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

Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol

Introduction: Integrating mental healthcare into primary care can reduce the global burden of mental disorders. Yet data on the effective implementation of real-world task-shared mental health programmes are limited. In 2012, the Rwandan Ministry of Health and the international healthcare organisation Partners in Health collaboratively adapted the Mentoring and Enhanced Supervision at Health Centers (MESH) programme, a successful programme of supported supervision based on task-sharing for HIV/AIDS care, to include care of neuropsychiatric disorders within primary care settings (MESH Mental Health). We propose 1 of the first studies in a rural low-income country to assess the implementation and clinical outcomes of a programme integrating neuropsychiatric care into a public primary care system. Methods and analysis A mixed-methods evaluation will be conducted. First, we will conduct a quantitative outcomes evaluation using a pretest and post-test design at 4 purposively selected MESH MH participating health centres. At least 112 consecutive adults with schizophrenia, bipolar disorder, depression or epilepsy will be enrolled. Primary outcomes are symptoms and functioning measured at baseline, 8 weeks and 6 months using clinician-administered scales: the General Health Questionnaire and the brief WHO Disability Assessment Scale. We hypothesise that service users will experience at least a 25% improvement in symptoms and functioning from baseline after MESH MH programme participation. To understand any outcome improvements under the intervention, we will evaluate programme processes using (1) quantitative analyses of routine service utilisation data and supervision checklist data and (2) qualitative semistructured interviews with primary care nurses, service users and family members. Ethics and dissemination This evaluation was approved by the Rwanda National Ethics Committee (Protocol #736/RNEC/2016) and deemed exempt by the Harvard University Institutional Review Board. Results will be submitted for peer-reviewed journal publication, presented at conferences and disseminated to communities served by the programme

Étude du devenir de l'état de stress post-traumatique chez les rescapés du génocide des Tutsi du Rwanda

Entre avril et juillet 1994, un génocide a été perpétré au Rwanda et a emporté plus d un million soixante-quatorze mille (1.074.000) Tutsi. En comparaison avec d autres génocides perpétrés dans le monde, ce drame présente les particularités d avoir été planifié et exécuté par l autorité et d être un génocide de masse et de proximité. Ses conséquences sont multiples et multisectorielles. Cependant, dans ma recherche je m intéresse aux conséquences psycho-traumatiques dans la population Tutsi rescapée qui consulte au Service de Consultations Psychosociales de Kigali au Rwanda, en évaluant l évolution de l état de stress post-traumatique dont ils souffrent. J ai interrogé les dossiers de 55 patients et la classification internationale des maladies mentales. J ai également eu des entretiens aussi bien avec des patients qu avec des cliniciens. Les résultats de ma recherche prouvent qu un traumatisme de forte intensité et la précarité socio-familiale sont des causes d échec thérapeutique. D une manière particulière, les manifestations dissociatives de l état de stress-traumatique chez les victimes de viol se placent comme un grand défi à l établissement d une relation thérapeutique. En analysant les cas cliniques, j ai également identifié chez certains patients des réactivations traumatiques entraînant la chronicisation sinon l apparition intermittente des manifestations psychopathologiques. Un autre phénomène trouvé concerne la place des maladies somatiques concomitantes à l ESPT. En effet, j ai eu affaire à des patients chez qui des troubles somatiques avaient fait écran aux manifestations de l ESPT, ralentissant ainsi la prise en charge. Enfin, j ai découvert un phénomène d aggravation de l ESPT par les états dépressifs majeurs chez la plupart des patients. En général, la clinique du trauma chez les rescapés du génocide contre les Tutsi du Rwanda met le chercheur face à des évolutions multiples. C est d une part une évolution bénigne, d autre part une rémission ponctuée par des périodes de rechutes et enfin une évolution vers la gravité.Between April and July 1994, a genocide was perpetrated in Rwanda during which more than one million seventy four thousand (1,074,000) Tutsi were killed. In comparison to other genocides committed of recent in the world, the Tutsi genocide is unique in the sense that it was planned and executed by the authority; it was also a mass genocide and a genocide of proximity. The consequences are multiple and multi-sectoral. My research has however focused on psycho-traumatic consequences in the population of Tutsi survivors, seeking services at the Psycho Social Consultations Centre based in Kigali, Rwanda; by assessing the evolution of post traumatic stress disorder (PTSD) they were suffering from.I reviewed medical records of 55 patients and the international classification of mental diseases. I also interviewed patients as well as clinicians. The study findings reveal that a high intensity traumatic event and the family precariousness are causes of therapeutic failures. Specifically, dissociative aspects of post traumatic stress disorder experienced by victims of sexual rape are indeed a big challenge to the establishment of a therapeutic relationship. I also observed while reviewing clinical cases, traumatic reactivations for some patients that caused chronicity or intermittent apparition of psychopathologic manifestations. Another phenomenon observed concerns the somatic diseases concomitant to PTSD. Indeed we had patients for whom somatic problems obstructed the manifestations of PTSD, hence delaying their treatment. Finally, I noticed a phenomenon of aggravation of PTSD by acute depressive disorders for almost all patients. Overall, the clinic of trauma of the survivors of the Genocide of the Tutsi of Rwanda leads the researcher to multiple evolutions. On one side we have a benign evolution, on the other side a remission punctuated by periods of relapses and finally, an evolution towards gravity.ST DENIS-BU PARIS8 (930662101) / SudocSudocFranceF

Health policies impacts on providers' Self-Esteem in Rwanda: some unexpected results

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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

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

Abstract 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.http://deepblue.lib.umich.edu/bitstream/2027.42/173639/1/12887_2020_Article_2475.pd

Mental Health and Antiretroviral Adherence Among Youth Living With HIV in Rwanda.

