Mental health related stigma, service provision and utilization in Northern India: situational analysis.

Stigma, discrimination, poor help seeking, dearth of mental health professionals, inadequate services and facilities all adversely impact the mental health treatment gap. Service utilization by the community is influenced by cultural beliefs and literacy levels. We conducted a situational analysis in light of the little information available on mental health related stigma, service provision and utilization in Haryana, a state in Northern India. This involved: (a) qualitative key informant interviews; (b) health facility records review; and (c) policy document review to understand the local context of Faridabad district in Northern India. Ethical approvals for the study were taken before the study commenced. Phone call in-depth interviews were carried out with a purposive sample of 13 participants (Mean = 38.07 years) during the COVID-19 pandemic, which included 4 community health workers, 4 people with mental illness, 5 service providers (primary health care doctors and mental health specialists). Data for health facility review was collected from local primary health and specialist facilities while key policy documents were critically analysed for service provision and stigma alleviation activities. Thematic analysis was used to analyse patterns within the interview data. We found poor awareness and knowledge about mental illnesses, belief in faith and traditional healers, scarcity of resources (medicines, trained professionals and mental health inpatient and outpatient clinics), poor access to appropriate mental health facilities, and high costs for seeking mental health care. There is a critical gap between mental health related provisions in policy documents and its implementation at primary and district level.

COVID-19 related stigma among the general population in Iran.

BACKGROUND: COVID-19 related stigma has been identified as a critical issue since the beginning of the pandemic. We developed a valid and reliable questionnaire to measure COVID-19 related enacted stigma, inflicted by the non-infected general population. We applied the questionnaire to measure COVID-19 related enacted stigma among Tehran citizens from 27 to 30 September 2020. METHODS: A preliminary questionnaire with 18 items was developed. The total score ranged from 18 to 54; a higher score indicated a higher level of COVID-19 related stigma. An expert panel assessed the face and content validity. Of 1637 randomly recruited Tehran citizens without a history of COVID-19 infection, 1064 participants consented and were interviewed by trained interviewers by phone. RESULTS: Item content validity index (I-CVI), Item content validity ratio (I-CVR), and Item face validity index (I-FVI) were higher than 0.78 for all 18 items. The content and face validity were established with a scale content validity index (S-CVI) of 0.90 and a scale face validity index (S-CVI) of 93.9%, respectively. Internal consistency of the questionnaire with 18 items was confirmed with Cronbach's alpha of 0.625. Exploratory factor analysis revealed five latent variables, including "blaming", "social discrimination", "dishonor label", "interpersonal contact", and "retribution and requital attitude". The median of the stigma score was 24 [25th percentile: 22, 75the percentile: 28]. A large majority (86.8%) of participants reported a low level of stigma with a score below 31. None of the participants showed a high level of stigma with a score above 43. We found that the higher the educational level the lower the participant's stigma score. CONCLUSION: We found a low level of stigmatizing thoughts and behavior among the non-infected general population in Tehran, which may be due to the social desirability effect, to the widespread nature of COVID-19, or to the adaptation to sociocultural diversity of the large city.

Operational challenges in the pre-intervention phase of a mental health trial in rural India: reflections from SMART Mental Health.

BACKGROUND: Availability of mental health services in low- and middle-income countries is largely concentrated in tertiary care with limited resources and scarcity of trained professionals at the primary care level. SMART Mental Health is a strategy that combines a community anti-stigma campaign with a primary health care workforce strengthening initiative, using electronic decision support with the goal of better identifying and supporting people with common mental disorders in India. METHODS: We describe the challenges faced and lessons learnt during the pre-intervention phase of SMART Mental Health cluster Randomised Controlled Trial. Pre-intervention phase includes preliminary activities for setting-up the trial and research activities prior to delivery of the intervention. Field notes from project site visit, project team meetings and detailed follow-up discussions with members of the project team were used to document operational challenges and strategies adopted to overcome them. The socio-ecological model was used as the analytical framework to organise the findings. RESULTS: Key challenges included delays in government approvals, addressing community health worker needs, and building trust in the community. These were addressed through continuous communication, leveraging support of relevant stakeholders, and addressing concerns of community health workers and community. Issues related to use of digital platform for data collection were addressed by a dedicated technical support team. The COVID-19 pandemic and political unrest led to significant and unexpected challenges requiring important adaptations to successfully implement the project. CONCLUSION: Setting up of this trial has posed challenges at a combination of community, health system and broader socio-political levels. Successful mitigating strategies to overcome these challenges must be innovative, timely and flexibly delivered according to local context. Systematic ongoing documentation of field-level challenges and subsequent adaptations can help optimise implementation processes and support high quality trials. TRIAL REGISTRATION: The trial is registered with Clinical Trials Registry India (CTRI/2018/08/015355). Registered on 16th August 2018. http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=23254&EncHid=&userName=CTRI/2018/08/015355.

