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Background: The delivery of high-quality services in chronically underfunded social or long-term care systems is a major challenge internationally. National guidelines, developed by the National Institute for Health and Care Excellence, set out how local authorities in England and Wales should fund and provide care based on best available evidence. Theoretical and participatory approaches can usefully inform the design and evaluation of implementation strategies for guidelines. The aim of the study is to develop a Theory-of-Change for how the implementation of these guidelines is expected to lead to impacts from a local authority perspective., Methods: As part of a comparative case study (The 'Valuing Care Guidelines' study; February 2022 to April 2024) with three local authority sites in England and Wales, we involved altogether 17 participants in two Theory-of-Change online workshops per site, each of 2 hours. Additional data gathered from the same participants as part of the overall study were used to conceptualise and enrich information from the workshops., Results: Participants described the Theory-of-Change map as follows: A wide range of activities (categorised in stages of 'pre-implementation', 'implementation', 'sustainment and scaling') and skills were required to implement guidelines, and achieve long-term organisational sustainability and service delivery outcomes, leading to final impacts for service users and carers. Participants described a co-creation implementation model, led by 'Implementation Support Practitioners', who utilised relational skills to achieve motivation, trust, and confidence at different organisational levels, addressing contextual barriers such as inadequate staffing, lack of resources and of organisational support systems. Consistent use of guidelines by frontline staff could only be achieved if the value of guideline implementation was promoted widely, and if consideration was given to the roles of stakeholders, such as the inspection body, local health care providers, users and carers., Conclusions: Our study is the first to investigate the implementation of national social care guidelines by local authorities in England and Wales. It generates insights that can guide implementation practice as well as inform the evaluation of future implementation strategies., (© 2024. The Author(s).)

Background: Despite the high burden of perinatal depression in Nepal, the detection rate is low. Community-based strategies such as sensitization programmes and the Community Informant Detection Tool (CIDT) have been found to be effective in raising awareness and thus promoting the identification of mental health problems. This study aims to adapt these community strategies for perinatal depression in the Nepalese context., Methods: We followed a four-step process to adapt the existing community sensitization program manual and CIDT. Step 1 included in-depth interviews with women identified with perinatal depression (n=36), and focus group discussions were conducted with health workers trained in community mental health (n=13), female community health volunteers (FCHVs), cadre of Nepal government for the prevention and promotion of community maternal and child health (n=16), and psychosocial counsellors (n=5). We explored idioms and understanding of depression, perceived causes, and possible intervention. Step 2 included draft preparation based on the qualitative study. Step 3 included a one-day workshop with the psychosocial counsellors (n=2) and health workers (n=12) to assess the understandability and comprehensiveness of the draft and to refine the content. A review of the CIDT and community sensitization program manual by a psychiatrist was performed in Step 4., Results: The first step led to the content development for the CIDT and community sensitization manual. Multiple stakeholders and experts reviewed and refined the content from the second to fourth steps. Idioms of depression and commonly cited risk factors were incorporated in the CIDT. Additionally, myths of perinatal depression and the importance of the role of family were added to the community sensitization manual., Conclusion: Both the CIDT and community sensitization manual are grounded in the local context and are simple, clear, and easy to understand., (© 2024. The Author(s).)

Background: Stigma exacerbates power imbalances and societal disparities, significantly impacting diverse identities and health conditions, particularly for low and middle-income countries (LMICs). Though crucial for dismantling harmful stereotypes, and enhancing healthcare utilisation, existing research on anti-stigma interventions is limited with its condition-focused approach. We aimed to thoroughly evaluate peer-reviewed and non-peer-reviewed literature for a comprehensive review of anti-stigma interventions for diverse identities and all health conditions in LMICs., Methods: This review systematically explored peer-reviewed and non-peer-reviewed literature, in ten electronic databases up to January 30, 2024, covering all anti-stigma interventions across various stigmatised identities and health conditions in LMICs. Quality assessment for this systematic review was conducted as per Cochrane Collaboration's suggested inclusions. The review was registered with PROSPERO (Registration: 2017 CRD42017064283)., Findings: Systematic synthesis of the 192 included studies highlights regional imbalances, while providing valuable insights on robustness and reliability of anti-stigma research. Most studies used quasi-experimental design, and most centred on HIV/AIDS or mental health related stigma, with very little work on other issues. Certain high-population LMICs had no/little representation., Interpretation: The interventions targeted diverse segments of populations and consequently yielded a multitude of stigma-related outcomes. However, despite the heterogeneity of studies, most reported positive outcomes underscoring the effectiveness of existing interventions to reduce stigma., Funding: This study is supported by the UK Medical Research Council Indigo Partnership (MR/R023697/1) award., Competing Interests: None to declare., (© 2024 Published by Elsevier Ltd.)

