The cardiometabolic profile and related dietary intake of Ugandans living with HIV and AIDS.

Introduction: Suboptimal diet and physical inactivity downgrade the putative benefits of Antiretroviral Therapy (ART) among People Living with HIV (PLWH). However, there is paucity of literature on dietary intake and cardiometabolic profiles of PLWH in Uganda. Methods: A cross-sectional study among PLWH in Uganda was conducted. Dietary intake was assessed using a 24h recall method of 2 non-consecutive days. The short International Physical Activity Questionnaire assessed participants' physical activity. Fasted blood samples were analyzed for Fasting Blood Glucose (FBG), total cholesterol, LDL-c, HDL-c and triglycerides. Blood pressure and anthropometric measurements were performed following step 2 of the WHO STEPS. Results: 253 patients completed in this study. A high prevalence of low HDL-c (31.9%), abdominal obesity (44.5%), high BMI (51.6%), raised FBG (45.3%), high SBP (31.5%), elevated triglycerides (26.4%) and metabolic syndrome (28%) was found. More women were identified with metabolic syndrome (31.5%) than men (19.2%). Low prevalence of high LDL-c (4.7%) and total cholesterol (9.8%) was found. Diets had a high carbohydrate (65.8 ± 10.4) E% and fiber intake (30.1 ± 12.7) g with minimal PUFA (6.1 ± 2.3) E%, fruits and vegetables (1.4 servings). High proportions were found of unmet intake for vitamin A (38.2%), B1(48.8%), B2 (29.6%), B12 (29%), folate (61.4%), Ca (76%), Zn (53.1%) and Mg (41.7%). Mean MET min was 6,700 ± 5,509 and over 68% of the participants had >3,000 MET min. Conclusion: Our findings reveal a high prevalence of metabolic disturbances among PLWH in Uganda and further highlight that their diets are suboptimal with low fruits and vegetable intake.

Group problem solving therapy for perinatal depression in primary health care settings in rural Uganda: an intervention cohort study.

BACKGROUND: Perinatal depression is of substantial public health importance in low and middle income countries. The study aimed to evaluate the impact of a mental health intervention delivered by non-specialist health workers on symptom severity and disability in women with perinatal depression in Uganda. METHODS: Pregnant women in the second and third trimester were consecutively screened using the Luganda version of the 9-item Patient Health Questionnaire (PHQ-9). Women who scored ≥5 on the PHQ-9 and who were confirmed to have depression by a midwife were recruited into a treatment cohort and offered a psychological intervention in a stepped care fashion. Women were assessed with PHQ-9 and WHODAS-2.0 at baseline and again at 3 and 6 months after the intervention. Negative regression analysis was done to examine change in PHQ-9 and WHODAS-2.0 scores from baseline to end line. Data were analysed using STATA version 14. RESULTS: A total of 2652 pregnant women (98.3%) consented to participate in the study and 153 (5.8%) were diagnosed as depressed. Over a quarter (28.8%) reported having experienced physical interpersonal violence (IPV) while (25.5%) reported sexual IPV in the past year. A third (34.7%) of women diagnosed with depression received 4 or more group PST sessions. There was a mean reduction in PHQ-9 score of 5.13 (95%CI - 6.79 to - 3.47, p < 0.001) and 7.13 (95%CI - 8.68 to - 5.59, p < 0.001) at midline and endline, respectively. WHODAS scores reduced significantly by - 11.78 points (CI 17.64 to - 5.92, p < 0.001) at midline and - 22.92 points (CI 17.64 to - 5.92, p < 0.001) at endline. Clinical response was noted among 69.1% (95%CI 60.4-76.6%) and 93.7% (95%CI 87.8-96.8%) of respondents at midline and endline, respectively. CONCLUSION: An evidence based psychological intervention implemented in primary antenatal care by trained and supervised midwives in a real-world setting may lead to improved outcomes for women with perinatal depression. Future randomised studies are needed to confirm the efficacy of this intervention and possibility for scale up.

Correction to: Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol.

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

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

Social acceptance of alcohol use in Uganda.

BACKGROUND: Alcohol use is part of many cultural, religious and social practices, and provides perceived pleasure to many users. In many societies, alcoholic beverages are a routine part of the social landscape for many in the population. Relatively low rates were reported for Alcohol Use Disorders (AUD) in a community-based survey and facility detection survey conducted in the study site contrary to findings in earlier formative studies where alcohol use was reported to be a major health problem. The aim of this study was to understand the reasons for under-reporting and the low detection rate for AUDs, exploring societal perceptions of alcohol use in the study district. METHODS: The study was conducted in Kamuli District (implementation site for the PRIME project). Semi-structured interviews and focus group discussions were conducted with purposively selected participants that included local and religious leaders, lay people, health workers as well as heavy alcohol drinkers and their spouses. Interviews were tape-recorded and transcribed verbatim. The analysis followed four thematic areas, which include the extent and acceptability of alcohol use, patterns of alcohol use, perceived health problems associated with alcohol use and help-seeking behavior for persons with alcohol related problems. RESULTS: The findings indicate that alcohol consumption in the study site was common and widely acceptable across all categories of people and only frowned upon if the person becomes a nuisance to others. These findings suggest that the health problems associated with alcohol use are overlooked except when they are life-threatening. Help-seeking for such problems was therefore reported to be relatively rare. CONCLUSION: Alcohol was readily available in the community and its consumption widely acceptable, with less social sanctions despite the legal restrictions to the minors. The social acceptance results in low recognition of alcohol use related health problems, consequently resulting in poor help-seeking behavior.

