Search

Objectives: To validate codelists for defining a range of mental health (MH) conditions with primary care data, using a mixed qualitative and quantitative approach and without requiring external data., Methods: We validated Read codelists, selecting and classifying them in three steps. The qualitative step included an in-depth revision of the codes by six doctors. Simultaneously, the quantitative step performed on UK primary care data included an exploratory factor analysis to cluster Read codes in MH conditions to obtain an independent classification. The statistical results informed the qualitative conclusions, generating a final selection and classification., Results: From a preselected list of 2007 Read codes, a total of 1638 were selected by all doctors. Later, they agreed on classifying these codes into 12 categories of MH disorders. From the same preselected list, a total of 1364 were quantitatively selected. Using data from 497,649 persons who used these Read codes at least once, we performed the exploratory factor analysis, retaining five factors (five categories). Both classifications showed good correspondence, while discrepancies informed decisions on reclassification., Conclusions: We produced a comprehensive set of medical codes lists for 12 MH conditions validated by a combination of clinical consensus panel and quantitative cluster analysis with cross-validation., (© 2024 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Importance: Current evidence of the association between prenatal exposure to glucocorticoids and long-term mental disorders is scarce and has limitations., Objective: To investigate the association between prenatal exposure to systemic glucocorticoids and mental disorders in offspring at the age of 15 years, comparing exposed vs unexposed offspring born to mothers with the same underlying disease (risk of preterm delivery and autoimmune or inflammatory disorders)., Design, Setting, and Participants: This nationwide population-based cohort study used data from registries in Denmark with follow-up until December 31, 2018. Participants included all Danish infants born alive from 1996 to 2016. Analyses were performed from January to December 2023., Exposures: Prenatal exposure to systemic glucocorticoids., Main Outcomes and Measures: Fifteen-year crude and adjusted risks, risk differences, and risk ratios (RR) for mental disorders using Kaplan-Meier estimator comparing exposed vs unexposed offspring born to mothers with the same underlying disease., Results: A total of 1 061 548 infants (52% male) were included in the final study cohort, including 31 518 born to mothers at risk of preterm delivery and 288 747 born to mothers with autoimmune or inflammatory disorders. Among offspring born to mothers at risk of preterm delivery, the adjusted risks for exposed vs unexposed were 6.6% vs 4.3% (RR, 1.5 [95% CI, 1.2-1.9]) for autism spectrum disorders; 1.6% vs 1.3% (RR, 1.3 [95% CI, 0.8-1.8]) for intellectual disabilities; 5.8% vs 4.3% (RR, 1.3 [95% CI, 1.0-1.7]) for attention-deficit hyperactivity disorder (ADHD); and 7.2% vs 4.6% (RR, 1.5 [95% CI, 1.1-2.0]) for mood, anxiety, and stress-related disorders. Among offspring born to mothers with autoimmune or inflammatory disorders, the adjusted risks for exposed vs unexposed were 4.8% vs 3.8% (RR, 1.3 [95% CI, 1.1-1.5]) for autism spectrum disorders; 1.1% vs 0.8% (RR 1.4, [95% CI, 0.9-2.0]) for intellectual disabilities; 5.5% vs 4.4% (RR, 1.3 [95% CI, 1.0-1.5]) for ADHD; and 6.6% vs 4.6% (RR, 1.4 [95% CI, 1.2-1.8]) for mood, anxiety, and stress-related disorders. Findings were confirmed through an active comparator and sibling design. However, confounding by disease severity could not be ruled out., Conclusions and Relevance: In this cohort study, prenatal exposure to glucocorticoids was associated with higher risk of some mental disorders. These data support continued caution in the use of glucocorticoids in pregnant people.

Background: Severe mental illness (SMI) has been associated with reduced bone density and increased risk of fractures, although some studies have shown inconsistent results., Aim: To examine the association between SMI and recorded diagnosis of osteoporosis and fragility fracture in people aged ≥50 years., Design and Setting: Population-based cohort study set in UK primary care., Method: Anonymised primary care data (IQVIA Medical Research Database) were used. Patients with a diagnosis of SMI aged 50-99 years (2000-2018) were matched to individuals without SMI. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Analyses were stratified by sex and age, accounting for social deprivation, year, smoking, alcohol, and body mass index., Results: In total, 444 480 people were included (SMI n = 50 006; unexposed n = 394 474). In men, diagnosis of SMI increased the likelihood of an osteoporosis diagnosis, with differences mainly observed among the youngest (aged 50-54 years: HR 2.12, 95% CI = 1.61 to 2.79) and the oldest (aged 85-99 years: HR 2.15, 95% CI = 1.05 to 4.37), and SMI increased the risk of fragility fractures across all ages. In women, SMI increased the risk of an osteoporosis diagnosis only in those aged 50-54 years (HR 1.16, 95% CI = 1.01 to 1.34), but increased the risk of fragility fractures across all ages. There were more than twice as many men with SMI with fragility fracture records than with an osteoporosis diagnosis: fragility fracture:osteoporosis = 2.10, compared with fragility fracture:osteoporosis = 1.89 in men without SMI. The fragility fracture:osteoporosis ratio was 1.56 in women with SMI versus 1.11 in women without SMI., Conclusion: SMI is associated with an increased likelihood of fragility fractures and osteoporosis underdiagnosis. Interventions should be considered to mitigate the increased risk of fractures in people with SMI., (© The Authors.)

Competing Interests: We declare no competing interests.