STRiDE was an ambitious four-year project in seven countries aiming to build capacity around generating and using research to support the development of policies to improve quality of life of people with dementia and their carers. The project's innovative approach combined rigorous academic research and hands-on civil society advocacy. This paper explores the project's unique strategy for policy change and compiles case-studies from several of the STRiDE countries. Finally, we share lessons learned and next steps to keep momentum for policy change going in each of these countries - and beyond., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In Kenya, approximately one in five girls aged 15-19 years old are pregnant or already a mother. Adolescent girls and young women experience significant mental health vulnerabilities during the pregnancy and postpartum periods, leading to poor antenatal and postnatal care attendance and inferior infant and maternal health outcomes. Pregnant adolescents often experience stigma and disenfranchisement due to their pregnancy status and at the same time lack access to mental health support within health settings, schools, religious institutions, and communities. This paper presents the results of qualitative interviews embedded within the human-centered design (HCD) process used to adapt the Helping Adolescents Thrive (HAT) program for Kenyan peripartum adolescents including young fathers. This qualitative study used two phases. First, a HAT advisory group participated in a series of four workshops to help identify and articulate mental health promotion needs and deepened the team's understanding of youth-centered thinking. Second, qualitative interviews were conducted with 39 pregnant and parenting adolescents to understand their perspectives on mental health prevention and promotion. Pregnant and parenting adolescents articulated different needs including poor support, stigma, and psychological disturbances. Parenting adolescents reported disturbed relationships, managing motherhood, poor health, and social empowerment. Participants highlighted sources of stress including economic challenges, fear of delivery, strained relationships, rejection, and stigma. Participants described psychological disturbances such as feeling stressed, worthless, withdrawn, and suicidal. Coping mechanisms reported by participants included engaging in domestic activities, hobbies, and social networking. Peers, family and spirituality were identified as important sources of support, as well as school integration, livelihoods, support groups and mentorships. Findings from this study can be used to strengthen and adapt HAT program, policy and practice for mental health prevention and promotion for pregnant and parenting adolescents., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kathono et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lawrie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Mental health service delivery needs radical reimagination in the United States where unmet needs for care remain large and most metrics on the burden of mental health problems have worsened, despite significant numbers of mental health professionals, spending on service provision and research. The COVID-19 pandemic has exacerbated the need for mental health care. One path to a radical reimagination is "Community Initiated Care (CIC)" which equips and empowers communities to address by providing brief psychosocial interventions by people in community settings. We co-developed a theory of change (ToC) for CIC with 24 stakeholders including representatives from community-based, advocacy, philanthropic and faith-based organizations to understand how CIC could be developed and adapted for specific contexts. We present a ToC which describes ways in which the CIC initiative can promote and strengthen mental health in communities in the United States with respect to community organization and leadership; community care and inclusion and normalizing mental health. We propose 10 strategies as part of CIC and propose a way forward for implementation and evaluation. This CIC model is a local, tailored approach which can expand the role of community members to strengthen our response to mental health needs in the United States., Competing Interests: The authors do not have any conflicts of interest., (© The Author(s) 2023.)

