Annika Sweetland

Relationship of Stigma to HIV Risk Among Women with Mental Illness

Urban women with severe mental illness (SMI) are vulnerable to stigma and discrimination related to mental illness and other stigmatized labels. Stigma experiences may increase their risk for negative health outcomes, such as HIV infection. This study tests the relationship between perceived stigma and HIV risk behaviors among women with SMI. The authors interviewed 92 women attending community mental health programs using the Stigma of Psychiatric Illness and Sexuality Among Women Questionnaire. There were significant relationships between personal experiences of mental illness and substance use accompanying sexual intercourse; perceived ethnic stigma and having a riskier partner type; and experiences of discrimination and having a casual or sex-exchange partner. Higher scores on relationship stigma were associated with a greater number of sexual risk behaviors. The findings underscore the importance of exploring how stigma attached to mental illness intersects with other stigmatized labels to produce unique configurations of HIV risk. HIV risk reduction interventions and prevention research should integrate attention to stigmatized identities in the lives of women with SMI.

MEASURING DEPRESSION AND ANXIETY IN SUB‐SAHARAN AFRICA

Despite being one of the leading causes of disability worldwide, fewer than 10% of depressed individuals in low‐resource settings have access to treatment. Mounting evidence suggests that nonspecialist workers are capable of providing counseling and case management at the community level. They often use brief psychiatric screening instruments as clinical tools to identify cases and monitor symptoms over time. In order for such tools to be used in diverse settings, they must demonstrate adequate reliability and validity in addition to cross‐cultural relevance. To be used to guide routine care they also need to be flexibly adapted and sensitive to change. The goal of this paper is to assess the cross‐cultural validity of brief psychiatric screening instruments in sub‐Saharan Africa, identify best practices, and discuss implications for clinical management and scale‐up of mental health treatment in resource‐poor settings.

Closing the mental health gap in low-income settings by building research capacity: perspectives from Mozambique.

BACKGROUND Neuropsychiatric disorders are the leading cause of disability worldwide, accounting for 22.7% of all years lived with disability. Despite this global burden, fewer than 25% of affected individuals ever access mental health treatment; in low-income settings, access is much lower, although nonallopathic interventions through traditional healers are common in many venues. Three main barriers to reducing the gap between individuals who need mental health treatment and those who have access to it include stigma and lack of awareness, limited material and human resources, and insufficient research capacity. We argue that investment in dissemination and implementation research is critical to face these barriers. Dissemination and implementation research can improve mental health care in low-income settings by facilitating the adaptation of effective treatment interventions to new settings, particularly when adapting specialist-led interventions developed in high-resource countries to settings with few, if any, mental health professionals. Emerging evidence from other low-income settings suggests that lay providers can be trained to detect mental disorders and deliver basic psychotherapeutic and psychopharmacological interventions when supervised by an expert. OBJECTIVES We describe a new North-South and South-South research partnership between Universidade Eduardo Mondlane (Mozambique), Columbia University (United States), Vanderbilt University (United States), and Universidade Federal de São Paulo (Brazil), to build research capacity in Mozambique and other Portuguese-speaking African countries. CONCLUSIONS Mozambique has both the political commitment and available resources for mental health, but inadequate research capacity and workforce limits the countrys ability to assess local needs, adapt and test interventions, and identify implementation strategies that can be used to effectively bring evidence-based mental health interventions to scale within the public sector. Global training and research partnerships are critical to building capacity, promoting bilateral learning between and among low- and high-income settings, ultimately reducing the mental health treatment gap worldwide.