Objective: This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges., Methods: A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field., Results: In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs., Conclusions: These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness., Methods: A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline)., Results: From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support., Conclusions: These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.

Against the backdrop of mounting calls for the global scaling-up of mental health services - including quality care and prevention services - there is very little guidance internationally on strategies for scaling-up such services. Drawing on lessons from scale-up attempts in six low- and middle-income countries, and using exemplars from the front-lines in South Africa, we illustrate how health reforms towards people-centred chronic disease management provide enabling policy window opportunities for embedding mental health scale-up strategies into these reforms. Rather than going down the oft-trodden road of vertical funding for scale-up of mental health services, we suggest using the policy window that stresses global policy shifts towards strengthening of comprehensive integrated primary health care systems that are responsive to multimorbid chronic conditions. This is indeed a substantial opportunity to firmly locate mental health within these horizontal health systems strengthening funding agendas. Although this approach will promote systems more enabling of scaling-up of mental health services, implications for donor funders and researchers alike is the need for increased time commitments, resources and investment in local control.

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 is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders. Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries (LMICs) and emerging economies. Towards this end, this paper aims to review 1) the nature and extent of tuberculosis and common mental disorder comorbidity and 2) person-centred tuberculosis care in low-to-middle income countries and emerging economies., Main Text: A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature, using established guidelines, for each of the study objectives. Four broad tuberculosis/mental disorder comorbidities were described in the literature, namely alcohol use and tuberculosis, depression and tuberculosis, anxiety and tuberculosis, and general mental health and tuberculosis. Rates of comorbidity varied widely across countries for depression, anxiety, alcohol use and general mental health. Alcohol use and tuberculosis were significantly related, especially in the context of poverty. The initial tuberculosis diagnostic episode had substantial socio-psychological effects on service users. While men tended to report higher rates of alcohol use and treatment default, women in general had worse mental health outcomes. Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity. Person-centred tuberculosis care interventions were almost absent, with only one study from Nepal identified., Conclusions: There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries. Despite the potential of person-centred interventions, evidence is limited. This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs, where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.

Aims: The aim of this study was to identify the risk correlates for coexisting common mental disorders (CMDs) in the chronic care population in South Africa, with the view to identifying particularly vulnerable patient populations., Methods: The sample comprised 2549 chronic care patients enrolled in the baseline and endline rounds of a facility detection survey conducted by the Programme for Improving Mental Health Care in three large facilities in the Dr Kenneth Kaunda district in the North West province of South Africa. Participants were screened for depression using the Patient Health Questionnaire (PHQ9) and for alcohol misuse using the Alcohol Use Disorders Identification Test (AUDIT). Data were analysed according to the number of morbidities, disorder type (physical or mental) and demographic variables. Multimorbidity was defined as the presence of two or more disorders (physical and/or mental)., Results: Just over one-third of the sample reported two or more physical conditions. Women were more at risk of being depressed than were men, with men more at risk of alcohol misuse. Those who were employed were at lower risk of having coexisting CMDs, while being younger, HIV positive, and food deprived were all found to be associated with higher risk for having coexisting CMDs., Conclusion: In the face of the large treatment gap for CMDs in South Africa, and the role that coexisting CMDs can play in exacerbating the burden of chronic physical diseases, mental health screening and treatment interventions should target HIV-positive, younger patients living in circumstances where there is household food insecurity.

Background: Integrating care for common mental disorders (CMDs) such as depression, anxiety and alcohol abuse into primary healthcare (PHC) should assist in reducing South Africa (SA)'s quadruple burden of disease. CMDs compromise treatment adherence, health behaviour change and self-management of illnesses. Appropriate identification of mental disorders in primary care can be facilitated by brief, easy-to-administer screening that promotes high specificity., Objectives: To establish the criterion-based validity of a seven-item Brief Mental Health (BMH) screening tool for assessing positive symptoms of CMDs in primary care patients., Methods: A total of 1 214 participants were recruited from all patients aged ≥18 years visiting 10 clinics as part of routine care in the Newcastle subdistrict of Amajuba District in KwaZulu-Natal Province, SA, over a period of 2 weeks. Consenting patients provided basic biographical information prior to screening with the BMH tool. PHC nurses remained blind to this assessment. PHC nurse-initiated assessment using the Adult Primary Care (APC) guidelines was the gold standard against which the performance of the BMH tool was compared. A specificity standard of 80% was used to establish cut-points. Specificity was favoured over sensitivity to ensure that those who did not have CMD symptoms were excluded, as well as to reduce over-referrals., Results: Of the participants, 72% were female. The AUD-C (alcohol abuse) performed well (area under the curve (AUC) 0.91 (95% confidence interval (CI) 0.88 - 0.95), cut-point ≥4, Cronbach alpha 0.87); PHQ-2 (depression) performed reasonably well (AUC 0.72 (95% CI 0.65 - 0.78), cut-point ≥3, alpha 0.71); and GAD-2 (anxiety) performance was acceptable (AUC 0.69 (95% CI 0.58 - 0.80), cut-point ≥3, alpha 0.62). Using the higher cut-off scores, patients who truly did not have CMD symptoms had negative predictive values (NPVs) of >90%. Overall, 26% of patients had CMD positive symptoms relative to 8% using the APC guidelines., Conclusions: Using a higher specificity index, the positive predictive value and NPV show that at higher cut-point values the BMH not only helps identify individuals with alcohol misuse, depression and anxiety symptoms but also identifies a majority of those who do not have symptoms (true negatives), thus not overburdening nurses with false positives needing assessment. Research is needed to assess whether use of such a short and valid screening tool is generalisable to other clinic contexts as well as how mental health screening should best be introduced into routine clinic functioning and practice.