Introduction: There is a lack of standard nomenclature and a limited understanding of programmes and services delivered to people in prisons as they transition into the community to support their integration and reduce reoffending related risk factors. The aim of this paper is to outline the protocol for a modified Delphi study designed to develop expert consensus on the nomenclature and best-practice principles of programmes and services for people transitioning from prison into the community., Methods and Analysis: An online, two-phase modified Delphi process will be conducted to develop an expert consensus on nomenclature and the best-practice principles for these programmes. In the preparatory phase , a questionnaire was developed comprising a list of potential best-practice statements identified from a systematic literature search. Subsequently, a heterogeneous sample of experts including service providers, Community and Justice Services, Not for Profits, First Nations stakeholders, those with lived experience, researchers and healthcare providers will participate in the consensus building phase (online survey rounds and online meeting) to achieve consensus on nomenclature and best-practice principles. Participants will indicate, via Likert scale, to what extent they agree with nomenclature and best-practice statements. If at least 80% of the experts agree to a term or statement (indicated via Likert scale), it will be included in a final list of nomenclature and best-practice statements. Statements will be excluded if 80% experts disagree. Nomenclature and statements not meeting positive or negative consensus will be explored in a facilitated online meeting. Approval from experts will be sought on the final list of nomenclature and best-practice statements., Ethics and Dissemination: Ethical approval has been received from the Justice Health and Forensic Mental Health Network Human Research Ethics Committee, the Aboriginal Health and Medical Research Council Human Research Ethics Committee, the Corrective Services New South Wales Ethics Committee and the University of Newcastle Human Research Ethics Committee. The results will be disseminated via peer-reviewed publication., Competing Interests: Competing interests: SH is the Executive Medical Director at Justice Health and Forensic Mental Health Network, LG is the Deputy Commissioner at Corrective Services NSW Department of Communities and Justice, RZ is a Senior Research Officer at Justice Health and Forensic Mental Health Network, and ES is the Custodial Health Research lead at Justice Health and Forensic Mental Health Network., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Infertility affects millions of people globally. Although an estimated 1 in 6 couples in Australia are unable to conceive without medical intervention, little is known about the mental health impacts of infertility. This study investigated how infertility impacts the mental health of women. The study used nationally representative Australian Longitudinal Study on Women's Health (ALSWH) data. We analysed data from survey periods 2-8 conducted every three years between 2000 and 2018 for 6582 women born in 1973-78. We used a Generalised Equation Modelling (GEE) method to investigate the association of primary, secondary and resolved fertility status and psychological distress over time. Multiple measures were used to measure psychological distress: the (1) the mental health index subscale of the 36-item short form survey (SF-36), (2) the Center for Epidemiological Studies Depression Scale (CESD-10), (3) the Goldberg Anxiety and Depression Scale (GADanx) anxiety subscale; and a (4) composite psychological distress variable. About a third (30%) of women reported infertility at any of the survey rounds; a steady increase over 18 years from 1.7% at round 2 to 19.3% at round 8. Half of the women reporting primary or secondary infertility reported psychological distress, with the odds of having psychological distress was higher in women reporting primary (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06-1.45), secondary (OR 1.27, 95% CI 1.10-1.46) or resolved infertility (OR 1.15, 95% CI 1.05-1.26) compared to women reporting normal fertility status. Women with partners, underweight or higher BMI, smoking, and high-risk alcohol use had higher odds of psychological distress, whereas women in paid work had significantly lower odds of psychological distress (p < 0.001). Diabetes, high blood pressure, asthma, and other chronic physical illness were independently associated with higher odds of psychological distress. Infertility has a significant impact on mental health even after it is resolved. Frequent mental health assessment and a holistic approach to address the lifestyle factors should be undertaken during the treatment of infertility., (© 2022. The Author(s).)

Involving people living with dementia in service design and planning has become more common in high-income countries. It remains rare in low- and middle-income countries where two-thirds of the world's people with dementia live. In this commentary article, we explore the barriers to inclusion of people living with dementia in planning in low- and middle-income countries and make a case for the inclusion of people living with dementia in care and service planning. We suggest how this can be done at individual, community or national and state level using the following principles: 1) respecting the rights of people living with dementia to self-determination; 2) valuing people living with dementia's unique understanding of dementia; 3) creating a culture of active inclusion which creates a space for people living with dementia to participate and 4) ensuring appropriate accommodations are in place to maximise participation.

