Perception of service users and their caregivers on primary care-based mental health services: a qualitative study in Nepal.

BACKGROUND: Integration of mental health services into primary health care systems has been advocated as a strategy to minimize the tremendous mental health treatment gap, particularly in low- and middle-income countries. Barriers to integration of mental health into primary health care have been widely documented; however, very little is known about the perception of service users and their caregivers on primary care-based mental health services. This study assessed service users' and caregivers' perceptions of mental health services provided by trained primary health care workers in Nepal. METHODS: A qualitative study was conducted among people with depression, psychosis, alcohol use disorder and epilepsy, and their caregivers in Chitwan, a district in southern Nepal. Semi-structured interviews were conducted with 43 service users and 38 caregivers to assess their perceptions about the accessibility of the services, types of services they received, skills and competencies of health care providers, satisfaction and barriers to receiving services. RESULTS: Overall, both service users and caregivers were satisfied with the mental health services provided by primary health care providers. They also perceived health workers to be competent and skillful because the services they received were effective in reducing their mental health problems. Both psychological and pharmacological services were made available free of cost, however, they considered psychological services more effective than pharmacological treatment. Major challenges and difficulties accessing services were associated with frequent transfer of trained health workers, non-availability of the same health care provider at follow-ups, frequent stock-out of medicines or non-availability of required medicines, lack of a confidential space for consultation in health facilities, and stigmatizing and negative behavior of some health workers. CONCLUSION: The results demonstrated that both service users and caregivers perceived primary care-based mental health services to be accessible, acceptable and effective. The key recommendations emerging from this study for improving mental health services in primary care include the provision of a separate cadre of psychosocial workers to provide psychological interventions, developing quick and efficient mechanisms for the procurement and supply of psychotropic medicines, establishing a confidential place within health facilities for consultation, and further training of health workers to reduce stigma.

Treatment processes of counseling for children in South Sudan: a multiple n=1 design.

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n=1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client's problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

A controlled evaluation of a brief parenting psychoeducation intervention in Burundi.

PURPOSE: Conduct problems and emotional distress have been identified as key problems among children and adolescents in post-war Burundi. This pilot study aims to evaluate the impact of a brief parenting psychoeducation intervention on children's mental health. METHODS: This study employs a controlled pre and post evaluation design. The two-session psychoeducation intervention was offered to groups of parents of children (mean age 12.3 years, 60.8 % female) who had been screened for elevated psychosocial distress. Children in the intervention group (n = 58) were compared to a waitlist control group (n = 62). Outcome indicators included child-reported levels of aggression (using the Aggression Questionnaire), depression symptoms (using the Depression Self Rating Scale) and perceived family social support. RESULTS: The intervention had a beneficial effect on reducing conduct problems compared to the control condition (Cohen d = 0.60), especially among boys, while not showing impact on depression symptoms or family social support. Parents evaluated the intervention positively, with increased awareness of positive parenting strategies and appropriate disciplinary techniques reported as the most common learning points. CONCLUSION: A brief parenting psychoeducation intervention conducted by lay community counselors is a promising public health strategy in dealing with widespread conduct problems in boys living in violence-affected settings and not so for social and emotional indicators and for girls. An efficacy study is warranted to confirm these preliminary findings.

Mental health interventions for children in adversity: pilot-testing a research strategy for treatment selection in low-income settings.

This study aimed to develop a research strategy to make informed decisions for intervention selection, especially for low- and middle-income countries, as a response to the urgent need to scale-up mental health care for children globally. With this study we address the critical lack of translation of research findings into policy and practice. The research strategy was piloted for development of a family-based intervention in violence-affected areas in Burundi. The research comprised four phases; (a) a qualitative phase to assess needs and determine tentative intervention objectives; (b) a global expert panel to identify and prioritize intervention modalities for low-resource settings; (c) systematic literature review and distillation of practice elements from evidence-based treatments; and (d) stakeholder meetings to explore social-cultural feasibility and acceptability of the developed intervention. The study was conducted between January and November 2010. The research strategy resulted in the development of a stepped family-based care intervention, which combines community mobilization, parent-management training and cognitive behavior therapy elements. This pilot-tested research strategy, encompassing global and local knowledge on needs, feasibility and effectiveness, has the potential to be useful for developing mental health and psychosocial interventions in other settings.

