers as having alcohol use disorders, depression, psychosis and, in the three low-income countries, epilepsy. Health service, travel and time costs, including any out-of-pocket (OOP) expenditures by households, were calculated (in US dollars for the year 2015) and assessed at baseline as well as prospectively using linear regression for their association with functional impairment. Cohort samples were characterized by low levels of educational attainment (Ethiopia and Uganda) and/or high levels of unemployment (Nepal, South Africa and Uganda). Total health service costs per case for the 3 months preceding baseline assessment averaged more than US$20 in South Africa,$10 in Nepal and US$3-7 in Ethiopia, India and Uganda; OOP expenditures ranged from$2 per case in India to $16 in Ethiopia. Higher service costs and OOP expenditure were found to be associated with greater functional impairment in all five sites, but differences only reached statistical significance in Ethiopia and India for service costs and India and Uganda for OOP expenditure. At the 12-month assessment, following initiation of treatment, service costs and OOP expenditure were found to be lower in Ethiopia, South Africa and Uganda, but higher in India and Nepal. There was a pattern of greater reduction in service costs and OOP spending for those whose functional status had improved in all five sites, but this was only statistically significant in Nepal