Integrated care is defined as health services that are managed and delivered such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and, according to their needs, throughout the life course. In this Review, we describe the most relevant concepts and models of integrated care for people with chronic (or recurring) mental illness and comorbid physical health conditions, provide a conceptual overview and a narrative review of the strength of the evidence base for these models in high-income countries and in low-income and middle-income countries, and identify opportunities to test the feasibility and effects of such integrated care models. We discuss the rationale for integrating care for people with mental disorders into chronic care; the models of integrated care; the evidence of the effects of integrating care in high-income countries and in low-income and middle-income countries; the key organisational challenges to implementing integrated chronic care in low-income and middle-income countries; and the practical steps to realising a vision of integrated care in the future., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

AimsSuicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC., Methods: Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder., Results: We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5-11.1% in community samples and 5.0-14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries., Conclusion: The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.

Background: The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts., Methods: One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy)., Discussion: Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.

Background: Severe mental illness (SMI) is associated with excess cardiovascular disease (CVD) morbidity, but little is known on provision of preventative interventions. We investigated statin initiation for primary CVD prevention in individuals with and without SMI., Methods: We used primary care data from The Health Improvement Network from 2006 to 2015 for UK patients aged 30-99years with no pre-existing CVD conditions and selected individuals with schizophrenia (n=13,252) or bipolar disorder (n=11,994). In addition, we identified samples of individuals without schizophrenia (n=66,060) and bipolar disorder (n=59,765), but with similar age and gender distribution. Missing data on CVD covariates were estimated using multiple imputation. Statin prescribing differences between individuals with and without SMI were investigated using multivariable Poisson regression models., Results: Initiation of statin prescribing was between 2 and 3 fold higher in people aged 30-59years with SMI than in those without after adjusting for CVD covariates. The rates in those aged 60-74years with SMI were similar or slightly higher relative to those without SMI. The incidence rate ratio (IRR) was 1.15 (95% CI 1.03-1.28) for bipolar disorder and 1.00 (0.91-1.11) for schizophrenia. The rate of statin prescribing was lower (IRR 0.81 (0.66-0.98)) amongst the oldest (aged 75+years) with schizophrenia relative to those without schizophrenia., Conclusions: Despite higher rates of new statin prescriptions to younger individuals with SMI relative to individuals without SMI, there was evidence of lower rates of statin initiation for older individuals with schizophrenia, and this group may benefit from additional measures to prevent CVD., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: To determine the cost-effectiveness of two bespoke severe mental illness (SMI)-specific risk algorithms compared with standard risk algorithms for primary cardiovascular disease (CVD) prevention in those with SMI., Setting: Primary care setting in the UK. The analysis was from the National Health Service perspective., Participants: 1000 individuals with SMI from The Health Improvement Network Database, aged 30-74 years and without existing CVD, populated the model., Interventions: Four cardiovascular risk algorithms were assessed: (1) general population lipid, (2) general population body mass index (BMI), (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those considered high risk ( > 10%) were assumed to be prescribed statin therapy while others received usual care., Primary and Secondary Outcome Measures: Quality-adjusted life years (QALYs) and costs were accrued for each algorithm including no algorithm, and cost-effectiveness was calculated using the net monetary benefit (NMB) approach. Deterministic and probabilistic sensitivity analyses were performed to test assumptions made and uncertainty around parameter estimates., Results: The SMI-specific BMI algorithm had the highest NMB resulting in 15 additional QALYs and a cost saving of approximately £53 000 per 1000 patients with SMI over 10 years, followed by the general population lipid algorithm (13 additional QALYs and a cost saving of £46 000)., Conclusions: The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of an SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aims: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age., Methods: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes., Results: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness., Conclusions: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account., (© 2016 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Objectives: To estimate the 'real-world effectiveness of statins for primary prevention of cardiovascular disease (CVD) and for lipid modification in people with severe mental illnesses (SMI), including schizophrenia and bipolar disorder., Design: Series of staggered cohorts. We estimated the effect of statin prescribing on CVD outcomes using a multivariable Poisson regression model or linear regression for cholesterol outcomes., Setting: 587 general practice (GP) surgeries across the UK reporting data to The Health Improvement Network., Participants: All permanently registered GP patients aged 40-84 years between 2002 and 2012 who had a diagnosis of SMI. Exclusion criteria were pre-existing CVD, statin-contraindicating conditions or a statin prescription within the 24 months prior to the study start., Exposure: One or more statin prescriptions during a 24-month 'baseline' period (vs no statin prescription during the same period)., Main Outcome Measures: The primary outcome was combined first myocardial infarction and stroke. All-cause mortality and total cholesterol concentration were secondary outcomes., Results: We identified 2944 statin users and 42 886 statin non-users across the staggered cohorts. Statin prescribing was not associated with significant reduction in CVD events (incident rate ratio 0.89; 95% CI 0.68 to 1.15) or all-cause mortality (0.89; 95% CI 0.78 to 1.02). Statin prescribing was, however, associated with statistically significant reductions in total cholesterol of 1.2 mmol/L (95% CI 1.1 to 1.3) for up to 2 years after adjusting for differences in baseline characteristics. On average, total cholesterol decreased from 6.3 to 4.6 in statin users and 5.4 to 5.3 mmol/L in non-users., Conclusions: We found that statin prescribing to people with SMI in UK primary care was effective for lipid modification but not CVD events. The latter finding may reflect insufficient power to detect a smaller effect size than that observed in randomised controlled trials of statins in people without SMI., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Aims: In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia., Methods: The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework., Results: Three main themes were identified. (1) Focused on 'Restoring the person's life', including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting., Conclusions: Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.