Practice-driven evaluation of a multi-layered psychosocial care package for children in areas of armed conflict.

Psychosocial and mental health service delivery frameworks for children in low-income countries are scarce. This paper presents a practice-driven evaluation of a multi-layered community-based care package in Burundi, Indonesia, Sri Lanka and Sudan, through a set of indicators; (a) perceived treatment gains; (b) treatment satisfaction; (c) therapist burden; (d) access to care; (e) care package costs. Across four settings (n = 29,292 children), beneficiaries reported high levels of client satisfaction and moderate post-treatment problem reductions. Service providers reported significant levels of distress related to service delivery. Cost analyses demonstrated mean cost per service user to vary from 3.46 to 17.32 depending on country and specification of costs. The results suggest a multi-layered psychosocial care package appears feasible and satisfactory in reaching out to substantial populations of distressed children through different levels of care. Future replication should address therapist burden, cost reductions to increase sustainability and increase evidence for treatment efficacy.

Screening for psychosocial distress amongst war-affected children: cross-cultural construct validity of the CPDS.

BACKGROUND: Large-scale psychosocial interventions in complex emergencies call for a screening procedure to identify individuals at risk. To date there are no screening instruments that are developed within low- and middle-income countries and validated for that purpose. The present study assesses the cross-cultural validity of the brief, multi-informant and multi-indicator Child Psychosocial Distress Screener (CPDS). METHODS: The CPDS data of total samples in targeted catchment areas of a psychosocial care program in four conflict-affected countries (Burundi n = 4193; Sri Lanka n = 2573; Indonesia n = 1624; Sudan n = 1629) were studied to examine the cross-cultural construct validity of the CPDS across settings. First, confirmatory factor analyses were done to determine the likelihood of pre-determined theory-based factor structures in each country sample. Second, multi-sample confirmatory factor analyses were done within each country sample to test measurement equivalence of the factor structure as a measure of construct validity. RESULTS: A 3-factor structure reflecting the theoretical premises of the instrument (e.g., child distress, child resilience and contextual factors) was found in the samples from Burundi, Sri Lanka and Indonesia, albeit with context specific deviations. The robustness of the 3-factor structure as an indicator of construct validity was confirmed within these three samples by means of multi-sample confirmatory factor-analyses. A 3-factor structure was not found in the Sudan sample. CONCLUSIONS: This study demonstrates the comparability of the assessment by the CPDS of the construct 'non-specific psychosocial distress' across three out of four countries. Robustness of the factor structure of the CPDS within different samples refers to the construct validity of the instrument. However, owing to context-specific deviations of inter-item relationships, the CPDS scores cannot be compared cross-culturally, a finding that confirms the need for attention to contextual factors when screening for non-specific psychosocial distress.

Migrant mental health: a model for indicators of mental health and health care consumption.

OBJECTIVE: This study explores the relationship between mental health and health care consumption among migrants in the Netherlands. DESIGN: Samples of the Turkish (n = 648), Moroccan (n = 102), and Surinamese (n = 311) populations in Amsterdam were examined. The study tested a hypothesized model of risk factors for psychiatric morbidity, indicators of well-being, and indicators of health care consumption. The model was specified on the basis of information from earlier research on the sample and literature on the topic. The model was tested and refined using structural equation modeling. MAIN OUTCOME MEASURES: Psychiatric morbidity and well-being measures were assessed with the CIDI 1.1 and MOS-sf-36 subscales, respectively. Health care consumption was assessed by the question "Have you ever consulted one or more of these professionals or health care facilities with respect to mental health problems or problems related to alcohol or drugs usage?" RESULTS: The primary result of this study was the confirmation that health care consumption among migrants is predicted by need and predisposition factors, such as health condition and sociodemographic characteristics. In addition, mental health care consumption of migrants is predicted by acculturation characteristics. This result suggests an effect of cultural and migrant-specific factors in help-seeking behavior and barriers to mental health care facilities. CONCLUSIONS: Findings confirm the existence of migrant-specific mechanisms in health care consumption. Mental health care professionals should be aware of these. However, ignoring common ground for interventions unnecessarily creates distance between migrant groups and between migrant and indigenous Dutch groups.