Protocol for process evaluation of SMART Mental Health cluster randomised control trial: an intervention for management of common mental disorders in India.

INTRODUCTION: In India about 95% of individuals who need treatment for common mental disorders like depression, stress and anxiety and substance use are unable to access care. Stigma associated with help seeking and lack of trained mental health professionals are important barriers in accessing mental healthcare. Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health integrates a community-level stigma reduction campaign and task sharing with the help of a mobile-enabled electronic decision support system (EDSS)-to reduce psychiatric morbidity due to stress, depression and self-harm in high-risk individuals. This paper presents and discusses the protocol for process evaluation of SMART Mental Health. METHODS AND ANALYSIS: The process evaluation will use mixed quantitative and qualitative methods to evaluate implementation fidelity and identify facilitators of and barriers to implementation of the intervention. Case studies of six intervention and two control clusters will be used. Quantitative data sources will include usage analytics extracted from the mHealth platform for the trial. Qualitative data sources will include focus group discussions and interviews with recruited participants, primary health centre doctors, community health workers (Accredited Social Health Activits) who participated in the project and local community leaders. The design and analysis will be guided by Medical Research Council framework for process evaluations, the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, and the normalisation process theory. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee of the George Institute for Global Health, India and the Institutional Ethics Committee, All India Institute of Medical Sciences (AIIMS), New Delhi. Findings of the study will be disseminated through peer-reviewed publications, stakeholder meetings, digital and social media platforms. TRIAL REGISTRATION NUMBER: CTRI/2018/08/015355.

Anxiety and depressive symptoms among physicians during the COVID-19 pandemic in Bangladesh: a cross-sectional study.

Objectives: In addition to risking their physical well-being, frontline physicians are enduring significant emotional burden both at work and home during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to investigate the levels of anxiety and depressive symptoms and to identify associated factors among Bangladeshi physicians during the COVID-19 outbreak. Methods and design: A cross-sectional study using an online survey following a convenience sampling technique was conducted between April 21 and May 10, 2020. Outcomes assessed included demographic questions, COVID-19 related questions, and the Hospital Anxiety and Depression Scale (HADS). Results: The survey was completed by 412 Bangladeshi physicians. The findings revealed that, in terms of standardized HADS cut-off points, the prevalence of anxiety and depressive symptoms among physicians was 67.72% and 48.5% respectively. Risk factors for higher rates of anxiety or depressive symptoms were: being female, physicians who had experienced COVID-19 like symptoms during the pandemic, those who had not received incentives, those who used self-funded personal protective equipment (PPE), not received adequate training, lacking perceived self-efficacy to manage COVID-19 positive patients, greater perceived stress of being infected, fear of getting assaulted/humiliated, being more connected with social media, having lower income levels to support the family, feeling more agitated, less than 2 h of leisure activity per day and short sleep duration. All these factors were found to be positively associated with anxiety and depression in unadjusted and adjusted statistical models. Conclusions: This study identifies a real concern about the prevalence of anxiety and depressive symptoms among Bangladeshi physicians and identifies several associated factors during the COVID-19 pandemic. Given the vulnerability of the physicians in this extraordinary period whilst they are putting their own lives at risk to help people infected by COVID-19, health authorities should address the psychological needs of medical staff and formulate effective strategies to support vital frontline health workers.