The burden of mental, neurological, and substance use (MNS) disorders increased by 41% between 1990 and 2010 and now accounts for one in every 10 lost years of health globally. This sobering statistic does not take into account the substantial excess mortality associated with these disorders or the social and economic consequences of MNS disorders on affected persons, their caregivers, and society. A wide variety of effective interventions, including drugs, psychological treatments, and social interventions, can prevent and treat MNS disorders. At the population-level platform of service delivery, best practices include legislative measures to restrict access to means of self-harm or suicide and to reduce the availability of and demand for alcohol. At the community-level platform, best practices include life-skills training in schools to build social and emotional competencies. At the health-care-level platform, we identify three delivery channels. Two of these delivery channels are especially relevant from a public health perspective: self-management (eg, web-based psychological therapy for depression and anxiety disorders) and primary care and community outreach (eg, non-specialist health worker delivering psychological and pharmacological management of selected disorders). The third delivery channel, hospital care, which includes specialist services for MNS disorders and first-level hospitals providing other types of services (such as general medicine, HIV, or paediatric care), play an important part for a smaller proportion of cases with severe, refractory, or emergency presentations and for the integration of mental health care in other health-care channels, respectively. The costs of providing a significantly scaled up package of specified cost-effective interventions for prioritised MNS disorders in low-income and lower-middle-income countries is estimated at US$3-4 per head of population per year. Since a substantial proportion of MNS disorders run a chronic and disabling course and adversely affect household welfare, intervention costs should largely be met by government through increased resource allocation and financial protection measures (rather than leaving households to pay out-of-pocket). Moreover, a policy of moving towards universal public finance can also be expected to lead to a far more equitable allocation of public health resources across income groups. Despite this evidence, less than 1% of development assistance for health and government spending on health in low-income and middle-income countries is allocated to the care of people with these disorders. Achieving the health gains associated with prioritised interventions will require not just financial resources, but committed and sustained efforts to address a range of other barriers (such as paucity of human resources, weak governance, and stigma). Ultimately, the goal is to massively increase opportunities for people with MNS disorders to access services without the prospect of discrimination or impoverishment and with the hope of attaining optimal health and social outcomes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: People with severe mental illnesses die up to 20 years earlier than the general population, with cardiovascular disease being the leading cause of death. National guidelines recommend that the physical care of people with severe mental illnesses should be the responsibility of primary care; however, little is known about effective interventions to lower cardiovascular disease risk in this population and setting. Following extensive peer review, funding was secured from the United Kingdom National Institute for Health Research (NIHR) to deliver the proposed study. The aim of the trial is to test the effectiveness of a behavioural intervention to lower cardiovascular disease risk in people with severe mental illnesses in United Kingdom General Practices., Methods/design: The study is a cluster randomised controlled trial in 70 GP practices for people with severe mental illnesses, aged 30 to 75 years old, with elevated cardiovascular disease risk factors. The trial will compare the effectiveness of a behavioural intervention designed to lower cardiovascular disease risk and delivered by a practice nurse or healthcare assistant, with standard care offered in General Practice. A total of 350 people will be recruited and followed up at 6 and 12 months. The primary outcome is total cholesterol level at the 12-month follow-up and secondary outcomes include blood pressure, body mass index, waist circumference, smoking status, quality of life, adherence to treatments and services and behavioural measures for diet, physical activity and alcohol use. An economic evaluation will be carried out to determine the cost effectiveness of the intervention compared with standard care., Discussion: The results of this pragmatic trial will provide evidence on the clinical and cost effectiveness of the intervention on lowering total cholesterol and addressing multiple cardiovascular disease risk factors in people with severe mental illnesses in GP Practices., Trial Registration: Current Controlled Trials ISRCTN13762819. Date of Registration: 25 February 2013. Date and Version Number: 27 August 2014 Version 5.

Objective: To understand the perspectives of women with severe mental illness concerning the use of psychotropic medicines while pregnant., Design: Interviews conducted by female peer researchers with personal experience of making or considering decisions about using psychotropic medicines in pregnancy, supported by professional researchers., Participants: 12 women who had had a baby in the past 5 years and had taken antipsychotics or mood-stabilisers for severe mental illness within the 12-month period immediately prior to that pregnancy. Recruitment to the study was via peer networks and the women interviewed came from different regions of England., Setting: Interviews were arranged in places where women felt comfortable and that accommodated their childcare needs including their home, local library and the research office., Results: The views expressed demonstrated complex attempts to engage with decision-making about the use of psychotropic medicines in pregnancy. In nearly all cases, the women expressed the view that healthcare professionals had access to limited information leaving women to rely on experiential and common sense evidence when making decisions about medicine taking during pregnancy., Conclusions: The findings complement existing work using electronic health records by providing explanations for the discontinuation of psychotropic medicines in pregnancy. Further work is necessary to understand health professionals' perspectives on the provision of services and care to women with severe mental illness during pregnancy., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

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: An essential element of mental health service scale up relates to an assessment of resource requirements and cost implications., Aims: To assess the expected resource needs of scaling up services in five districts in sub-Saharan Africa and south Asia., Method: The resource quantities associated with each site's specified care package were identified and subsequently costed, both at current and target levels of coverage., Results: The cost of the care package at target coverage ranged from US$0.21 to 0.56 per head of population in four of the districts (in the higher-income context of South Africa, it was US$1.86). In all districts, the additional amount needed each year to reach target coverage goals after 10 years was below $0.10 per head of population., Conclusions: Estimation of resource needs and costs for district-level mental health services provides relevant information concerning the financial feasibility of locally developed plans for successful scale up., (© The Royal College of Psychiatrists 2016.)