A 15-year open study on a cohort of West-African out-patients with a chronic psychosis.

BACKGROUND: We wanted to find out if the additional costs of depot neuroleptic in comparison to oral medication was justified by a decrease in admission days. METHODS: An open study on a cohort of chronic psychotic out-patients (n=45) consisting of a retrospective 10-year period on oral medication followed by a prospective 5-year period of treatment with haloperidol decanoate. After recording socio-demographic characteristics and a DSM-III-R diagnosis, patients were assessed before and after the administration of depot neuroleptic with the BPRS, the NOSIE, the SDRS and a list of side effects. A semi-structured interview was conducted with the patients and their families to ask about the change in social relationships with family members and other people after starting the depot treatment. Social intervention was limited to involvement of the family in the monthly depot medication outpatient clinic and to an explanation of the rationale of follow-up treatment and deinstitutionalisation of psychiatric care in the village of origin. RESULTS: The number of admission days decreased from an average of 100 days a year on oral medication to 5 days a year on depot neuroleptic. Patients report a sharp decrease in symptoms paralleled by an increase in social functioning over the first 3 months. After 6-9 months this pattern stabilised and was maintained over the period from 1 to 5 years whereas the dosage was further decreased to an average of 1 cc decanoate or 20 haldol equivalents monthly. CONCLUSIONS: This study suggests that depot neuroleptic in the context of a public mental health approach is a highly effective and feasible treatment for West African patients suffering from a chronic functional psychosis.

The relation between coping, social support and psychological and somatic symptoms among torture survivors in Nepal.

BACKGROUND: Little is known about the relation between coping, social support, and psychological and somatic symptoms among survivors of torture living outside the West. METHOD: In a population-based dataset of 315 tortured Bhutanese refugees, univariate and multivariate relationships between coping and social support and symptoms were estimated. These relationships were verified in a second sample of 57 help-seeking Nepalese torture survivors. RESULTS: A relationship was observed between the total number of coping strategies used and anxiety and depression. Negative coping, in contrast to positive coping, was related to all symptom outcome measures. Received social support was stronger related to symptoms than perceived social support. The findings from the first sample were replicated in the second sample. CONCLUSION: We found hypothesized relationships between coping, social support, and psychological and somatic symptoms among survivors of torture living in Nepal. The findings from this study confirm the importance of understanding specific types of coping and social support to develop intervention programmes for torture survivors in Non-western settings.

Lifetime events and posttraumatic stress disorder in 4 postconflict settings.

CONTEXT: Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences. OBJECTIVE: To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries. DESIGN, SETTING, AND PARTICIPANTS: Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585). MAIN OUTCOME MEASURE: Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire. RESULTS: The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively). CONCLUSIONS: Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.

Schizophrenia among Surinamese in the Netherlands: high admission rates not explained by high emigration rates.

BACKGROUND: A high risk of schizophrenia has been found among Caribbean immigrants in the Netherlands and Great Britain. One hypothesis to explain these findings is that patients with a diagnosis of schizophrenia or patients with symptoms of psychosis not specifically diagnosed, emigrate more than the general population. Such selection might account for high rates of Surinamese patients with a diagnosis of schizophrenia in Netherlands psychiatric hospitals. We examined this hypothesis. METHODS: The files of patients with schizophrenia or patients suffering from unspecified psychosis were selected from the archives of the National Psychiatric Hospital in Surinam. These patients were traced to investigate patterns of emigration. Data from the Central Bureau for Statistics in the Netherlands and from the Central Population Bureau in Surinam provided the percentage of the general Surinamese population that emigrated to the Netherlands. The difference between the two percentages was evaluated using the chi-squared test. Using the same method the percentage of remigration from the Netherlands among Surinamese patients was compared with the percentage of remigration among the general Surinamese population. RESULTS: Surinamese patients with schizophrenia or unspecified psychosis did not emigrate more frequently to the Netherlands compared with the general Surinamese population. They did remigrate significantly more frequently. CONCLUSION: High migration rates do not explain the high hospital admission rates for schizophrenia among Surinamese in the Netherlands.