Evidence from middle-income countries indicates high and increasing prevalence of dementia and need for services. However, there has been little investment in care, treatment or support for people living with dementia and their carers. The Strengthening Responses to Dementia in Developing Countries (STRiDE) project aims to build both research capacity and evidence on dementia care and services in Brazil, Indonesia, India, Jamaica, Kenya, Mexico and South Africa. This article presents the Theory of Change (ToC) approach we used to co-design our research project and to develop a strategic direction for dementia care, treatment and support, with stakeholders. ToC makes explicit the process underlying how a programme will achieve its impact. We developed ToCs in each country and across the STRiDE project with researchers, practitioners, people living with dementia, carers and policymakers at different levels of government. This involved (1) an initial ToC workshop with all project partners (43 participants); (2) ToC workshops in each STRiDE country (22-49 participants in each); (3) comparison between country-specific and overall project ToCs; (4) review of ToCs in light of WHO dementia guidelines and action plan and (5) a final review. Our experiences suggest ToC is an effective way to generate a shared vision for dementia care, treatment and support among diverse stakeholders. However, the project contribution should be clearly delineated and use additional strategies to ensure appropriate participation from people living with dementia and their carers in the ToC process.

Background: Women in prison are a vulnerable group, often with a history of abuse, out-of-home care, mental health problems and unemployment. Many are mothers when they become involved in the criminal justice system and their gender and parenting related needs are often not considered. The aim of this rapid review was to thematically synthesize the existing research on the needs and experiences of mothers while in, and following release from, prison in Australia., Methods: We conducted a rapid systematic search of electronic databases, search engines, the websites of key agencies, and contacted key agencies and researchers., Results: Twenty-two publications from 12 studies met the inclusion criteria and were thematically synthesized in relation to the mothers, their children, family and community, and systems and services which mothers had contact with. We found that mothers in prison have a history of disadvantage which is perpetuated by the trauma of imprisonment. Release from prison is a particularly challenging time for mothers. In relation to their children, the included studies showed that the imprisonment of mothers impacts their maternal identity and role and disrupts the mother-child relationship. Specific strategies are needed to maintain the mother-child relationship, and to ensure the needs and rights of the child are met. In relation to family and community, we found that although family and social support is an important need of women in prison, such support may not be available. Moreover, the stigma associated with having been in prison is a significant barrier to transitions into the community, including finding employment and housing. In relation to systems and services, although limited services exist to support women in prison and on release, these often do not consider the parenting role. Evaluations of parenting programs in prison found them to be acceptable and beneficial to participants but barriers to access limit the number of women who can participate., Conclusion: Mothers have gender- and parenting-specific needs which should be considered in planning for corrective services in Australia. Any service redesign must place the woman and her children at the centre of the service., (© 2021. The Author(s).)

Background: Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multi-country initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention., Objective: This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa., Methods: Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team., Results: The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur., Conclusions: The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in low-to-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.

Background: The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal., Aims: To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP., Method: A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers., Results: The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors., Conclusions: Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.

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., (© World Health Organization 2020. All rights reserved. The World Health Organization has granted the Publisher permission for the reproduction of this article.)

Background: There has been a growing global movement championed by the World Health Organization (WHO) to integrate mental health into primary health care as the most effective way of reducing the mental health treatment gap. This study aimed to investigate the impact of WHO Mental Health Gap Action Programme (mhGAP) training and supervision on primary health workers' knowledge, confidence, attitudes and detection rate of major mental disorders in Mulanje, Malawi., Method: The study used a quasi-experimental method (single cohort pre- and post-measures) with an interrupted time-series design. A 2 day mhGAP training was delivered to 43 primary healthcare workers (PHWs) working in 18 primary care clinics serving the entire population of Mulanje, Malawi (population 684,107). Modules covered were psychosis, moderate-severe depression, and alcohol & substance use disorders. The PHWs completed pre and post-tests to assess knowledge, confidence and attitudes. Number of diagnosed cases was obtained from clinic registers for 5 months prior to and 7 months following training. Data was analyzed using mean scores, t-test, one-way analysis of variance and linear regression., Results: The mean knowledge score increased significantly from 11.8 (SD: 0.33) before training to 15.1 (SD: 0.38) immediately after training; t (42) = 7.79, p < 0.01. Similarly, mean knowledge score was significantly higher 6 months post training at 13.9 (SD: 2.52) compared to before; t (42) = 4.57, p < 0.01. The mean confidence score also increased significantly from 39.9 (SD: 7.68) before training to 49.6 (SD: 06.14) immediately after training; t (84) = 8.43, p < 0.01. It was also significantly higher 6 months post training 46.8, (SD: 6.03) compared to before; t (84) = 6.60, p < 0.01. One-way analysis of variance showed no significant difference in mean scores on all four components of the scale used to measure attitudes. A significant positive change in the trend in mental health service utilization after the intervention was demonstrated using a segmented linear regression (β = 2.43 (95% CI 1.02; 3.83) as compared to before (β = - 0.22 (95% CI - 2.67; 2.23) and immediately after (β = 1.63 (95% CI - 7.31; 10.57)., Conclusion: The findings of this study add to the growing evidence for policy makers of the effectiveness of mhGAP training and supervision in a resource-constrained country., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

