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Early adolescents (ages 10–14) living in low- and middle-income countries have heightened vulnerability to psychosocial risks, but available evidence from these settings is limited. This study used data from the Global Early Adolescent Study to characterize prototypical patterns of emotional and behavioral problems among 10,437 early adolescents (51% female) living in the Democratic Republic of Congo (DRC), Malawi, Indonesia, and China, and explore the extent to which these patterns varied by country and sex. LCA was used to identify and classify patterns of emotional and behavioral problems separately by country. Within each country, measurement invariance by sex was evaluated. LCA supported a four-class solution in DRC, Malawi, and Indonesia, and a three-class solution in China. Across countries, early adolescents fell into the following subgroups: Well-Adjusted (40–62%), Emotional Problems (14–29%), Behavioral Problems (15–22%; not present in China), and Maladjusted (4–15%). Despite the consistency of these patterns, there were notable contextual differences. Further, tests of measurement invariance indicated that the prevalence and nature of these classes differed by sex. Findings can be used to support the tailoring of interventions targeting psychosocial adjustment, and suggest that such programs may have utility across diverse cross-national settings.
Integrating services for depression into primary care is key to reducing the treatment gap in low- and middle-income countries. We examined the value of providing the Healthy Activity Programme (HAP), a behavioral activation psychological intervention, within services for depression delivered by primary care workers in Chitwan, Nepal using data from the Programme for Improving Mental Health Care.
People diagnosed with depression were randomized to receive either standard treatment (ST), comprised of psychoeducation, antidepressant medication, and home-based follow up, or standard treatment plus psychological intervention (T + P). We estimated incremental costs and health effects of T + P compared to ST, with quality adjusted life years (QALYs) and depression symptom scores over 12 months as health effects. Nonparametric uncertainty analysis provided confidence intervals around each incremental effectiveness ratio (ICER); results are presented in 2020 international dollars.
Sixty participants received ST and 60 received T + P. Implementation costs (ST = $329, T + P = $617) were substantially higher than service delivery costs (ST = $18.7, T + P = $22.4) per participant. ST and T + P participants accrued 46.5 and 49.4 QALYs, respectively. The ICERs for T + P relative to ST were $4422 per QALY gained (95% confidence interval: $2484 to $9550) – slightly above the highly cost-effective threshold – and −$53.21 (95% confidence interval: −$105.8 to −$30.2) per unit change on the Patient Health Questionnaire.
Providing HAP within integrated depression services in Chitwan was cost-effective, if not highly cost-effective. Efforts to scale up integrated services in Nepal and similar contexts should consider including evidence-based psychological interventions as a part of cost-effective mental healthcare for depression.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
This study provides a morphological and phylogenetic characterization of two novel species of the order Haplosporida (Haplosporidium carcini n. sp., and H. cranc n. sp.) infecting the common shore crab Carcinus maenas collected at one location in Swansea Bay, South Wales, UK. Both parasites were observed in the haemolymph, gills and hepatopancreas. The prevalence of clinical infections (i.e. parasites seen directly in fresh haemolymph preparations) was low, at ~1%, whereas subclinical levels, detected by polymerase chain reaction, were slightly higher at ~2%. Although no spores were found in any of the infected crabs examined histologically (n = 334), the morphology of monokaryotic and dikaryotic unicellular stages of the parasites enabled differentiation between the two new species. Phylogenetic analyses of the new species based on the small subunit (SSU) rDNA gene placed H. cranc in a clade of otherwise uncharacterized environmental sequences from marine samples, and H. carcini in a clade with other crustacean-associated lineages.
There is a need for accurate and efficient assessment tools that cover a range of mental health and psychosocial problems. Existing, lengthy self-report assessments may reduce accuracy due to respondent fatigue. Using data from a sample of adults enrolled in a psychotherapy randomized trial in Thailand and a cross-sectional sample of adolescents in Zambia, we leveraged Item Response Theory (IRT) methods to create brief, psychometrically sound, mental health measures.
We used graded-response models to refine scales by identifying and removing poor performing items that were not well correlated with the underlying trait, and by identifying well-performing items at varying levels of a latent trait to assist in screening or monitoring purposes.
In Thailand, the original 17-item depression scale was shortened to seven items and the 30-item Posttraumatic Stress Scale (PTS) was shortened to 10. In Zambia, the Child Posttraumatic Stress Scale (CPSS) was shortened from 17 items to six. Shortened scales in both settings retained the strength of their psychometric properties. When examining longitudinal intervention effects in Thailand, effect sizes were comparable in magnitude for the shortened and standard versions.
Using Item Response Theory (IRT) we created shortened valid measures that can be used to help guide clinical decisions and function as longitudinal research tools. The results of this analysis demonstrate the reliability and validity of shortened scales in each of the two settings and an approach that can be generalized more broadly to help improve screening, monitoring, and evaluation of mental health and psychosocial programs globally.