Background: Little is known about the service and system interventions required for successful integration of mental healthcare into primary care across diverse low- and middle-income countries (LMIC)., Aims: To examine the commonalities, variations and evidence gaps in district-level mental healthcare plans (MHCPs) developed in Ethiopia, India, Nepal, Uganda and South Africa for the PRogramme for Improving Mental health carE (PRIME)., Method: A comparative analysis of MHCP components and human resource requirements., Results: A core set of MHCP goals was seen across all countries. The MHCPs components to achieve those goals varied, with most similarity in countries within the same resource bracket (low income v. middle income). Human resources for advanced psychosocial interventions were only available in the existing health service in the best-resourced PRIME country., Conclusions: Application of a standardised methodological approach to MHCP across five LMIC allowed identification of core and site-specific interventions needed for implementation., (© The Royal College of Psychiatrists 2016.)

There is compelling evidence from high-quality studies that mental health promotion and primary prevention interventions can reduce the risk of mental disorders, enhance protective factors for good mental and physical health, and lead to lasting positive effects on a range of social and economic outcomes. This paper reviews the available evidence in order to guide the implementation of mental health promotion and prevention interventions in the Eastern Mediterranean Region. The paper identifies a number of priority areas that can generate clear health and social gains in the population and be implemented and sustained at a reasonable cost. The interventions cover population groups across the lifespan from infancy to adulthood and include actions delivered across different settings and delivery platforms. "Best practices" were identified as interventions for which there is evidence not only of their effectiveness but also of their feasibility within resource constraints. The implications of the findings for capacity development are considered.

Objective: To examine the recorded indication for antipsychotic prescriptions in UK primary care., Design: Cohort study., Setting: Primary care., Participants: Individuals prescribed antipsychotics between 2007 and 2011., Measures: The proportion of individuals prescribed antipsychotics with a diagnosis of (1) psychosis and bipolar disorder, (2) other diagnoses including depression, anxiety and dementia and (3) none of these diagnoses., Results: We identified 47,724 individuals prescribed antipsychotic agents. 13,941 received first-generation agents and 27,966 received second-generation agents. The rates of prescribing were higher in females (incidence rate ratio (IRR) 1.092 (95% CI 1.088 to 1.095), older people (80+ vs 40-49; IRR 2.234 (2.222 to 2.246)) and in those from the most deprived areas (most deprived vs least deprived IRR 3.487 (3.567 to 3.606). Of those receiving first-generation antipsychotics, less than 50% had a diagnosis of psychosis/bipolar disorder. For the second-generation agents, the numbers ranged from 4824 (36%) for quetiapine to 7094 (62%) for olanzapine. In patients without psychosis/bipolar disorder, common diagnoses included anxiety, depression, dementia, sleep and personality disorders. For example, in risperidone users, 14% had an anxiety code, 22% depression, 12% dementia, 11% sleep disorder and 4% personality disorder. The median daily doses and duration of treatment were greater in those with schizophrenia (eg, risperidone median daily dose 4 mg; IQR 2-6: median duration 1.2 years) than in those with non-psychotic/bipolar disorders such as depression or anxiety (eg, risperidone 1 mg; IQR 1-2: 0.6 years). A relatively large proportion (between 6% and 17%) of people receiving individual antipsychotics had none of the diagnoses stated above., Conclusions: In UK primary care, a large proportion of people prescribed antipsychotics have no record of psychotic or bipolar disorder. They are often older people with conditions including dementia, non-psychotic depression, anxiety and sleep disorders., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Stigma and discrimination against people with mental illness remain barriers to help seeking and full recovery for people in need of mental health services. Yet there is scarce research investigating the experiences of psychiatric stigma on mental health service users in low- and middle-income countries (LMICs). The aim of this study was therefore to explore the experiences of psychiatric stigma by service users in order to inform interventions to reduce such stigma and discrimination in one LMIC, namely South Africa., Methods: Participants comprised a total of 77 adults aged above 18 years, made up of service providers including professional nurses (10), lay counsellors (20), auxiliary social workers (2); and service users (45)., Results: Psychiatric stigma was found to be perpetuated by family members, friends, employers, community members and health care providers. Causes of psychiatric stigma identified included misconceptions about mental illness often leading to delays in help-seeking. Experiencing psychiatric stigma was reported to worsen the health of service users and impede their capacity to lead and recover a normal life., Conclusion: Media campaigns and interventions to reduce stigma should be designed to address specific stigmatizing behaviours among specific segments of the population. Counselling of families, caregivers and service users should include how to deal with experienced and internalized stigma.