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., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest.

Background: The PRogramme for Improving Mental health care (PRIME) designed, implemented and evaluated a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India.AimsTo provide quantitative measures of outputs related to implementation processes, describe the role of contextual factors that facilitated and impeded implementation processes, and discuss what has been learned from the MHCP implementation., Method: A convergent parallel mixed-methods design was used. The quantitative strand consisted of process data on mental health indicators whereas the qualitative strand consisted of in-depth interviews and focus group discussions with key stakeholders involved in PRIME implementation., Results: The implementation of the MHCP in Sehore district in Madhya Pradesh, India, demonstrated that it is feasible to establish structures (for example Mann-Kaksha) and operationalise processes to integrate mental health services in a 'real-world' low-resource primary care setting. The key lessons can be summarised as: (a) clear 'process maps' of clinical interventions and implementation steps are helpful in monitoring/tracking the progress; (b) implementation support from an external team, in addition to training of service providers, is essential to provide clinical supervision and address the implementation barriers; (c) the enabling packages of the MHCP play a crucial role in strengthening the health system and improving the context/settings for implementation; and (d) engagement with key community stakeholders and incentives for community health workers are necessary to deliver services at the community-platform level., Conclusions: The PRIME implementation model could be used to scale-up mental health services across India and similar low-resource settings.Declaration of interestNone.

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Integrating mental health counselling into primary care services is a recommended strategy for reducing the mental health treatment gap in low- and middle-income countries. To support this strategy, potential barriers to counselling integration must be identified and addressed. Organizational preparedness for implementation may influence the extent to which the introduction of counselling is successful. Features of primary care facilities associated with preparedness for the implementation of mental health counselling have not been explored. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study uses a novel approach to explore variations in preparedness of primary care services to implement counselling and factors potentially associated with these variations. Findings suggest there is considerable variation in the preparedness of facilities to implement counselling. Organizational factors such as resource availability, management style and facility environment are potentially associated with capability for implementing mental health counselling. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Health planners could use this method to identify poorly functioning services that may benefit from additional interventions to build preparedness for counselling implementation. Future research should examine whether differences in facility preparedness impact on the implementation and outcomes of this service. Abstract Introduction Differences in primary care facilities' preparedness for implementing mental health counselling may affect the implementation process but have rarely been studied. Aim To assess the feasibility of using a novel methodological approach to explore variations in capability for implementing mental health counselling and factors potentially associated with this variation among primary care services in the Western Cape, South Africa. Methods Staff from 26 facilities participated in discussions about their facility's mental health implementation capability. Three researchers conducted observations of the facility's environment, staff-patient interactions and resources. We used qualitative comparative analysis to identify factors potentially associated with implementation capability. Results Facilities appeared to vary in their capability for implementing counselling services. The availability of person-centred health services, a therapeutic environment and sufficient human resources may be requirements for implementation preparedness. Other factors that seem to support preparedness include the availability of confidential space for counselling and an adequately managed facility. Discussion This study identified several features of well-functioning primary care facilities. Facilities with these features may be better prepared to implement a new counselling service. Implications for practice This method may identify facilities that are poorly prepared for implementation that could benefit from preparedness-building interventions. Whether differences in preparedness affect counselling outcomes is yet to be established., (© 2019 John Wiley & Sons Ltd.)