Maternal thyroid peroxidase antibodies during pregnancy: a marker of impaired child development?

Women with antibodies against the enzyme thyroid peroxidase [TPO-Ab; formerly microsomal antibodies (MsAb)] are at particular risk for developing postpartum thyroid dysfunction; the latter is significantly associated with postpartum depression. Although the negative effect of postpartum maternal depression on child development is well documented, the consequences of elevated titers of TPO-Ab during pregnancy and subsequent postpartum thyroid dysfunction on child development are not known. In a prospective study of a cohort of 293 pregnant women, the occurrence of TPO-Ab during gestation, thyroid dysfunction, and depression was investigated. Five years after delivery, child development was assessed in 230 children of the original cohort using the Dutch translation of the McCarthy Scales of Children's Abilities. Children of women with TPO-Ab during late gestation (n = 19, with normal thyroid function) had significantly lower scores (by t test) on the McCarthy Scales of Children's Abilities than antibody-negative women. The difference on the General Cognitive Scale, which reflects IQ scores, was substantial (10.5 points; t = 2.8; P = 0.005). After correction for possibly confounding variables, maternal TPO-Ab during gestation was found to be the most important factor related to the scores on the General Cognitive Scale (odds ratio = 10.5; 95% confidence interval = 3-34; P = 0.003). We conclude that children of pregnant women who had elevated titers of TPO-Ab but normal thyroid function are at risk for impaired development.

Depressive symptomatology of post-menopausal breast cancer patients: a comparison of women recently treated by mastectomy or by breast-conserving therapy.

The aim of this study was to detect differences in depressive symptomatology in post-menopausal breast cancer patients who had recently undergone either mastectomy or breast conserving therapy. We measured depressive symptoms shortly after diagnosis and surgery as well as 6 months later. There were no significant differences in mean scores and relative risk estimates between the two treatment groups at either time of measurement. From this study we conclude that women treated by breast-conserving therapy have comparable levels of depressive symptoms to women treated by mastectomy during the first 8 months after diagnosis. Breast-conserving therapy can have cosmetic and physical advantages, but requires as much psychological adjustment as mastectomy does.

Blues and depression during early puerperium: home versus hospital deliveries.

OBJECTIVE: To investigate whether women who give birth at home are less prone to mood disturbances during the early puerperium than those who give birth in hospital. DESIGN: A prospective study of 303 pregnant women who registered for antenatal care. SETTING: The antenatal clinic at St Joseph's Hospital, Veldhoven, The Netherlands, and five antenatal consultation programmes of local midwives working in the surrounding region. SUBJECTS: Three hundred and eighty-two consecutive caucasian women registering for antenatal care were approached. Of these, 303 consented to participate and 293 completed the study. MAIN OUTCOME MEASURE: The predictor variable was the way in which the women gave birth: spontaneous vaginal parturition at home or in hospital as follows: spontaneously; vaginal parturition after stimulation with medication; vaginal parturition with forceps/vacuum extraction; or caesarean section. The outcome variables were blues and depression. The occurrence of blues was assessed at 4 weeks postpartum, using Pitt's criteria. The occurrence of depression was assessed at 4 weeks postpartum using the Research Diagnostic Criteria. The possible confounding effects of a set of obstetrical and psycho-social variables relating to the early puerperium were investigated using logistic regression analysis. RESULTS: Of the 293 women who completed the study, 52% gave birth at home. Significantly more nullipara gave birth in hospital. Parturition occurred where it had been planned in 77% of women; referral occurred later on in pregnancy in 11% and during labour in 12%. Nullipara had to be referred significantly more often than multipara. In general, there was no difference in the incidence of blues and depression between women who gave birth at home and those who gave birth in hospital. Obstetric factors were not related to the occurrence of blues or depression in the early puerperium. CONCLUSIONS: Women who gave birth in hospital are no more prone to postpartum mood disturbances, such as blues and depression, than women who give birth at home.