A systematic review and meta-analysis on prevalence of and risk factors associated with depression, anxiety and insomnia in infectious diseases, including COVID-19: a call to action.

Infectious disease epidemics have become more frequent and more complex during the 21st century, posing a health threat to the general public and leading to psychological symptoms. The current study was designed to investigate the prevalence of and risk factors associated with depression, anxiety and insomnia symptoms during epidemic outbreaks, including COVID-19. We systematically searched the PubMed, Embase, Web of Science, OVID, Medline, Cochrane databases, bioRxiv and medRxiv to identify studies that reported the prevalence of depression, anxiety or insomnia during infectious disease epidemics, up to August 14th, 2020. Prevalence of mental symptoms among different populations including the general public, health workers, university students, older adults, infected patients, survivors of infection, and pregnant women across all types of epidemics was pooled. In addition, prevalence of mental symptoms during COVID-19 was estimated by time using meta-regression analysis. A total of 17,506 papers were initially retrieved, and a final of 283 studies met the inclusion criteria, representing a total of 948,882 individuals. The pooled prevalence of depression ranged from 23.1%, 95% confidential intervals (95% CI: [13.9-32.2]) in survivors to 43.3% (95% CI: [27.1-59.6]) in university students, the pooled prevalence of anxiety ranged from 25.0% (95% CI: [12.0-38.0]) in older adults to 43.3% (95% CI: [23.3-63.3]) in pregnant women, and insomnia symptoms ranged from 29.7% (95% CI: [24.4-34.9]) in the general public to 58.4% (95% CI: [28.1-88.6]) in university students. Prevalence of moderate-to-severe mental symptoms was lower but had substantial variation across different populations. The prevalence of mental problems increased over time during the COVID-19 pandemic among the general public, health workers and university students, and decreased among infected patients. Factors associated with increased prevalence for all three mental health symptoms included female sex, and having physical disorders, psychiatric disorders, COVID infection, colleagues or family members infected, experience of frontline work, close contact with infected patients, high exposure risk, quarantine experience and high concern about epidemics. Frequent exercise and good social support were associated with lower risk for these three mental symptoms. In conclusion, mental symptoms are common during epidemics with substantial variation across populations. The population-specific psychological crisis management are needed to decrease the burden of psychological problem and improve the mental wellbeing during epidemic.

Mental healthcare in primary and community-based settings: evidence beyond the WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide.

OBJECTIVES: The WHO's Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) has been widely used in low and middle-income countries. We reviewed literature describing interventions and training programmes beyond the mhGAP-IG, in primary healthcare (PHC) and community-based healthcare (CBH). DESIGN: We searched studies excluded from our updated mhGAP-IG systematic review, and included in other relevant systematic reviews, for evidence and experience of initiatives integrating mental health into PHC and CBH. Our 24 November 2020 mhGAP-IG search encompassed MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, 3ie and Google Scholar. Although heterogeneity prevented meta-analysis, we descriptively summarised the evidence-base. RESULTS: Out of 1827 results, we identified 208 relevant records. They described randomised controlled trials of mental health interventions (98 studies, n=55 523 participants), non-randomised studies measuring clinical outcomes (22 studies, n=7405), training outcomes (36 studies, n=12 280) and implementation outcomes (21 studies, n=1090), plus descriptive accounts (18 studies, n=2526), baseline surveys and exploratory studies (6 studies, n=17 093) and commentaries (7 studies). Most (40%) were conducted in the African region, region of the Americas (16%), and South-East Asia (13%). Randomised and non-randomised studies reported improved symptoms, substance use, functioning, parenting and child outcomes. Non-randomised studies reported improved clinical knowledge, confidence and skills following training. CONCLUSIONS: The literature beyond the mhGAP-IG is extensive and shares common findings. Future priorities are less-studied regions, interventions for severe mental illness, exploring ways that mhGAP-IG and alternative approaches complement each other in different contexts and scaling-up mental health integration.PROSPERO registration numberCRD42017068459.