Background: The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme's Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC., Methods: We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5., Results: The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities., Conclusions: Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions., Competing Interests: Competing interests: None declared.

Mental health has been included in the UN Sustainable Development Goals. However, uncertainty exists about the extent to which the major social determinants of mental disorders are addressed by these goals. The aim of this study was to develop a conceptual framework for the social determinants of mental disorders that is aligned with the Sustainable Development Goals, to use this framework to systematically review evidence regarding these social determinants, and to identify potential mechanisms and targets for interventions. We did a systematic review of reviews using a conceptual framework comprising demographic, economic, neighbourhood, environmental events, and social and culture domains. We included 289 articles in the final Review. This study sheds new light on how the Sustainable Development Goals are relevant for addressing the social determinants of mental disorders, and how these goals could be optimised to prevent mental disorders., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Context: A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown., Objective: To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage., Methods: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months., Setting: Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda., Participants: 8036 adults residing in these districts between May 2013 and May 2014., Main Outcome Measures: Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD., Results: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%., Conclusions: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans., Competing Interests: The authors have declared that no competing interests exist.

Background: Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the design and evaluation of public health interventions. This review aims to determine how ToCs have been developed and used in the development and evaluation of public health interventions globally., Methods: We searched for papers reporting the use of "theory of change" in the development or evaluation of public health interventions in databases of peer-reviewed journal articles such as Scopus, Pubmed, PsychInfo, grey literature databases, Google and websites of development funders. We included papers of any date, language or study design. Both abstracts and full text papers were double screened. Data were extracted and narratively and quantitatively summarised., Results: A total of 62 papers were included in the review. Forty-nine (79 %) described the development of ToC, 18 (29 %) described the use of ToC in the development of the intervention and 49 (79 %) described the use of ToC in the evaluation of the intervention. Although a large number of papers were included in the review, their descriptions of the ToC development and use in intervention design and evaluation lacked detail., Conclusions: The use of the ToC approach is widespread in the public health literature. Clear reporting of the ToC process and outputs is important to strengthen the body of literature on practical application of ToC in order to develop our understanding of the benefits and advantages of using ToC. We also propose a checklist for reporting on the use of ToC to ensure transparent reporting and recommend that our checklist is used and refined by authors reporting the ToC approach.

Background: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district., Method: Population-based (n = 1485) and facility-based (n = 1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT)., Results: The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9 % (95 % Confidence Interval (CI) = 6.8 % to 8.9 %). The prevalence was significantly higher in the facility sample (10.3 %) compared with the community sample (6.3 %). The 12-month prevalence of suicide attempt was 4.4 % (95 % CI = 3.6 % to 5.3 %), non-significantly higher among the facility sample (5.4 %) compared with the community sample (3.8 %). Over half of those with suicidal ideation (56.4 %) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5 % of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8 % of the community sample and 10.2 % of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups., Conclusion: Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care.

Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care., Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness., Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community., Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

Background: Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings., Aims: To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda., Method: Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change., Results: The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation., Conclusions: To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings., (© The Royal College of Psychiatrists 2016.)

Background: In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level., Aims: To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care., Method: Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP., Results: Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified., Conclusions: The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up., (© The Royal College of Psychiatrists 2016.)

Background: There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings., Aims: To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME)., Method: ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13-22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members., Results: One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts., Conclusions: ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation., (© The Royal College of Psychiatrists 2016.)

Background: Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority., Aims: To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia., Method: A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation)., Results: The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability., Conclusions: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC., (© The Royal College of Psychiatrists 2016.)