Depression: a silent driver of the global tuberculosis epidemic

Depression is a common comorbid condition for patients with tuberculosis (TB) (1–3), and is associated with higher morbidity and mortality (4,5), antibiotic drug resistance (1,3,6), and community transmission. Depressed individuals with TB are less likely to seek care promptly, if at all, and once in treatment are significantly less likely to take medications consistently and/or completely (2,4,7). These treatment irregularities can lead to drug resistance, morbidity and mortality. Therefore, depression may be an unrecognized driver of the TB and multidrug resistant TB (MDR-TB) epidemics. MDR-TB treatment is significantly more expensive, takes approximately four times as long to complete, and produces acute physical and psychiatric side effects, which makes treatment adherence and completion a considerable challenge. Since few low-income settings have the resources or capacity to deliver the specialized care that is required, ensuring prompt and complete TB management in all settings is critical to curb the global TB and emerging MDR-TB epidemics. Using a two-stage snowbalxfl approach to reviewing the literature, first searching MEDLINE (1946-2013), PubMed (196-2013), and PsycINFO (1806-2013) databases with key relevant search terms, then reviewing the references of those articles, we identified 31 studies from 11 countries that assessed depression prevalence among individuals with active TB. These included one low-income (Kenya), three lower-middle income (India, Nigeria, Pakistan), five upper-middle income (South Africa, Peru, Romania, Russia, Turkey), and two high-income countries (Greece, United States). The studies were of mixed methodological quality. A majority of them relied on brief screening instruments to identify probable cases of depression, seven used clinical diagnostic interviews, and two did not specify the method of assessment. Only two studies included a healthy comparison group. Sample sizes ranged from 30 to 691 (mean 158, median 100). Two-thirds were conducted among outpatient populations and the remaining among inpatients in hospitals. The current prevalence of depression among individuals receiving treatment for TB ranged from 11.3% to 80.2%, with a mean weighted prevalence of 48.9% (95% CI 48.3%-49.6%). In the two studies that compared the prevalence of depression among TB outpatients to healthy controls, that prevalence was three to six times higher among the former. Though we expected to find consistent rates within or between countries of similar income levels, a great deal of variability was observed. The widest variation occurred within countries (India, Nigeria, Pakistan, Peru and Russia). However, in these cases, the weighted mean prevalence within countries revealed relatively narrow confidence intervals with a strong central tendency. There was little difference in rates between studies using structured diagnostic interviews versus brief screening instruments, and no single screening instrument produced higher or lower rates than any other used. The most commonly used brief screening tool, adopted in eight studies, was the Beck Depression Inventory. Though available evidence is of mixed methodological quality, it suggests that the prevalence of depression among individuals with active TB may be equally high or higher than in people with other chronic medical conditions. However, more research is sorely needed to estimate the true community prevalence of depression among individuals with TB. Treating comorbid depression has been associated with better TB outcomes, including medication adherence, treatment completion, and cure. A prospective controlled study in India found that TB patients who received individual psychotherapy during treatment were significantly more likely to adhere to and complete treatment and, thus, be cured of their disease (8). In rural Ethiopia, the organization of peer-led “TB clubs” increased clinic attendance and adherence, case detection, and community awareness about TB (9). In Peru, a psychosocial support group intervention was developed for MDR-TB patients which improved treatment adherence and completion, as well as social rehabilitation after treatment (1). Finally, antidepressants, in isolation or in conjunction with other therapies, have also been effectively used to treat depression among patients with TB (10). Though TB disproportionately affects individuals in low-resource settings with few mental health specialists, a growing body of evidence suggests that non-specialist health workers can be trained to deliver basic mental health care, including case detection, symptom management and triage, and such strategies may be very useful and relevant in the context of TB.

Mental Health Research in the Global Era: Training the Next Generation

Psychiatric disorders are among the leading cause of disability worldwide, yet fewer than 25 % of affected individuals are estimated to have access to treatment. In many low-income settings, it is estimated that less than 10 % of affected individuals are able to access basic mental health care and, even when they do, it is often below minimum ethical and clinical standards [1]. The discipline of global mental health is dedicated to reducing mental health disparities within and between countries by preventing mental disorders and improving access to psychiatric treatment, particularly in low-resource settings [2]. The study of cross-cultural mental health dates back to the late 1800s, when European psychiatrists and anthropologists began to identify and document locally specific mental diseases in their colonies [3]. Transcultural psychiatry branched into two research traditions: “relativists,” who were focused on characterizing culture-bound syndromes, and “universalists,” who sought to identify universality across cultures in the manifestation of mental disorders [2]. Both research traditions emerged from a colonial paradigm, wherein Western researchers studied the non-Western “other.” Whereas relativists relied primarily on qualitative and ethnographic methods [4], universalists employed epidemiological methods to estimate the cross-cultural prevalence of mental disorders, as defined by Western criteria. Cross-cultural mental health research has evolved significantly from its colonial roots to what is now a global partnership model emphasizing interdependency, bi-directional knowledge generation and transfer, and shared ownership (see Fig. 1). Though the relativist and universalist perspectives still exist, most global mental health researchers have gravitated towards an integrationist perspective, recognizing both broad universality in mental disorders across cultures as well as meaningful cross-cultural variation. Global mental health research now requires an interdisciplinary approach to bridge multiple perspectives and address complex questions related to cultural adaptation, effectiveness, dissemination, and implementation. It is grounded in the social justice and human rights perspective that all people have the right to health and mental health [5], with an emphasis on creating sustainable interventions to reduce mental health disparities. This paradigm shift has many implications for the training of the next generation of global mental health researchers, including both identifying and developing critical new skill sets to propel the field forward. Fig. 1 History and evolution of global mental health research and training