Training for mental health professionals in responding to experienced and anticipated mental health related discrimination (READ-MH): protocol for an international multisite feasibility study.

Background: Mental health and other health professionals working in mental health care may contribute to the experiences of stigma and discrimination among mental health service users, but can also help reduce the impact of stigma on service users. However the few studies of interventions to equip such professionals to be anti-stigma agents those took place in High-Income Countries. This study assesses the feasibility, potential effectiveness and costs of Responding to Experienced and Anticipated Discrimination training for health professionals working in mental health care (READ-MH) across Low- and Middle-Income Countries (LMICs). Methods: This is an uncontrolled pre-post mixed methods feasibility study of READ-MH training at seven sites across five LMICs (China, Ethiopia, India, Nepal, and Tunisia). Outcome measures: knowledge based on course content; attitudes to working to address the impact of stigma on service users; and skills in responding constructively to service users' reports of discrimination. The training draws upon the evidence bases for stigma reduction, health advocacy and medical education and is tailored to sites through situational analyses. Its content, delivery methods and intensity were agreed through a consensus exercise with site research teams. READ-MH will be delivered to health professionals working in mental health care immediately after baseline data collection; outcome measures will be collected post-training and three months post-baseline, followed by qualitative data collection. Fidelity will be rated during delivery of READ-MH, and data on training costs will be collected. Quantitative data will be assessed using generalised linear mixed models. Qualitative data will be evaluated by thematic analysis to identify feedback about the training methods and content, including the implementability of the knowledge and skills learned. Pooled and site-specific training costs per trainee and per session will be reported. Conclusions: The training development used a participatory and contextualized approach. Evaluation design strengths include the diversity of settings; the use of mixed methods; the use of a skills-based measure; and knowledge and attitude measures aligned to the target population and training. Limitations are the uncertain generalisability of skills performance to routine care, and the impact of COVID-19 restrictions at several sites limiting qualitative data collection for situational analyses.

Safety of Psychotropic Medications in People With COVID-19: Evidence Review and Practical Recommendations.

(Reprinted with permission from the BMC Medicine (2020) 18:215).

"COVID-19 mental health impact and responses in low-income and middle income countries: Reimagining global mental health": Correction

Reports an error in "COVID-19 mental health impact and responses in low-income and middle-income countries: Reimagining global mental health" by Lola Kola, Brandon A. Kohrt, Charlotte Hanlon, John A. Naslund, Siham Sikander, Madhumitha Balaji, Corina Benjet, Eliza Yee Lai Cheung, Julian Eaton, Pattie Gonsalves, Maji Hailemariam, Nagendra P. Luitel, Daiane B. Machado, Eleni Misganaw, Olayinka Omigbodun, Tessa Roberts, Tatiana Taylor Salisbury, Rahul Shidhaye, Charlene Sunkel, Victor Ugo, Andre Janse van Rensburg, Oye Gureje, Soumitra Pathare, Shekhar Saxena, Graham Thornicroft and Vikram Patel (The Lancet Psychiatry, 2021[Jun], Vol 8[6], 535-550). In this Review, Lola Kola's degree should have been PhD and Brandon A Kohrt's degree should have been PhD. Madhumitha Balaji's affiliation should have been "Sangath, India". These corrections have been made to the online version as of Mar 8, 2021, and will be made to the printed version. (The following abstract of the original article appeared in record 2021-51602-023.) Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies;notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Mental health services for infectious disease outbreaks including COVID-19: a rapid systematic review.

