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

Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial

Background: The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods: The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion: The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings

Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: pragmatic parallel cluster randomised controlled trial.

Background: We tested the real-world effectiveness of a collaborative task-sharing model on depressive symptom reduction in hypertensive Primary Health Care (PHC) patients in South Africa. Method: A pragmatic parallel cluster randomised trial in 20 clinics in the Dr Kenneth Kaunda district, North West province. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Control clinics received care as usual (CAU), involving referral to PHC doctors and/or mental health specialists. Intervention clinics received CAU plus enhanced mental health training and a lay counselling referral service. Participant inclusion criteria were ≥ 18 years old, Patient Health Questionnaire-9 (PHQ-9) score ≥ 9 and receiving hypertension medication. Primary superiority outcome was ≥ 50% reduction in PHQ-9 score at 6 months. Statistical analyses comprised mixed effects regression models and a non-inferiority analysis. Trial registration number: NCT 02425124. Results: Between April 2015 and October 2015, 1043 participants were enrolled (504 intervention and 539 control); 82% were women; half were ≥ 55 years. At 6 and 12 months follow-up, 91% and 89% of participants were interviewed respectively. One control group participant committed suicide. There was no significant difference in the primary outcome between intervention (N=256/456) and control (N=232/492) groups (55.9% versus 50.9%; adjusted risk difference = -0.04 ([95% CI = -0.19; 0.11], p = 0.6). The difference in PHQ-9 scores was within the defined equivalence limits at 6 and 12 months for the non-inferiority analysis. Limitations: The trial was limited by low exposure to depression treatment by trial participants and by observed co-intervention in control clinics Conclusions: Incorporating lay counselling services within collaborative care models does not produce superior nor inferior outcomes to models with specialist only counselling services. Funding: This work was supported by the UK Department for International Development [201446] as well as the National Institute of Mental Health, United States of America, grant number 1R01MH100470-01. Graham Thornicroft is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College London and King's College Hospital NHS Foundation Trust