Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC.

BACKGROUND: In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings. METHODS: The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants. RESULTS: A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores. LIMITATIONS: This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings. CONCLUSIONS: The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Multiple somatic symptoms in primary care: A field study for ICD-11 PHC, WHO's revised classification of mental disorders in primary care settings.

OBJECTIVE: A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated with distress or dysfunction. HA involves persistent, intrusive fears of having an illness or intense preoccupation with and misinterpretation of bodily sensations. This study examined how the proposed descriptions for BSS and HA corresponded to what was observed by working primary care physicians (PCPs) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. METHOD: PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability. RESULTS: Of 587 patients with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability. CONCLUSION: Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care.

Developing and implementing mental health policy in Zanzibar, a low income country off the coast of East Africa.

BACKGROUND: The Zanzibar Ministry of Health and Social Welfare, concerned about mental health in the country, requested technical assistance from WHO in 1997. AIMS: This article describes the facilitation over many years by a WHO Collaborating Centre, of sustainable mental health developments in Zanzibar, one of the poorest countries in the world, using systematic approaches to policy design and implementation. METHODS: Based on intensive prior situation appraisal and consultation, a multi-faceted set of interventions combining situation appraisal to inform planning; sustained policy dialogue at Union and state levels; development of policy and legislation, development of strategic action plans, establishment of intersectoral national mental health implementation committee, establishment of national mental health coordination system, integration of mental health into primary care, strengthening of primary-secondary care liaison, rationalisation and strengthening of secondary care system, ensuring adequate supply of medicines, use of good practice guidelines and health information systems, development of services for people with intellectual disability, establishment of formal mechanism for close liaison between the mental health services and other governmental, non-governmental and traditional sectors, mental health promotion, suicide prevention, and research and development. RESULTS: The policy and legislation introduced in 1999 have resulted in enhanced mental health activities over the ensuing decade, within a setting of extreme low resource. However, advances ebb and flow and continued efforts are required to maintain progress and continue mental health developments. Lessons learnt have informed the development of mental health policies in neighbouring countries. CONCLUSIONS: A multi-faceted and comprehensive programme can be effective in achieving considerable strengthening of mental health programmes and services even in extremely low resource settings, but requires sustained input and advocacy if gains are to be maintained and enhanced.

Development of a mental health policy and system in Tanzania: an integrated approach to achieve equity.

OBJECTIVE: Although most donor and development agency attention is focused on communicable diseases in mainland Tanzania, the importance of noncommunicable diseases, including mental illness, is increasingly apparent. METHODS: This report describes a ten-year collaborative project (1999-2009) to meet these challenges through a sustainable mental health policy introduced across Tanzania. The country used an integrated approach, combining situation appraisal, integrated mental health policy and planning, mechanisms for sustainable implementation with largely local resources integrated into local systems, and monitoring to fine-tune the implementation. RESULTS: The project led to inclusion of mental health in relevant health policy instruments, treatment at the primary care level, stronger referral and intersectoral coordination, and a focus on rehabilitation and public education. CONCLUSIONS: Although much remains to be done, Tanzania's commitment to mental health is now sustainedly embedded within its policies, national and local budgets, and training activities.

Prevalence of psychotic symptoms and their risk factors in urban Tanzania.

This study aimed to determine the prevalence of psychotic symptoms in urban Tanzania and their relationship with demographic, socio-economic and social factors. A random sample of 899 adults aged 15-59 was surveyed. The main outcome measure was endorsement of one or more psychotic symptoms identified by the Psychosis Screening Questionnaire. 3.9% respondents reported one or more psychotic symptoms in the preceding year. Significantly higher rates of symptoms were found in those who had recently experienced two or more stressful life events, those with CMD and people who had used cannabis in the preceding year.

Common mental disorders and risk factors in urban Tanzania.

A cross sectional population based epidemiological survey of 899 adults aged between 15 and 59 was undertaken in two urban areas of demographic surveillance sites in Dar es Salaam, Tanzania, using the Clinical Interview Schedule Revised. Significantly higher rates were found among those who had experienced more than three severe life events in the last six months and relationship difficulties and death of a loved one.

Mental health and the development agenda in Sub-Saharan Africa.