The upsurge in the number of people affected by the COVID-19 is likely to lead to increased rates of emotional trauma and mental illnesses. This article systematically reviewed the available data on the benefits of interventions to reduce adverse mental health sequelae of infectious disease outbreaks, and to offer guidance for mental health service responses to infectious disease pandemic. PubMed, Web of Science, Embase, PsycINFO, WHO Global Research Database on infectious disease, and the preprint server medRxiv were searched. Of 4278 reports identified, 32 were included in this review. Most articles of psychological interventions were implemented to address the impact of COVID-19 pandemic, followed by Ebola, SARS, and MERS for multiple vulnerable populations. Increasing mental health literacy of the public is vital to prevent the mental health crisis under the COVID-19 pandemic. Group-based cognitive behavioral therapy, psychological first aid, community-based psychosocial arts program, and other culturally adapted interventions were reported as being effective against the mental health impacts of COVID-19, Ebola, and SARS. Culturally-adapted, cost-effective, and accessible strategies integrated into the public health emergency response and established medical systems at the local and national levels are likely to be an effective option to enhance mental health response capacity for the current and for future infectious disease outbreaks. Tele-mental healthcare services were key central components of stepped care for both infectious disease outbreak management and routine support; however, the usefulness and limitations of remote health delivery should also be recognized.

Correction to: Safety of psychotropic medications in people with COVID-19: evidence review and practical recommendations.

An amendment to this paper has been published and can be accessed via the original article.

Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic.

BACKGROUND: The COVID pandemic has been devastating for not only its direct impact on lives, physical health, socio-economic status of individuals, but also for its impact on mental health. Some individuals are affected psychologically more severely and will need additional care. However, the current health system is so fragmented and focused on caring for those infected that management of mental illness has been neglected. An integrated approach is needed to strengthen the health system, service providers and research to not only manage the current mental health problems related to COVID but develop robust strategies to overcome more long-term impact of the pandemic. A series of recommendations are outlined in this paper to help policy makers, service providers and other stakeholders, and research and research funders to strengthen existing mental health systems, develop new ones, and at the same time advance research to mitigate the mental health impact of COVID19. The recommendations refer to low, middle and high resource settings as capabilities vary greatly between countries and within countries. DISCUSSION: The recommendations for policy makers are focused on strengthening leadership and governance, finance mechanisms, and developing programme and policies that especially include the most vulnerable populations. Service provision should focus on accessible and equitable evidence-based community care models commensurate with the existing mental health capacity to deliver care, train existing primary care staff to cater to increased mental health needs, implement prevention and promotion programmes tailored to local needs, and support civil societies and employers to address the increased burden of mental illness. Researchers and research funders should focus on research to develop robust information systems that can be enhanced further by linking with other data sources to run predictive models using artificial intelligence, understand neurobiological mechanisms and community-based interventions to address the pandemic driven mental health problems in an integrated manner and use innovative digital solutions. CONCLUSION: Urgent action is needed to strengthen mental health system in all settings. The recommendations outlined can be used as a guide to develop these further or identify new ones in relation to local needs.

Safety of psychotropic medications in people with COVID-19: evidence review and practical recommendations.

BACKGROUND: The novel coronavirus pandemic calls for a rapid adaptation of conventional medical practices to meet the evolving needs of such vulnerable patients. People with coronavirus disease (COVID-19) may frequently require treatment with psychotropic medications, but are at the same time at higher risk for safety issues because of the complex underlying medical condition and the potential interaction with medical treatments. METHODS: In order to produce evidence-based practical recommendations on the optimal management of psychotropic medications in people with COVID-19, an international, multi-disciplinary working group was established. The methodology of the WHO Rapid Advice Guidelines in the context of a public health emergency and the principles of the AGREE statement were followed. Available evidence informing on the risk of respiratory, cardiovascular, infective, hemostatic, and consciousness alterations related to the use of psychotropic medications, and drug-drug interactions between psychotropic and medical treatments used in people with COVID-19, was reviewed and discussed by the working group. RESULTS: All classes of psychotropic medications showed potentially relevant safety risks for people with COVID-19. A set of practical recommendations was drawn in order to inform frontline clinicians on the assessment of the anticipated risk of psychotropic-related unfavorable events, and the possible actions to take in order to effectively manage this risk, such as when it is appropriate to avoid, withdraw, switch, or adjust the dose of the medication. CONCLUSIONS: The present evidence-based recommendations will improve the quality of psychiatric care in people with COVID-19, allowing an appropriate management of the medical condition without worsening the psychiatric condition and vice versa.