The experience of mental health service users in health system strengthening: lessons from Uganda.

BACKGROUND: Mental, neurological and substance use disorders are a public health burden in Uganda. Mental health service user involvement could be an important strategy for advocacy and improving service delivery, particularly as Uganda redoubles its efforts to integrate mental health into primary health care (PHC). However, little is known on the most effective way to involve service users in mental health system strengthening. METHODS: This was a qualitative key informant interview study. At national level, 4 interviews were conducted with national level health workers and 3 service user organization representatives. At the district level, 2 interviews were conducted with district level health workers and 5 service user organization representatives. Data were analyzed using content thematic analysis. FINDINGS: Overall, there was low mental service user participation in health system strengthening at both national and district levels. Health system strengthening activities included policy development, implementation of programs and research. Informants mentioned several barriers to service user involvement in mental health system strengthening. These were grouped into three categories: institutional, community and individual level factors. Institutional level barriers included: limited funding to form, train and develop mental health service user groups, institutional stigma and patronage by founder members of user organizations. Community level barriers included: abject poverty and community stigma. Individual level barriers included: low levels of awareness and presence of self-stigma. Informants also recommended some strategies to enhance service user involvement. CONCLUSION: The Uganda Ministry of Health should develop a strategy to improve service user participation in mental health system strengthening. This requires an appreciation of the importance of service users in improving service delivery. To address the barriers to service user involvement identified in this study requires concerted efforts by the Uganda Ministry of Health and the district health services, specifically with regard to attitudes of health workers, dealing with stigma at all levels, raising awareness about the rights of service users to participate in health systems strengthening activities, building capacity and financial empowerment of service user organizations.

Evaluation of capacity-building strategies for mental health system strengthening in low- and middle-income countries for service users and caregivers, policymakers and planners, and researchers.

BACKGROUND: Strengthening of mental health systems in low- and middle-income countries (LMICs) requires the involvement of appropriately skilled and committed individuals from a range of stakeholder groups. Currently, few evidence-based capacity-building activities and materials are available to enable and sustain comprehensive improvements. AIMS: Within the Emerald project, the goal of this study was to evaluate capacity-building activities for three target groups: (a) service users with mental health conditions and their caregivers; (b) policymakers and planners; and (c) mental health researchers. METHOD: We developed and tailored three short courses (between 1 and 5 days long). We then implemented and evaluated these short courses on 24 different occasions. We assessed satisfaction among 527 course participants as well as pre-post changes in knowledge in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). Changes in research capacity of partner Emerald institutions was also assessed through monitoring of academic outputs of participating researchers and students and via anonymous surveys. RESULTS: Short courses were associated with high levels of satisfaction and led to improvements in knowledge across target groups. In relation to institutional capacity building, all partner institutions reported improvements in research capacity for most aspects of mental health system strengthening and global mental health, and many of these positive changes were attributed to the Emerald programme. In terms of outputs, eight PhD students submitted a total of 10 papers relating to their PhD work (range 0-4) and were involved in 14 grant applications, of which 43% (n = 6) were successful. CONCLUSIONS: The Emerald project has shown that building capacity of key stakeholders in mental health system strengthening is possible. However, the starting point and appropriate strategies for this may vary across different countries, depending on the local context, needs and resources. DECLARATION OF INTEREST: S.E.L. received consulting fees from Lundbeck.

Evaluation of performance and perceived utility of mental healthcare indicators in routine health information systems in five low- and middle-income countries.

BACKGROUND: In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC. METHOD: A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect - with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6-9 months afterwards. RESULTS: Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements. CONCLUSION: This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy. DECLARATION OF INTEREST: None.

Experience of implementing new mental health indicators within information systems in six low- and middle-income countries.

BACKGROUND: Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking. AIMS: To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda). METHOD: A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The 'Performance of Routine Information Systems' framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants. RESULTS: Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability. CONCLUSIONS: Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services. DECLARATION OF INTEREST: None.

Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform.

BACKGROUND: There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs). AIMS: To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs. METHOD: Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks. RESULTS: Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation. CONCLUSIONS: Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important. DECLARATION OF INTEREST: None.