Background: Brief depression screening questionnaires may increase detection of depression in primary care settings but there have been few validation studies carried out in typical populations in low-income countries., Methods: Cultural validation of the Patient Health Questionnaire (PHQ-9/PHQ-2), the 20-item Self-Reporting Questionnaire (SRQ-20) and the Kessler scales (K6/K10) was carried out in 306 adults consecutively attending primary care facilities in small towns in Ethiopia. To assess criterion validity, the gold standard assessment for presence of Major Depressive Disorder (MDD) was made by Ethiopian psychiatric nurses using the Mini International Neuropsychiatric Interview., Results: The prevalence of gold standard MDD was 5.9%, with irritability more common than depressed mood or anhedonia. The area under the receiver operating characteristic curve indicated good performance of the PHQ-9, SRQ-20, K6 and K10 (0.83-0.85) but only fair for the PHQ-2 (0.78). No cut-off score had acceptable sensitivity combined with adequate positive predictive value. All screening questionnaires were associated with disability and the PHQ-9 and SRQ-20 were associated with higher health service contacts, indicating convergent validity. Construct validity of all scales was indicated by unidimensionality on exploratory factor analysis., Limitations: Test-retest reliability was not assessed., Conclusions: Brief depression screening questionnaires were found to be valid in primary care in this low-income country. However, these questionnaires do not have immediate applicability in routine clinical settings. Further studies should evaluate utility of indicated screening embedded within health system changes that support MDD detection. Investigation of irritability as a core depression symptom is warranted., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care., Methods: An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan., Results: A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later., Conclusions: The ToC approach was found to be an important component in the development of the MHCP and to encourage broad political support for the integration of mental health services into primary care. The method may have broader applicability in planning complex health interventions in low resource settings.

Background: As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia., Methods: The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population., Results: The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD = 60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD., Conclusion: Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required.

Background: The Medical Research Councils' framework for complex interventions has been criticized for not including theory-driven approaches to evaluation. Although the framework does include broad guidance on the use of theory, it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach. A prospective, theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective, sustainable and scalable., Methods: We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool, Theory of Change (ToC), into the MRC framework for complex interventions. We provide a guide to what ToC is, how to construct one, and how to integrate its use into research projects seeking to design, implement and evaluate complex interventions using the MRC framework. We test this approach by using ToC within two randomized controlled trials and one non-randomized evaluation of complex interventions., Results: Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework. It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly designing an intervention that is embedded in the local context. For the feasibility and piloting stage, ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design. ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact, combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework., Conclusions: Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions, thereby increasing the likelihood that the intervention will be ultimately effective, sustainable and scalable. We urge researchers developing and evaluating complex interventions to consider using this approach, to evaluate its usefulness and to build an evidence base to further refine the methodology., Trial Registration: Clinical trials.gov: NCT02160249.

Unlabelled: Given the high prevalence of HIV in South Africa and co-morbid mental disorders in people living with HIV/AIDs (PLWHA) we sought to validate a brief screening tool in primary HIV care., Methods: 366 PLWHA were recruited prior to combination anti-retroviral treatment (CART) initiation from two primary health HIV clinics. A mental health nurse administered a socio-demographic questionnaire and the Mini Neuropsychiatric Interview (MINI) and a lay counsellor administered the Substance and Mental Illness Symptom Screener (SAMISS)., Results: Using the MINI, 17 % of participants were identified with either depression, anxiety disorders or adjustment disorder and 18 % with substance or alcohol abuse/dependence. The sensitivity and specificity of the SAMISS was 94 % (95 % CI: 88-98 %) and 58 % (95 % CI: 52-65 %) respectively, with the alcohol component (sensitivity: 94 %; specificity: 85 %) performing better than the mental illness component of the SAMISS (sensitivity: 97 %; specificity: 60 %). The specificity of the tool improved when the cut-off for the mental illness component was increased., Conclusion: The SAMISS may provide a useful first tier screening tool for common mental disorders in primary care for PLWHA.

Background: The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known about its use to develop mental health care plans in low and middle income countries where mental health services remain inadequate., Aims: ToC workshops were held as part of formative phase of the Programme for Improving Mental Health Care (PRIME) in order 1) to develop a structured logical and evidence-based ToC map as a basis for a mental health care plan in each district; (2) to contextualise the plans; and (3) to obtain stakeholder buy-in in Ethiopia, India, Nepal, South Africa and Uganda. This study describes the structure and facilitator's experiences of ToC workshops., Methods: The facilitators of the ToC workshops were interviewed and the interviews were recorded, transcribed and analysed together with process documentation from the workshops using a framework analysis approach., Results: Thirteen workshops were held in the five PRIME countries at different levels of the health system. The ToC workshops achieved their stated goals with the contributions of different stakeholders. District health planners, mental health specialists, and researchers contributed the most to the development of the ToC while service providers provided detailed contextual information. Buy-in was achieved from all stakeholders but valued more from those in control of resources., Conclusions: ToC workshops are a useful approach for developing ToCs as a basis for mental health care plans because they facilitate logical, evidence based and contextualised plans, while promoting stakeholder buy in. Because of the existing hierarchies within some health systems, strategies such as limiting the types of participants and stratifying the workshops can be used to ensure productive workshops.