Background: There is increasing emphasis on primary care services for individuals with severe mental illnesses (SMI), including schizophrenia, bipolar disorder, and other non-organic psychotic disorders. However we lack information on how many people receive these different diagnoses in primary care. Primary care databases offer an opportunity to explore the recording of new SMI diagnoses in representative general practices., Methods: We used data from The UK Health Improvement Network (THIN) primary care database including longitudinal patient records for individuals aged over 16 years from 437 general practices. We determined the annual GP recorded rate of first diagnosis of SMI by age, gender, social deprivation and urbanicity between 2000 and 2010., Results: We identified 10,520 individuals with a first record of schizophrenia, bipolar disorder or other non-organic psychosis among 4,164,794 patients. This corresponded to a rate of first diagnosis of 46.4 per 100,000 person years at risk (PYAR) (95% CI 45.4 to 47.4) in the 16-65 age group. The rate of first record of schizophrenia was 9.2 per 100,000 PYAR (95% CI 8.7 to 9.6) in this age group, bipolar disorder was 15.0 per 100,000 PYAR (95% CI 14.4 to 15.5) and other non-organic psychotic disorder was 22.3 per 100,000 PYAR (95% CI 21.6 to 23.0)., Conclusions: The rates of GP recorded SMI in primary care records were broadly comparable to incidence rates from previous epidemiological studies of SMI and show similar patterns by socio-demographic characteristics. However there were some differences by specific diagnoses. GPs may be recording rates that are higher than those used to commission services.

Background: It has been estimated that, at any point in time, about 1% of the general adult population of the United Kingdom is receiving long-term (ie, ≥ 3 months) oral glucocorticoid therapy. These patients may develop neuropsychiatric disorders when the drug is discontinued., Method: Data were obtained for all adult patients registered from January 1, 1990, through December 31, 2008, at UK general practices that were contributors to The Health Improvement Network database. Data from 21,995 adult patients who had been exposed to long-term oral glucocorticoids and who had discontinued the drugs after an exposure ranging from 1 to 3 years were analyzed. The within-person incidence rate ratios (IRRs) for Read codes and/or prescriptions for depression, delirium/confusion, mania, panic disorders, and suicide or suicide attempt during the withdrawal period were estimated using a self-controlled case series methodology. The predictors of the outcomes were ascertained using Cox proportional hazards models., Results: The risk of depression (IRR = 1.13; 95% CI, 1.00-1.28; P = .04) and of delirium/confusion (IRR = 2.67; 95% CI, 1.96-3.63; P < .001) was significantly higher during the discontinuation period compared to a reference period defined as ranging from 5 to 3 months before the drug cessation. Older people were at higher risk of delirium/confusion. The use of long-acting glucocorticoids was associated with a higher risk of both depression (adjusted hazard ratio [HR] = 1.92; 95% CI, 1.07-3.46) and delirium/confusion (adjusted HR = 4.96; 95% CI, 2.60-9.49) during the withdrawal period., Conclusions: Discontinuation of long-term glucocorticoid therapy is associated with an increased risk of both depression and delirium/confusion. People treated with long-acting glucocorticoids are particularly at risk., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

Background: A recent United Kingdom (UK) report found that breast and colorectal cancers were more common in people with severe mental illness (SMI) and recommended targeted screening. Epidemiological evidence is however inconsistent., Objectives: To estimate relative incidence rates for colorectal, breast and lung cancer, and the overall incidence of the commonest other UK cancers, in people with SMI compared with people without SMI., Method: Cohort study in the UK using The Health Improvement Network (THIN) primary care database between 1990 and June 2008. Poisson regression was used to obtain adjusted incidence rate ratios (IRRs) for cancer, comparing two cohorts of people over 18; with and without a diagnosis of SMI., Results: We identified 20,632 people with SMI and 116,152 people without, with median follow up of over 6years. No significant associations were observed between SMI and cancers of the breast (adjusted IRR 1.17; 95% confidence interval 0.95-1.45), colon (0.70; 0.46-1.05), rectum (1.05; 0.65-1.69) or lung (0.84; 0.65-1.10). The adjusted IRR for an aggregate cancer outcome in SMI was 0.95; 0.85-1.06. Results were similar for schizophrenia and bipolar disorder., Conclusions: In a cohort analysis within a large UK primary care database, the incidence of colo-rectal, breast and lung cancer, and of all common cancers, did not differ significantly in people with SMI, including schizophrenia, compared with people without SMI. Our results do not support enhanced screening procedures for cancer in people with SMI., (Copyright © 2012 Elsevier B.V. All rights reserved.)

There is new policy commitment to mental health in South Africa, demonstrated in the national mental health summit of April 2012. This provides an opportunity to take stock of our mental health services. At primary care level key challenges include- training and supervision of staff in the detection and management of common mental disorders, and the development of community-based psychosocial rehabilitation programmes for people with severe mental illness (in collaboration with existing non-governmental organizations). At secondary level, resources need to be invested in 72-hour observation facilities at designated district and regional hospitals, in keeping with the Mental Health Care Act. At tertiary level, greater continuity of care with primary and secondary levels is required to prevent "revolving door" patterns of care. There are major challenges and also opportunities related to the high level of comorbidity between mental illness and a range of other public health priorities, notably HIV/AIDS, cardiovascular disease and diabetes. The agenda for mental health services research needs to shift to a focus on evaluating interventions. With current policy commitment, the time to act and invest in evidence-based mental health services is now.