The Use of Technology for Large-scale Education Planning and Decision-making

In 2007, Nigeria made history by launching the Conditional Grants Scheme (CGS), one of the worlds largest poverty elimination campaigns aimed at achieving the Millennium Development Goals (MDGs) by 2015. As part of CGS, the Office of the Senior Special Assistant to the President of Nigeria on the MDGs (OSSAP-MDGs) collaborated with The Earth Institute, Columbia University to develop the Nigeria MDG Information System (NMIS), a web-based platform designed to support data-driven decision-making, local-level planning, and budgeting by Local Government Areas. This paper discusses the evolution of NMIS as a data repository and describes its uses. NMIS maps and visually displays school-related data that can be used for education planning. NMIS illustrates the integration of educational and technological innovations and demonstrates ways in which challenges related to Education Management Information Systems can be overcome. NMIS could serve as a good example for other developing countries that seek to create large databases for public planning. This paper shares lessons learned in terms of the content, design, and potential uses of such information systems for local-level education planning. This paper concludes by highlighting that a data system alone is not sufficient to ensure effective analysis and use of data and multiple rounds of end-user training and case studies must accompany the system.

Correlations between caregiver psychiatric symptoms and offspring psychopathology in a low-resource setting

Objective: Associations between parental/caregiver depression and adverse child outcomes are well established and have been described through one or more mechanisms: child psychopathology following exposure to a depressed caregiver, child psychopathology exacerbating a caregiver’s depression, and caregiver and offspring depression sharing the same etiology. Data from low and middle-income countries is scarce. We examined correlations between common symptoms of mental disorders in caregivers and their offspring’s psychopathology in a Brazilian sample. Methods: In this cross-sectional study, adult caregivers were screened for depression during routine home visits by community health workers as part of the Brazilian Family Health Strategy. Caregivers with suspected depression were assessed using the Zung Self-Rating Depression Scale and the Self-Reporting Questionnaire (SRQ-20). Children’s symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ). Results: The sample included 68 primary caregivers and 110 children aged 6 to 15 years. Higher caregiver scores on the SRQ-20 correlated significantly with psychiatric symptoms in offspring. Conclusion: These results substantiate our hypothesis that child psychopathology correlates with caregivers’ psychiatric symptoms. This paper adds to the growing literature on community mental health assessment and can help guide future strategies for reducing the burden of common mental disorders in caregivers and children alike in low and middle-income countries.

Tuberculosis and mental health in the Asia-Pacific

Objective: This opinion piece encourages mental health researchers and clinicians to engage with mental health issues among tuberculosis patients in the Asia-Pacific region in a culturally appropriate and ethical manner. The diversity of cultural contexts and the high burden of tuberculosis throughout the Asia-Pacific presents significant challenges. Research into tuberculosis and mental illness in this region is an opportunity to develop more nuanced models of mental illness and treatment, while simultaneously contributing meaningfully to regional tuberculosis care and prevention. Conclusions: We overview key issues in tuberculosis and mental illness co-morbidity, highlight ethical concerns and advocate for a regional approach to tuberculosis and mental health that is consistent with the transnational challenges presented by this airborne infectious disease. Integrating tuberculosis and mental health services will go a long way to addressing the needs of vulnerable populations and stopping the transmission of one of the world’s biggest infectious killers.

Prevalence of depression among patients with presumptive pulmonary tuberculosis in Rio de Janeiro, Brazil

Objective: To estimate the prevalence of major depressive episode (MDE) in patients with presumptive pulmonary tuberculosis (pre-PTB, defined by cough lasting ≥ 3 weeks) and compare it between patients with pulmonary tuberculosis (PTB) and without PTB. Methods: Patients with pre-PTB (n=260) were screened for depression using the Patient Health Questionnaire (PHQ-9). Those individuals with scores ≥ 10 were subsequently assessed with the depression module of the Mini International Neuropsychiatric Interview (MINI-Plus) to confirm diagnosis. Associations of categorical variables with PTB and MDE were calculated using the chi-square test and OR. Results: PTB was confirmed in 98 patients (37.7%). A high proportion of both groups (active PTB and no PTB) screened positive for depression (60.2 vs. 62.1%, respectively). Among 159 patients who screened positive for depression, a subset of 97 (61.0%) were further evaluated with the MINI-Plus; current MDE was confirmed in 54.6% (53/97). On univariate and multivariate analysis, female sex was the only factor associated with the diagnosis of current MDE (p = 0.04). Conclusion: The prevalence of MDE was high among individuals with prolonged respiratory symptoms, independent of PTB diagnosis. This is consistent with other studies of depression in primary care in Brazil.