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care., Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts., Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care., Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

Background: The aim of this study was to evaluate outcomes for participants in BasicNeeds' Mental Health and Development programme in rural Kenya., Methods: All new entrants to the programme in the Meru South and Nyeri North districts were enrolled in the study over a 3-month period (n = 203). Assessments of mental health, functioning, economic status and quality of life were conducted at baseline and at 1-year and 2-year follow up, using a single group cohort design., Results: Over the 2 years there were significant improvements in scores on the General Health Questionnaire (21.5 [95% CI: 20.2-22.8] to 6 [95% CI: 4.8-7.2] p < 0.01), Global Assessment of Functioning scale (78 [95% CI: 75.5-80.3] to 94 [95% CI: 90.7-97.3] p < 0.01), summed WHO Quality of Life-Brief scale (39.5 [95% CI: 38.6-40.4] to 57.2 [95% CI: 56.2-58.3] p < 0.01) and the proportion who were engaged in either income generation or productive work (45.3-64.0%, p < 0.01)., Conclusions: The mental health and development model shows improvements in mental health, functioning, income generation and quality of life among people living with severe mental illness in rural Kenya. The findings demonstrate the feasibility and benefits of integrating mental health and poverty alleviation components in mental health care in Africa.

HIV infection is associated with an increased prevalence of common mental disorders and with the development of HIV associated neurological disorders (HAND). The aim of this research was to determine the reliability of lay adherence counsellors in the administration of the substance abuse and mental illness symptom screener (SAMISS) for common mental disorders and International HIV Dementia Scale (IHDS) for HAND in a South African sample of 269 people living with HIV/AIDS and on HAART in a primary healthcare setting. We used a cross-sectional design with each patient assessed by a mental health nurse and counsellor, 1 week apart. Reliability was fair for the SAMISS overall (κ = 0.39, CI(95) 0.29-0.49, P < 0.01), but was higher for the substance abuse component compared to the mental illness component. Reliability for the IHDS between counsellors and nurses was slight (κ = 0.11, CI(95) 0.00-0.27, P < 0.02). Counsellors tended not to miss symptoms, and detected symptoms more often than nurses for the both the SAMISS and IHDS. Strategies to improve the ability of primary healthcare providers to screen for neurocognitive disorders as well as avoiding over-detection of mental illness and substance abuse symptoms need to be developed and implemented for the primary healthcare setting.

The relationship between mental illness and HIV/AIDS is complex and bidirectional. A significant amount of research has been performed in high-income countries but less is known about HIV and mental health in sub-Saharan Africa. The objectives of the review were to search the literature for quantitative studies conducted in sub-Saharan Africa on mental health and HIV and to critically evaluate and collate the studies in order to identify research needs and priorities. The databases Ovid, MEDLINE, PsycINFO and the Social Sciences Citation Index (SSCI) were searched for variations of search terms related to HIV/AIDS and mental health and studies limited to the populations of African countries. In addition, we hand-searched indexes of key journals and the databases of academic theses. We included 104 papers or research publications. The majority of these were published after 2005. The major topics covered were: mental-health-related HIV-risk behaviour, HIV in psychiatric populations, and mental illness in HIV-positive populations. The reported prevalence levels of mental illness among people living with HIV or AIDS (PLHIV) was high, with all but one study noting a prevalence of 19% or higher. Neurocognitive changes in adults with HIV were also prevalent, with reported deficits of up to 99% in symptomatic PLHIV and 33% in non-symptomatic PLHIV. Research on HIV in relation to mental health is increasing; however, there is a need for good-quality prospective studies to investigate the bidirectional effects of mental illness and HIV on each other.