In Rwanda, significant progress has been made in advancing access to antiretroviral therapy (ART) among youth. As availability of ART increases, adherence is critical for preventing poor clinical outcomes and transmission of HIV. The goals of the study are to (1) describe ART adherence and mental health problems among youth living with HIV aged 10 to 17; and (2) examine the association between these factors among this population in rural Rwanda. A cross-sectional analysis was conducted that examined the association of mental health status and ART adherence among youth (n = 193). ART adherence, mental health status, and related variables were examined based on caregiver and youth report. Nonadherence was defined as ever missing or refusing a dose of ART within the past month. Multivariate modeling was performed to examine the association between mental health status and ART adherence. Approximately 37% of youth missed or refused ART in the past month. In addition, a high level of depressive symptoms (26%) and attempt to hurt or kill oneself (12%) was observed in this population of youth living with HIV in Rwanda. In multivariate analysis, nonadherence was significantly associated with some mental health outcomes, including conduct problems (odds ratio 2.90, 95% confidence interval 1.55-5.43) and depression (odds ratio 1.02, 95% confidence interval 1.01-1.04), according to caregiver report. A marginally significant association was observed for youth report of depressive symptoms. The findings suggest that mental health should be considered among the factors related to ART nonadherence in HIV services for youth, particularly for mental health outcomes, such as conduct problems and depression

Feasibility study to evaluate capabilities for conducting psychiatric clinical research within the Rwandan mental healthcare system

Objective To evaluate the feasibility of conducting a large clinical trial within the Rwandan mental healthcare system that would establish the safety, efficacy and benefit of paliperidone palmitate once-monthly (PP1M) and once-every-3-months (PP3M) long-acting injectable formulations in adults with schizophrenia.Study design An open-label, prospective feasibility study.Setting/Participants 33 adult patients with schizophrenia were enrolled at 3 sites across Rwanda.Interventions The study design included 3 phases of treatment: an oral run-in to establish tolerability to risperidone (1 week), lead-in treatment with flexibly dosed PP1M to identify a stable dose (17 weeks) and maintenance treatment with PP3M (24 weeks).Primary and secondary outcome measures Feasibility endpoints included compliance with governmental and institutional requirements, acceptable supply chain delivery and proper onsite administration of risperidone/PP1M/PP3M, adequate site infrastructure, adequate training of clinical staff and successful completion of study procedures and scales. A variety of study scales were administered to assess outcomes relevant to patients, caregivers, clinicians and payers in Rwanda and other resource-limited settings.Results This study was terminated early by the sponsor because certain aspects of study conduct needed to be addressed to maintain Good Clinical Practice requirements and meet regulatory standards. Results identified areas for improvement in study execution, including study governance, site infrastructure, study preparation and conduct of procedures, study budget and study assessments. Despite the identification of areas in need of adjustment, none of these limitations were considered insurmountable.Conclusions This work was designed to strengthen global research in schizophrenia by building the capacity of researchers to prepare and conduct pharmaceutical trials in resource-limited settings. Although the study was ended early, modifications motivated by the results will facilitate the successful design and completion of more comprehensive studies, including an ongoing, follow-up interventional trial of PP1M/PP3M in a larger population of patients in Rwanda.Trial registration number NCT0371365

Mental Health and Antiretroviral Adherence Among Youth Living With HIV in Rwanda.

Background and objectivesIn Rwanda, significant progress has been made in advancing access to antiretroviral therapy (ART) among youth. As availability of ART increases, adherence is critical for preventing poor clinical outcomes and transmission of HIV. The goals of the study are to (1) describe ART adherence and mental health problems among youth living with HIV aged 10 to 17; and (2) examine the association between these factors among this population in rural Rwanda.MethodsA cross-sectional analysis was conducted that examined the association of mental health status and ART adherence among youth (n = 193). ART adherence, mental health status, and related variables were examined based on caregiver and youth report. Nonadherence was defined as ever missing or refusing a dose of ART within the past month. Multivariate modeling was performed to examine the association between mental health status and ART adherence.ResultsApproximately 37% of youth missed or refused ART in the past month. In addition, a high level of depressive symptoms (26%) and attempt to hurt or kill oneself (12%) was observed in this population of youth living with HIV in Rwanda. In multivariate analysis, nonadherence was significantly associated with some mental health outcomes, including conduct problems (odds ratio 2.90, 95% confidence interval 1.55-5.43) and depression (odds ratio 1.02, 95% confidence interval 1.01-1.04), according to caregiver report. A marginally significant association was observed for youth report of depressive symptoms.ConclusionsThe findings suggest that mental health should be considered among the factors related to ART nonadherence in HIV services for youth, particularly for mental health outcomes, such as conduct problems and depression

Correction: Ethics in Community-Based Research with Vulnerable Children: Perspectives from Rwanda.

[This corrects the article DOI: 10.1371/journal.pone.0157042.]