The need for greater attention to mental health promotion and the prevention of mental disorders in South Africa is highlighted by the cycle of poverty and mental ill-health, the potential for social gains, the question of affordability of treatment in the face of the increasing burden of mental disorders, and the limitations of existing treatment methods. This article, which provides a desk review of the current status of mental health promotion and prevention of mental disorders in South Africa, suggests that South Africa has a number of policies that bode well for promoting mental health from infancy through to old age. There is, however, a need for programmatic interventions to promote resilience in vulnerable populations. Of note, is the need for programmes to address maternal depression and strengthen attachment and psychosocial stimulation during infancy, strengthen families, promote health enhancing school environments, and address intimate partner violence and build health enhancing social capital. Given the multifaceted nature of risk and protective influences, the need for a multi-sectoral plan of action is highlighted.

Objective: The incidence and the risk of suicidal behaviors and severe neuropsychiatric disorders in people treated with systemic glucocorticoids are poorly known. The authors assessed the incidence rates of depression, mania, delirium, panic disorder, and suicidal behaviors in patients treated with glucocorticoids in primary care settings and the risk factors for developing these outcomes., Method: Data were obtained for all adult patients registered between 1990 and 2008 at U.K. general practices contributing to The Health Improvement Network (THIN) primary care database. The incidence rates for the outcomes of interest were assessed in patients who received prescriptions for oral glucocorticoids and compared with those in patients who did not receive such prescriptions. The predictors of these outcomes in exposed patients were ascertained using Cox proportional hazards models., Results: Overall, 786,868 courses of oral glucocorticoids were prescribed for 372,696 patients. The authors identified 109 incident cases of suicide or suicide attempt and 10,220 incident cases of severe neuropsychiatric disorders in these patients. The incidence of any of these outcomes was 22.2 per 100 person-years at risk for first-course treatments. Compared to people with the same underlying medical disease who were not treated with glucocorticoids, the hazard ratio for suicide or suicide attempt in exposed patients was 6.89 (95% CI=4.52–10.50); for depression, 1.83 (95% CI=1.72–1.94); for mania, 4.35 (95% CI=3.67–5.16); for delirium, confusion, or disorientation, 5.14 (95% CI=4.54–5.82); and for panic disorder, 1.45 (95% CI=1.15–1.85). Older men were at higher risk of delirium/confusion/disorientation and mania, while younger patients were at higher risk of suicide or suicide attempt. Patients with a previous history of neuropsychiatric disorders and those treated with higher dosages of glucocorticoids were at greater risk of neuropsychiatric outcomes., Conclusions: Glucocorticoids increase the risk of suicidal behavior and neuropsychiatric disorders. Educating patients and their families about these adverse events and increasing primary care physicians' awareness about their occurrence should facilitate early monitoring.

Objectives: To identify progress and challenges in mental healthcare in South Africa, as well as future mental health services research priorities., Method: A systematic review of mental health services research. Literature searches were conducted in Medline, PsychInfo and Sabinet databases from January 2000 to October 2010 using key phrases. Hand searches of key local journals were also conducted. Of 215 articles retrieved, 92 were included. Data were extracted onto a spreadsheet and analysed thematically., Results: While progress in epidemiological studies has been good, there is a paucity of intervention and economic evaluation studies. The majority of studies reviewed were on the status of mental healthcare services. They indicate some progress in decentralised care for severe mental disorders, but also insufficient resources to adequately support community-based services, resulting in the classic revolving-door phenomenon. Common mental disorders remain largely undetected and untreated in primary healthcare. Cross-cutting issues included the need for promoting culturally congruent services as well as mental health literacy to assist in improving help-seeking behaviour, stigma reduction, and reducing defaulting and human rights abuses., Conclusion: While there has been some progress in the decentralisation of mental health service provision, substantial gaps in service delivery remain. Intervention research is needed to provide evidence of the organisational and human resource mix requirements, as well as cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.

Background: People with severe mental illnesses (SMI), including schizophrenia, are at increased risk of cardiovascular disease (CVD). Guidelines recommend regular CVD screening and in the United Kingdom, since 2004, General Practitioners are remunerated for annual reviews., Objectives: To compare annual rates of CVD screening provision in people with and without SMI between 2000 and 2008., Method: We identified 18,696 people with SMI and 95,512 people without SMI in the UK The Health Improvement Network (THIN) primary care database. We compared the rates of measurement of blood pressure (BP), glucose, cholesterol and body mass index (BMI)., Results: Prior to 2004, all people with SMI, were significantly less likely to receive each measurement, (including people above and below 60 years of age). In 2003; adjusted incidence rate ratios (95% CI) for screening in people with SMI under 60 years compared to people without SMI were: BMI: 0.62 (0.58-0.65); BP: 0.59 (0.56-0.62); glucose: 0.66 (0.61-0.70) and cholesterol: 0.54 (0.49-0.59). By 2007 people with SMI under 60 were equally likely receive a measurement of BMI: 1.00 (0.96-1.04), glucose: 1.00 (0.96-1.05) and cholesterol: 0.95 (0.90-1.0); the gap in screening for BP had narrowed 0.87 (0.83-0.90). However people with SMI over 60 years of age remained significantly less likely to be screened. There was little difference in screening according to social deprivation., Conclusions: In UK primary care, people with SMI over 60 years of age remain less likely than the general population to receive annual CVD screening despite higher risk of developing CVD., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Purpose of Review: Against the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs., Recent Findings: Key strategies and actions are as follows: (i) the adoption of a decentralized stepped care approach embracing task shifting to nonspecialists for those disorders for which it has been shown to be effective; (ii) ensuring adequate numbers of mental health specialists to provide a supportive supervisory framework and referral pathways; (iii) ensuring adequate infrastructure to support decentralized care; (iv) promoting mental health literacy; (v) adoption of a social inclusion and developmental model of disability in caring for people with chronic mental illness; and (vi) embracing a multisectoral community collaborative approach., Summary: Optimizing mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions. Studies demonstrating the cost-effectiveness of integrated stepped packages of care embracing a task-shifting approach, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors, can assist this process. Specialist mental health training programmes in LMICs also need to be responsive to the changing demands on service providers, incorporating a public health approach and equipping specialists for diversification of their roles within the task shifting model.