For more than 60 years, Colombia experienced an armed conflict involving government forces, guerrillas, and other illegal armed groups. Violence, including torture and massacres, has caused displacement of entire rural communities to urban areas. Lack of information on the problems displaced communities face and on their perceptions on potential solutions to these problems may prevent programs from delivering appropriate services to these communities. This study explores the problems of Afro-Colombian survivors from two major cities in Colombia; the activities they do to take care of themselves, their families, and their community; and possible solutions to these problems.
This was a qualitative, interview-based study conducted in Quibdó and Buenaventura (Colombia). Free-list interviews and focus groups explored the problems of survivors and the activities they do to take care of themselves, their families, and their community. Key-informant interviews explored details of the identified mental health problems and possible solutions.
In Buenaventura, 24 free-list interviews, one focus group, and 17 key-informant interviews were completed. In Quibdó, 29 free-list interviews, one focus group, and 15 key-informant interviews were completed. Mental health problems identified included: (1) problems related to exposure to torture/violent events; (2) problems with adaptation to the new social context; and (3) problems related to current poverty, lack of employment, and ongoing violence. These problems were similar to trauma symptoms and features of depression and anxiety, as described in other populations. Solutions included psychological help, talking to friends/family, relying on God’s help, and getting trained in different task or jobs.
Afro-Colombian survivors of torture and violence described mental health problems similar to those of other trauma-affected populations. These results suggest that existing interventions that address trauma-related symptoms and current ongoing stressors may be appropriate for improving the mental health of survivors in this population.
Santaella-TenorioJ, Bonilla-EscobarFJ, Nieto-GilL, Fandiño-LosadaA, Gutiérrez-MartínezMI, BassJ, BoltonP. Mental Health and Psychosocial Problems and Needs of Violence Survivors in the Colombian Pacific Coast: A Qualitative Study in Buenaventura and Quibdó. Prehosp Disaster Med. 2018;33(6):567–574.
Lactobacillus acidophilus fermentation products have been used to improve the performance of nursery pigs. However, research on the influence of this supplement on health is lacking. This study was designed to determine if feeding a Lactobacillus acidophilus fermentation product to weaned pigs would reduce stress and acute phase responses (APR) following a lipopolysaccharide (LPS) challenge. Pigs (n=30; 6.4±0.1 kg) were individually housed in stainless steel pens with ad libitum access to feed and water. Pigs were weighed upon arrival, assigned to one of three groups (n=10/treatment), and fed for 18 days: (1) Control, fed a non-medicated starter diet; (2) Control diet with the inclusion of a Lactobacillus acidophilus fermentation product at 1 kg/metric ton (SGX1) and (3) Control diet with the inclusion of a Lactobacillus acidophilus fermentation product at 2 kg/metric ton (SGX2). On day 7 pigs were anesthetized for insertion of an i.p. temperature device, and similarly on day 14 for insertion of a jugular catheter. Pigs were challenged i.v. with LPS (25 µg/kg BW) on day 15. Blood samples were collected at 0.5 h (serum) and 1 h (complete blood cell counts) intervals from −2 to 8 h and at 24 h relative to LPS administration at 0 h. Pigs and feeders were weighed on days 7, 14 and 18. The supplemented pigs had increased BW and average daily gain before the challenge. In response to LPS, there was a greater increase in i.p. temperature in Control pigs compared with supplemented pigs. In addition, cortisol was reduced in SGX2 pigs while cortisol was elevated in SGX1 pigs at several time points post-challenge. White blood cells, neutrophils and lymphocytes were decreased in SGX1 and SGX2 compared with Control pigs. Furthermore, the pro-inflammatory cytokine response varied by treatment and dose of treatment. Specifically, serum TNF-α was greatest in SGX2, intermediate in Control, and least in SGX1 pigs, while the magnitude and temporal pattern of IFN-γ in SGX2 pigs was delayed and reduced. In contrast, IL-6 concentrations were reduced in both SGX treatment groups compared with Control pigs. These data demonstrate that different supplementation feed inclusion rates produced differential responses, and that feeding SynGenX to weaned pigs attenuated the APR to an LPS challenge.
