Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial.

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

"We find what we look for, and we look for what we know": factors interacting with a mental health training program to influence its expected outcomes in Tunisia.

BACKGROUND: Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists' mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper's objective is to fill that lack. METHODS: We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis. RESULTS: Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training's expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions. CONCLUSIONS: Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.

Tailoring a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) to Tunisia: process and relevant adaptations.

BACKGROUND: In order to make mental health services more accessible, the Tunisian Ministry of Health, in collaboration with the School of Public Health at the University of Montreal, the World Health Organization office in Tunisia and the Montreal World Health Organization-Pan American Health Organization Collaborating Center for Research and Training in Mental Health, implemented a training programme based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) (version 1.0), developed by the World Health Organization. This article describes the phase prior to the implementation of the training, which was offered to general practitioners working in primary care settings in the Greater Tunis area of Tunisia. METHODS: The phase prior to implementation consisted of adapting the standard mhGAP-IG (version 1.0) to the local primary healthcare context. This adaptation process, an essential step before piloting the training, involved discussions with stakeholder groups, as well as field observations. RESULTS: Through the adaptation process, we were able to make changes to the standard training format and material. In addition, the process helped uncover systemic barriers to effective mental health care. CONCLUSIONS: Targeting these barriers in addition to implementing a training programme may help reduce the mental health treatment gap, and promote implementation that is successful and sustainable.

[The name in schizophrenia: a study of 60 patients]. / Le patronyme dans la schizophrénie: une etude à propos de 60 patients.

BACKGROUND: Clinical aspects in schizophrenia suggest a unique relationship with the proper name. aim: Discuss the validity of the hypothesis that the non-transmission of the surname may be a vulnerability factor in schizophrenia. METHODS: Descriptive cross-sectional study conducted among 60 patients with schizophrenia and their families. Data were collected using a semi-structured interview. results: Seven patients carried a different surname from their father (11.6% of participants). The disparity has only concerned the child with schizophrenia. Family characteristics (birth rank, desired character of pregnancy, family history of schizophrenia) and evolutif profile of the disease were comparable between patients with a family name according to the father and those with a different surname. CONCLUSIONS: It appears that patients with schizophrenia maintain a special relationship with the proper name, which could be involved in the genesis of schizophrenia. Our early hypothesis, supported by the psychoanalytic, transgenerational and behavioral theories, would be a plausible starting point for studies with a broader spectrum including witnesses of the general and psychiatric populations.

[A descriptive study of the procedures of psychiatric admissions at Razi hospital]. / Etude descriptive des modalités d'hospitalisation en psychiatrie á l'hôpital Razi.

BACKGROUND: The law 92-83, has established the rights of the mentally ill to respect for individual freedom and to appropriate care. However some gaps in its implementation led to the revision by Act 2004-40. AIM: To study the evolution of the number of admissions with and without consent (hospitalizations at the request of a third party and compulsory hospitalizations), between 2000 and 2009. METHODS: Retrospective study of the archives of the mental health unit of Razi hospital. The study population included inpatients under the mode of voluntary and involuntary admission either compulsory hospitalizations or at the request of a third party. RESULTS: An increase in the number of hospitalizations without the consent from 2000 to 2009 was noted. The number of compulsory hospitalizations and the one of hospitalizations at the request of a third party rose respectively from 1,048 to 1,443 and from 22 to 1,323. So the number of free hospitalizations has decreased while the number of involuntary hospitalizations has increased, leading to a constant number of total hospitalizations. The sex ratio for compulsory hospitalizations has increased from 2.04 to 5.83 while it markedly decreased for hospitalizations at the request of a third party (from 10 to 1.7).Men, unlike women, were more likely to be hospitalized compulsorily than at the request of a third party. CONCLUSION: There is a larger use of hospital admissions under constraints than free ones; is it due to a concern for the respect of law or an abuse in the deprivation of freedom for some patients?

[Sleep in elderly]. / Sommeil du sujet âgé consultant en première ligne : A propos de 50 cas.

BACKGROUND: Sleep disorders in the elderly are common. However, they are often under diagnosed and poorly supported. AIM: To study the characteristics of sleep in the elderly consultant at the front line. METHODS: A cross-sectional survey was conducted on a random sample of fifty persons aged 65 years and over, consultant in the center of basic health of Ezzahra and in a private practice in the same delegation. RESULTS: The sleep efficiency index was 0.85. Nighttime awakenings were present in 44 persons (88%). Unexplained late night awakening was reported by 19 subjects (38%). Among the respondents, 40 (80%) were considered to have at least one sleep disorder. The subjective complaint of insomnia was present in 70% of subjects. Excessive daytime sleepiness and/or hypersomnia were present in 70% of subjects. Nocturnal snoring was reported by 22 persons (44%). Nine subjects (18%) had respiratory pauses during sleep. Despite the high incidence of sleep disorder among the respondents, only 6 persons (15%) among them consulted their General Practitioner for this reason. Among patients with sleep disorder, 14 persons (40%) were taking hypnotics, from which 6 (43%) by self-medication. CONCLUSION: Sleep disorders in the elderly as well as self-medication with hypnotics are common and under diagnosed. They should be sought systematically in front-line consultation.