Subjective well-being of elderly women: conceptual differences between cancer patients, women suffering from chronic ailments and healthy women.

Studies have shown that the mean scores on global subjective well-being measures of cancer patients do not differ from the mean scores of other patient samples or samples of healthy individuals. These results give rise to speculations about the nature of the concept subjective well-being. Therefore, we compared the structure of the concept subjective well-being between three groups of elderly women (cancer patients, women suffering from chronic ailments and healthy women). This was done by examining the relationships between five dimensions of subjective well-being (perceived physical health, self-esteem, negative affect, optimism and loneliness) and two measures of global subjective well-being (affective well-being and life satisfaction) in each group of women. The results clearly demonstrate the differences in the relative importance of the five dimensions for the global evaluation of well-being between the three groups. The most notable finding was that perceived physical health appears to be more strongly related to global subjective well-being, when the objective health status is worse. The unequal relative importance of dimensions of subjective well-being should be taken into account when comparing the mean scores on subjective well-being measures between populations with different states of health.

Prevalence of post partum depression--or is it post-puerperium depression?

In a longitudinal study, the prevalence of post partum depression was investigated in 293 women. They were assessed during gestation at 32 weeks, and consecutively after parturition with an interval of six weeks from four weeks until 34 weeks' post partum. The prevalence of post partum depression (RDC) varied between seven and 14%, with a peak at ten weeks' post partum. It was found that women were depressed significantly more often at ten weeks' post partum compared with pregnancy, the first post partum weeks and the later post partum period. This finding suggests that it is not directly after parturition that women are more prone to depression. The relationship between variables such as blues, parity, PMS and depression showed that at different assessments in the post partum period different women are depressed, women who do not necessarily share the same characteristics. This finding may explain why in some studies a relationship was found between certain kinds of variables and post partum depression while in others not. PMS was found to be significantly related to post partum depression only at the time of the women resumed menstruation. It is suggested that screening on post partum depression partly involves screening on depressive symptoms related to PMS.

Microsomal antibodies during gestation in relation to postpartum thyroid dysfunction and depression.

RATIONALE: Microsomal antibodies have been related to postpartum thyroid dysfunction and postpartum depression. OBJECTIVES: To detect the value of microsomal antibodies during gestation in a random population, as a risk factor for thyroid dysfunction and depression during the postpartum period. MAIN FINDINGS: The presence of microsomal antibodies was investigated in a random population of 293 women at 32 weeks' gestation. At the same time, postpartum thyroid function was assessed repeatedly in all women every six weeks up to 34 weeks' postpartum. Postpartum thyroid dysfunction, defined as the presence of abnormal TSH, in combination with abnormal fT4 and/or fT3 values, occurred in 21 women (7.2%) during the postpartum period. Depression was assessed using the Research Diagnostic Criteria without knowing the results of biochemical thyroid function tests. At 32 weeks' gestation there were 27 (9.2%) women with elevated microsomal antibody titres. Compared with microsomal-antibody negative women at 32 weeks' gestation, these women had an RR of 20 for developing postpartum thyroid dysfunction and an RR of 1.7 for developing postpartum depression. CONCLUSIONS: Women with elevated microsomal antibody titres during gestation are particularly at risk for postpartum thyroid dysfunction, but only have a slightly increased risk for postpartum depression.

Characteristics of the Edinburgh Post Natal Depression Scale in The Netherlands.

The Edinburgh Post Natal Depression Scale (EPDS), a 10-item self-rating depression scale, was translated into Dutch and compared in 293 postpartum women with other self-rating scales commonly in use in The Netherlands. In addition the structure of EPDS was analyzed by various factor analyses to reveal some of its dimensional aspects. The Dutch version of EPDS was found to be a self-rating scale with good psychometric characteristics which measures what it claims to measure: the strength of depressive symptoms. With LISREL a 2-factor model could be distinguished which contained subscales reflecting depressive symptoms and cognitive anxiety.