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

Medico-religious collaboration: a model for mental health care in a resource poor country

Background: Reducing the treatment gap for the treatment of people with psychiatric disorders (also known as the ‘mental health gap’) is of increasing importance worldwide. In Low and Middle Income Countries (LMICs) human and material resources for orthodox (‘western’) mental health care are severely inadequate. As such, alternative mental health practices tend to thrive. Such alternative systems of care could be formally linked with western services to achieve a more integrated pattern of care in order to improve access for all users of mental health services in these communities, while ensuring a reduction in harm and promoting the human rights of people with mental health problems.Aim: To describe a medico-religious mental health care collaborative model in a rural community in Nigeria, which may be suitable for scaling up mental health care in LMICs as a whole.Methods: This is a descriptive report of a psychiatric service in collaboration with a Christian religious settlement, based in Ogun State, Western Nigeria. Questionnaires, focus group discussions and direct observation were employed. Client records from the religious center and from the visiting psychiatric team were also examined, and all the data from all sources were synthesized.Results: Interactions between the medical and religious mental health care providers improved consistently over the study period. Acceptance of medical services and understanding of the need for collaboration increased. Increased utilization by people with mental illness from the nearby settlement was observed. In the course of collaboration, the occurrence of harmful practices(though still much in practice), reduced considerably as evidenced by stoppage of prolonged sleep and food deprivation (in form of night vigils and fasting) and flagellation, while physical restrictions with chains, especially for newly admitted sufferers still continued unabated despite the discouragement of such practice by medical practitioners.Conclusions: A structured collaborative arrangement between medical and religious health care practitioners offers a great possibility towards the scaling up of mental health care in a resource poor setting such as Nigeria. In addition, it offers potential benefits to services users, such as: improved access to proven reliable medical care, better continuity of care, and reduction in harmful traditional practices usually used to treat these groups of people. Challenges of fundamental human rights abuse and funding are important areas for local mental health policies to address in such settings. In addition, institutional support is still inadequate and there is need for program sustainability.Keywords: Collaboration, Medico-religion, Mental health, Resource poor, LMI

Indirect social contact interventions to reduce mental health-related stigma in low- and middle-income countries: systematic review.

AIMS: Mental health-related stigma and discrimination are a complex and widespread issue with negative effects on numerous aspects of life of people with lived experience of mental health conditions. Research shows that social contact is the best evidence-based intervention to reduce stigma. Within the context of a rapid development of remote technology, and COVID-19-related restrictions for face-to-face contact, the aim of this paper is to categorise, compare and define indirect social contact (ISC) interventions to reduce stigma and discrimination in mental health in low- and middle-income countries (LMICs). METHODS: MEDLINE, Global Health, EMBASE, PsychINFO, Cochrane Central Register of Control Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched using a strategy including terms related to 'stigma and discrimination', 'intervention', 'indirect social contact', 'mental health' and 'low- and middle-income countries'. Relevant information on ISC interventions was extracted from the included articles, and a quality assessment was conducted. Emerging themes were coded using a thematic synthesis method, and a narrative synthesis was undertaken to present the results. RESULTS: Nine studies were included in the review overall. One study was ineffective; this was not considered for the categorisation of interventions, and it was considered separately for the comparison of interventions. Of the eight effective studies included in synthesis, interventions were categorised by content, combination of stigma-reducing strategies, medium of delivery, delivery agents, target condition and population, as well as by active or passive interaction and follow-up. Most of the interventions used education and ISC. Recovery and personal experience were important content components as all studies included either one or both. Cultural adaptation and local relevance were also important considerations. CONCLUSIONS: ISC interventions were effective in overall terms for both the general public and healthcare providers, including medical students. A new definition of ISC interventions in LMICs is proposed. More research and better reporting of intervention details are needed to explore the effectiveness of ISC strategies in LMICs, especially in regions where little relevant research has been conducted

Reported stigma and discrimination by people with a diagnosis of schizophrenia

Aims. This article examines the extent of stigma and discrimination as reported by people with a diagnosis of schizophrenia. The hypothesis is that when people express in their own words the discrimination they experience such discrimination will be found to be widespread. Methods. Seventy-five people with a diagnosis of schizophrenia from 15 different countries were interviewed with a mixed methods instrument to assess reported discrimination. The data were analysed for frequency counts and then a thematic analysis was performed. A conceptual map is provided. Results. The study was a cross-cultural one but, contrary to expectations, few transnational differences were found. The main hypothesis was supported. Conversely, we found that when participants reported ‘positive discrimination', this could as easily be conceptualised as being treated similarly to how others in society would expect to be treated. Conclusion. Negative discrimination is ubiquitous and sometimes connotatively very strong, with reports of humiliation and abuse. ‘Positive discrimination' conversely indicates that people with a mental illness diagnosis expect discrimination and are grateful when it does not occur. The literature on self-stigma is discussed and found wanting. Similarly, the theory that contact with mentally ill people reduces stigma and discrimination is not fully supported by our result