Effective methods for knowledge transfer to strengthen mental health systems in low- and middle-income countries.

BACKGROUND: The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare.A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice. AIMS: To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries. METHOD: We focused on the involvement of policy planners, managers, patients and carers. RESULTS: Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project. CONCLUSIONS: This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.

Strengthening mental health systems in low- and middle-income countries: recommendations from the Emerald programme.

BACKGROUND: There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The 'Emerging mental health systems in low- and middle-income countries (LMICs)' (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems. AIMS: To provide a set of proposed recommendations for mental health system strengthening in LMICs. METHOD: The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012-2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening. RESULTS: The proposed recommendations align closely with the World Health Organization's key health system strengthening 'building blocks' of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald. CONCLUSIONS: These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders. DECLARATION OF INTEREST: None.

Mental health financing challenges, opportunities and strategies in low- and middle-income countries: findings from the Emerald project.

BACKGROUND: Current coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment. AIMS: To identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. METHOD: In the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country's disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options. RESULTS: Key challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries. CONCLUSIONS: Including mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities. DECLARATION OF INTEREST: D.C. is a staff member of the World Health Organization.

Partnerships in a Global Mental Health Research Programme-the Example of PRIME.

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

Detection and treatment initiation for depression and alcohol use disorders: facility-based cross-sectional studies in five low-income and middle-income country districts.

OBJECTIVES: To estimate the proportion of adult primary care outpatients who are clinically detected and initiate treatment for depression and alcohol use disorder (AUD) in low-income and middle-income country (LMIC) settings. DESIGN: Five cross-sectional studies. SETTING: Adult outpatient services in 36 primary healthcare facilities in Sodo District, Ethiopia (9 facilities); Sehore District, India (3); Chitwan District, Nepal (8); Dr Kenneth Kaunda District, South Africa (3); and Kamuli District, Uganda (13). PARTICIPANTS: Between 760 and 1893 adults were screened in each district. Across five districts, between 4.2% and 20.1% screened positive for depression and between 1.2% and 16.4% screened positive for AUD. 96% of screen-positive participants provided details about their clinical consultations that day. PRIMARY OUTCOMES: Detection of depression, treatment initiation for depression, detection of AUD and treatment initiation for AUD. RESULTS: Among depression screen-positive participants, clinical detection of depression ranged from 0% in India to 11.7% in Nepal. Small proportions of screen-positive participants received treatment (0% in Ethiopia, India and South Africa to 4.2% in Uganda). Among AUD screen-positive participants, clinical detection of AUD ranged from 0% in Ethiopia and India to 7.8% in Nepal. Treatment was 0% in all countries aside Nepal, where it was 2.2%. CONCLUSIONS: The findings of this study suggest large detection and treatment gaps for adult primary care patients, which are likely contributors to the population-level mental health treatment gap in LMIC. Primary care facilities remain unfulfilled intervention points for reducing the population-level burden of disease in LMIC.

Alcohol use in a rural district in Uganda: findings from community-based and facility-based cross-sectional studies.

BACKGROUND: Uganda has one of the highest per capita alcohol consumption rates in sub-Saharan Africa. However, the prevalence of alcohol use disorders (AUD) remains unknown in many areas, especially in rural districts. This study aimed to estimate the prevalence of alcohol consumption and of alcohol use disorder among men, and to describe the distribution of drinking intensity, among men in in Kamuli District, Uganda. METHODS: Men attending primary care clinics in Kamuli District were consecutively interviewed in a facility-based cross-sectional study, and a separate group of men were interviewed in a population-based cross-sectional study. In both studies the men were administered a structured questionnaire, which included the alcohol use disorder identification test (AUDIT) to screen for AUD, as well as sections about demographic characteristics, depression screening, internalized stigma for alcohol problems and treatment-seeking. RESULTS: Among the 351 men enrolled in the Community study, 21.8% consumed alcohol in the past 12 months, compared to 39.6% of 778 men in the Facility Survey. The proportion of men who screened positive for AUD was 4.1% in the community study and 5.8% in the facility study. AUDIT scores were higher among older men, men with paid/self-employment status and higher PHQ-9 score (P < 0.05). Nearly half (47.5%) of the men with AUDIT-positive scores reported that alcohol use problems had ruined their lives. A majority (55.0%) of men with AUDIT-positive scores did not seek treatment because they did not think AUD was a problem that could be treated. CONCLUSIONS: Internalized stigma beliefs among AUDIT-positive men impede treatment-seeking. As part of any efforts to increase detection and treatment services for alcohol use problems, routine screening and brief interventions for internalized stigma must be incorporated within the normal clinical routine of primary health care.

Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol.

BACKGROUND: The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts. METHODS: One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy). DISCUSSION: Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.