The majority of the black African population in South Africa utilize both traditional and public sector Western systems of healing for mental health care. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems. The aim of this study was to explore perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved in the provision of community mental health services. Qualitative individual and focus group interviews were conducted with key health care providers and service users in one typical rural South African health sub-district. The majority of service users held traditional explanatory models of illness and used dual systems of care, with shifting between treatment modalities reportedly causing problems with treatment adherence. Traditional healers expressed a lack of appreciation from Western health care practitioners but were open to training in Western biomedical approaches and establishing a collaborative relationship in the interests of improving patient care. Western biomedically trained practitioners were less interested in such an arrangement. Interventions to acquaint traditional practitioners with Western approaches to the treatment of mental illness, orientation of Western practitioners towards a culture-centred approach to mental health care, as well as the establishment of fora to facilitate the negotiation of respectful collaborative relationships between the two systems of healing are required at district level to promote an equitable collaboration in the interests of improved patient care.

Background: Obesity is a major public health problem that is associated with substantial morbidity and mortality., Objective: The authors investigated the associations between health-related quality of life (HRQL) and Body Mass Index (BMI), gender, age, mental and somatic disorders, as well as therapy-seeking status., Method: A cross-sectional controlled study assessed 640 male and female individuals, clustered into four weight categories., Results: Linear-regression analyses revealed that higher BMI, higher age, and higher numbers of current somatic and mental disorders negatively predicted the physical dimension of HRQL. Higher numbers of both mental and somatic disorders as well as female gender and younger age seemed to be independent negative predictors of mental HRQL, whereas BMI was not associated with mental HRQL. Therapy status was not related to mental or physical HRQL., Conclusion: Physical and mental disorders are important detrimental factors for both physical and mental dimensions of HRQL.

Context: People with severe mental illness (SMI) appear to have an elevated risk of death from cardiovascular disease, but results regarding cancer mortality are conflicting., Objective: To estimate this excess mortality and the contribution of antipsychotic medication, smoking, and social deprivation., Design: Retrospective cohort study., Setting: United Kingdom's General Practice Research Database. Patients Two cohorts were compared: people with SMI diagnoses and people without such diagnoses. Main Outcome Measure Mortality rates for coronary heart disease (CHD), stroke, and the 7 most common cancers in the United Kingdom., Results: A total of 46 136 people with SMI and 300 426 without SMI were selected for the study. Hazard ratios (HRs) for CHD mortality in people with SMI compared with controls were 3.22 (95% confidence interval [CI], 1.99-5.21) for people 18 through 49 years old, 1.86 (95% CI, 1.63-2.12) for those 50 through 75 years old, and 1.05 (95% CI, 0.92-1.19) for those older than 75 years. For stroke deaths, the HRs were 2.53 (95% CI, 0.99-6.47) for those younger than 50 years, 1.89 (95% CI, 1.50-2.38) for those 50 through 75 years old, and 1.34 (95% CI, 1.17-1.54) for those older than 75 years. The only significant result for cancer deaths was an unadjusted HR for respiratory tumors of 1.32 (95% CI, 1.04-1.68) for those 50 to 75 years old, which lost statistical significance after controlling for smoking and social deprivation. Increased HRs for CHD mortality occurred irrespective of sex, SMI diagnosis, or prescription of antipsychotic medication during follow-up. However, a higher prescribed dose of antipsychotics predicted greater risk of mortality from CHD and stroke., Conclusions: This large community sample demonstrates that people with SMI have an increased risk of death from CHD and stroke that is not wholly explained by antipsychotic medication, smoking, or social deprivation scores. Rates of nonrespiratory cancer mortality were not raised. Further research is required concerning prevention of this mortality, including cardiovascular risk assessment, monitoring of antipsychotic medication, and attention to diet and exercise.

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.

Background: This paper reports on a two-stage community-based epidemiological study of selected minor psychiatric disorders conducted on an adult African population in South Africa., Methods: Using a modified random cluster sampling method, 354 adults were identified as the first-stage sample, with the SRQ-20 being used as a first-stage screen. Clinical interviews based on DSM-IV checklists for generalized anxiety disorder, major depression and dysthymia were administered as the second-stage criterion to 81 subjects from the sample., Results: The weighted prevalence for generalised anxiety and depressive disorders was 23.9% (95% CI 15.1%-32.7%), comprising: generalized anxiety 3.7%, major depression 4.8%, dysthymia 7.3%, and major depression and dysthymia 8.2%. Statistically significant associations were found between caseness and age, marital status, employment, income and educational level., Conclusions: The results are discussed in relation to comparative local and international data as well as in the context of the current restructuring of the mental-health care system in South Africa from tertiary curative care to integrated primary mental-health care.