A study of psychiatrists’ concepts of mental illness

Background: There are multiple models of mental illness that inform professional and lay understanding. Few studies have formally investigated psychiatrists' attitudes. We aimed to measure how a group of trainee psychiatrists understand familiar mental illnesses in terms of propositions drawn from different models. Method: We used a questionnaire study of a sample of trainees from South London and Maudsley National Health Service (NHS) Foundation Trust designed to assess attitudes across eight models of mental illness (e.g. biological, psychodynamic) and four psychiatric disorders. Methods for analysing repeated measures and a principal components analysis (PCA) were used. Results: No one model was endorsed by all respondents. Model endorsement varied with disorder. Attitudes to schizophrenia were expressed with the greatest conviction across models. Overall, the ‘biological’ model was the most strongly endorsed. The first three components of the PCA (interpreted as dimensions around which psychiatrists, as a group, understand mental illness) accounted for 56% of the variance. Each main component was classified in terms of its distinctive combination of statements from different models: PC1 33% biological versus non-biological; PC2 12% ‘eclectic’ (combining biological, behavioural, cognitive and spiritual models); and PC3 10% psychodynamic versus sociological. Conclusions: Trainee psychiatrists are most committed to the biological model for schizophrenia, but in general are not exclusively committed to any one model. As a group, they organize their attitudes towards mental illness in terms of a biological/non-biological contrast, an ‘eclectic’ view and a psychodynamic/sociological contrast. Better understanding of how professional group membership influences attitudes may facilitate better multidisciplinary working

Public knowledge, attitudes, social distance and reported contact regarding people with mental illness 2009-2015

Objective To investigate whether public knowledge, attitudes, desire for social distance and reported contact in relation to people with mental health problems have improved in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009–2015. Methods Using data from an annual face-to-face survey of a nationally representative sample of adults, we analysed longitudinal trends in the outcomes with regression modelling using standardised scores of the measures overall and by age and gender subgroups. Results There were improvements in all outcomes. The improvement for knowledge was 0.17 standard deviation units in 2015 compared to 2009 (95% CI 0.10, 0.23); for attitudes 0.20 standard deviation units (95% CI 0.14, 0.27) and for social distance 0.17 standard deviation units (95% CI 0.11, 0.24). Survey year for 2015 vs. 2009 was associated with a higher likelihood of reported contact (OR 1.32, 95% CI 1.13, 1.53). Statistically significant interactions between year and age suggest the campaign had more impact on the attitudes of the target age group (25–45) than those aged over 65 or under 25. Women's reported contact with people with mental health problems increased more than did men's. Conclusion The results provide support for the effectiveness of TTC

Developing implementation research capacity: longitudinal evaluation of the King's College London Implementation Science Masterclass, 2014-2019.

BACKGROUND: Despite an increasing number of training opportunities in implementation science becoming available, the demand for training amongst researchers and practitioners is unmet. To address this training shortfall, we developed the King's College London 'Implementation Science Masterclass' (ISM), an innovative 2-day programme (and currently the largest of its kind in Europe), developed and delivered by an international faculty of implementation experts. METHODS: This paper describes the ISM and provides delegates' quantitative and qualitative evaluations (gathered through a survey at the end of the ISM) and faculty reflections over the period it has been running (2014-2019). RESULTS: Across the 6-year evaluation, a total of 501 delegates have attended the ISM, with numbers increasing yearly from 40 (in 2014) to 147 (in 2019). Delegates represent a diversity of backgrounds and 29 countries from across the world. The overall response rate for the delegate survey was 64.5% (323/501). Annually, the ISM has been rated 'highly' in terms of delegates' overall impression (92%), clear and relevant learning objectives (90% and 94%, respectively), the course duration (85%), pace (86%) and academic level 87%), and the support provided on the day (92%). Seventy-one percent of delegates reported the ISM would have an impact on how they approached their future work. Qualitative feedback revealed key strengths include the opportunities to meet with an international and diverse pool of experts and individuals working in the field, the interactive nature of the workshops and training sessions, and the breadth of topics and contexts covered. CONCLUSIONS: Yearly, the UK ISM has grown, both in size and in its international reach. Rated consistently favourably by delegates, the ISM helps to tackle current training demands from all those interested in learning and building their skills in implementation science. Evaluation of the ISM will continue to be an annual iterative process, reflective of changes in the evidence base and delegates changing needs as the field evolves

Discrimination reported by people with schizophrenia: cross-national variations in relation to the Human Development Index.

AIMS: Mental health related stigma and discrimination is a universal phenomenon and a contributor to the adversity experienced by people with schizophrenia. Research has produced inconsistent findings on how discrimination differs across settings and the contextual factors that underpin these differences. This study investigates the association between country-level Human Development Index (HDI) and experienced and anticipated discrimination reported by people with schizophrenia. METHODS: This study is a secondary data analysis of a global cross-sectional survey completed by people living with schizophrenia across 29 countries, between 2005 and 2008. Experienced and anticipated discrimination were assessed using the Discrimination and Stigma Scale (DISC-10). Countries were classified according to their 2006 HDI. Negative binomial and Poisson regression analyses with a robust standard errors approach were conducted to investigate associations between country-level HDI and discrimination. RESULTS: In the regression analyses, no evidence was found for a linear association between HDI and experienced or anticipated discrimination. Further exploratory analyses showed a significant non-linear association between HDI ratings and experienced discrimination. Participants in "high" and "very high" HDI countries reported more experienced discrimination compared to those in "medium" HDI countries. CONCLUSIONS: HDI does, to some extent, appear to be associated with how far discrimination is experienced across different contexts. More high-quality cross-national research, including research focused on "medium" and "low" countries, is needed to substantiate these findings and identify underlying factors that may explain the pattern observed for experienced discrimination, including generating new datasets that would enable for these analyses to be repeated and contrasted with more recent data. An in-depth understanding of these factors will further aid the adaptation of cross-cultural and context specific anti-stigma interventions in future