This article synthesizes the views of participants in two roundtables that were convened in Nairobi (March 2007) and London (July 2008) to identify key challenges to the prioritization of mental health in Africa and possible solutions. Participants included leading development experts and policy makers from head and country offices of international donors, national directors of mental health for several African countries, key mental health and public health professionals, epidemiologists, and an international nongovernmental organization. The challenges they identified to mainstreaming mental health include lack of understanding of the contribution of mental disorders to morbidity and mortality, competition for limited resources within health reform efforts, poor distribution of interventions and lack of inclusion of mental health among core generic health indicators, lack of economic research evidence, lack of a strategic approach to human resources planning, lack of partnerships with the social development sector, and mental health professionals' need for public health skills to effectively conduct national advocacy. Potential solutions include further investment in economic research, better strategic identification of the levers and entry points for integrating mental health into health sector reform plans, more vigorous engagement of mental health professionals in general health sector reforms, strengthening the linkage between mental health and social development, and intensive resource mobilization. In summary, partnerships, underpinned by collaborative training, research, and mutual dialogue with other health and nonhealth sectors, are needed.

Personality disorder: a new global perspective.

Personality disorder is now being accepted as an important condition in mainstream psychiatry across the world. Although it often remains unrecognized in ordinary practice, research studies have shown it is common, creates considerable morbidity, is associated with high costs to services and to society, and interferes, usually negatively, with progress in the treatment of other mental disorders. We now have evidence that personality disorder, as currently classified, affects around 6% of the world population, and the differences between countries show no consistent variation. We are also getting increasing evidence that some treatments, mainly psychological, are of value in this group of disorders. What is now needed is a new classification that is of greater value to clinicians, and the WPA Section on Personality Disorders is currently undertaking this task.

Prevalence of alcohol consumption and hazardous drinking, tobacco and drug use in urban Tanzania, and their associated risk factors.

Evidence suggests substance abuse in Tanzania is a growing public health problem. A random sample of 899 adults aged 15-59 in two urban sites of differing levels of poverty surveyed alcohol, tobacco and illicit substance use. Rates of substance use were 17.2%. 8.7% and 0.8% for alcohol, tobacco and cannabis, respectively. Living in the less affluent area was associated with higher lifetime rates of tobacco and alcohol use. Substance use is less prevalent in Tanzania than in richer countries, but lifetime consumption is higher in poorer areas. The association of substance use with a range of socio-economic factors warrants further research.

Knowledge, attitudes and practice pertaining to depression among primary health care workers in Tanzania.

BACKGROUND: Examination of consultation data in a variety of primary care settings in Tanzania shows that, while psychoses are routinely diagnosed and treated at primary care level, depression is rarely recorded as a reason for consultation. Since, epidemiological studies elsewhere show that depression is a much more common disorder than psychosis, a series of studies were undertaken to elucidate this apparent paradox in Tanzania and inform mental health policy; firstly, a household prevalence study to ascertain the prevalence of common mental disorders at community level in Tanzania; secondly, a study to ascertain the prevalence of common mental disorders in primary care attenders; and thirdly, a study to ascertain the current status of the knowledge, attitude and practice pertaining to depression among primary health care workers. This paper reports the findings of the latter study. METHODS: All the primary health care workers (N = 14) in four primary health care centres in Tanzania were asked to complete the Depression Attitude Questionnaire, which assesses the health worker's knowledge and attitude towards the causes, consequences and treatment of depression. RESULTS: The majority of respondents felt that rates of depression had increased in recent years, believed that life events were important in the aetiology of depression, and generally held positive views about pharmacological and psychological treatments of depression, prognosis and their own involvement in the treatment of depressed patients.However, the majority of respondents felt that becoming depressed is a way that people with poor stamina deal with life difficulties. CONCLUSION: The findings suggest a need to strengthen the training of primary health care workers in Tanzania about the detection of depression, pharmacological and psychological treatments, and psychosocial interventions.

Classification in primary care: experience with current diagnostic systems.

Mental disorders tend to be seen first in primary care settings around the world. To be helpful, classifications of mental disorders for primary care need to be simple. In response to these basic observations and requirements, a primary care version of the mental disorder section of ICD-10 has been developed by the WHO (ICD-10-PHC). This classification version has been used quite extensively internationally. The results of field trials with ICD-10-PHC are summarised here along with recommendations to make classifications and information systems more helpful to upgrade primary care of mental disorders around the world.