Marteilia refringens causes marteiliosis in oysters, mussels and other bivalve molluscs. This parasite previously comprised two species, M. refringens and Marteilia maurini, which were synonymized in 2007 and subsequently referred to as M. refringens ‘O-type’ and ‘M-type’. O-type has caused mass mortalities of the flat oyster Ostrea edulis. We used high throughput sequencing and histology to intensively screen flat oysters and mussels (Mytilus edulis) from the UK, Sweden and Norway for infection by both types and to generate multi-gene datasets to clarify their genetic distinctiveness. Mussels from the UK, Norway and Sweden were more frequently polymerase chain reaction (PCR)-positive for M-type (75/849) than oysters (11/542). We did not detect O-type in any northern European samples, and no histology-confirmed Marteilia-infected oysters were found in the UK, Norway and Sweden, even where co-habiting mussels were infected by the M-type. The two genetic lineages within ‘M. refringens’ are robustly distinguishable at species level. We therefore formally define them as separate species: M. refringens (previously O-type) and Marteilia pararefringens sp. nov. (M-type). We designed and tested new Marteilia-specific PCR primers amplifying from the 3’ end of the 18S rRNA gene through to the 5.8S gene, which specifically amplified the target region from both tissue and environmental samples.
Background: In RRMS patients with inadequate response to prior therapy, 2 alemtuzumab courses (12 mg/day; baseline: 5 days; 12 months later: 3 days) significantly improved outcomes versus SC IFNB-1a over 2 years (CARE-MS II [NCT00548405]). Efficacy remained durable in a 4-year extension (NCT00930553); patients could receive as-needed alemtuzumab retreatment (≥12 months apart) for disease activity, or another disease-modifying therapy (DMT). Through Year 6, 88% remained on study; 50% received neither alemtuzumab retreatment nor another DMT; 16% received ≥4 courses; 3% received ≥5 courses. We evaluated Course 4 (C4) efficacy in patients receiving ≥4 courses. Methods: Annualized relapse rate (ARR); improved/stable Expanded Disability Status Scale (EDSS) score (versus baseline); 6-month confirmed disability improvement (CDI). 11% of patients met inclusion criteria: ≥4 courses within 60 months of baseline; no DMT. Those receiving C5 were censored at that time. Results: ARR decreased after C4 (12 months pre-C4 [-12M]: 0.75; 12 months post-C4 [+12M]: 0.19; P<0.0001), remaining low (0.23) at Year 3 post-C4. More patients had stable/improved EDSS scores +12M (67.5%) versus at C4 administration (53.5%). Percentage with CDI increased post-C4 (-12M: 10.0%; +12M: 26.7%). Conclusions: C4 reduced relapses and stabilized/improved disability in patients with disease activity after initial treatment (C1, C2) plus one additional course (C3).
This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention.
This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors.
Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d = 1.37), externalizing (d = 0.85), and posttraumatic stress (d = 1.71), and improvements in well-being (d = 0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility.
This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.
Self-report measurement instruments are commonly used to screen for mental health disorders in Low and Middle-Income Countries (LMIC). The Western origins of most depression instruments may constitute a bias when used globally. Western measures based on the DSM, do not fully capture the expression of depression globally. We developed a self-report scale design to address this limitation, the International Depression Symptom Scale-General version (IDSS-G), based on empirical evidence of the signs and symptoms of depression reported across cultures. This paper describes the rationale and process of its development and the results of an initial test among a non-Western population.
We evaluated internal consistency reliability, test–retest reliability and inter-rater reliability of the IDSS-G in a sample N = 147 male and female attendees of primary health clinics in Yangon, Myanmar. For criterion validity, IDSS-G scores were compared with diagnosis by local psychiatrists using the Structured Clinical Interview for DSM (SCID). Construct validity was evaluated by investigating associations between the IDSS-G and the Patient Health Questionnaire (PHQ), impaired function, and suicidal ideation.
The IDSS-G showed high internal consistency reliability (α = 0.92), test–retest reliability (r = 0.87), and inter-rater reliability (ICC = 0.90). Strong correlations between the IDSS-G and PHQ-9, functioning, and suicidal ideation supported construct validity. Criterion validity was supported for use of the IDSS-G to identify people with a SCID diagnosed depressive disorder (major depression/dysthymia). The IDSS-G also demonstrated incremental validity by predicting functional impairment beyond that predicted by the PHQ-9. Results suggest that the IDSS-G accurately assesses depression in this population. Future testing in other populations will follow.
This study investigated local perceptions of changes stemming from a long-standing Group Interpersonal Psychotherapy (IPT-G) program for the treatment of depression in rural Uganda. The study was conducted in a low-income, severely HIV/AIDS-affected area where in 2001 the prevalence of depression was estimated at 21% among adults.
Data were collected using free-listing and key informant qualitative interviews. A convenience sample of 60 free-list respondents was selected from among IPT-G participants, their families, and other community members from 10 Ugandan villages. Twenty-two key informants and six IPT-G facilitators were also interviewed.
Content analysis yielded five primary categories of change in the community related to the IPT-G program: (1) improved school attendance for children; (2) improved productivity; (3) improved sanitation in communities; (4) greater cohesion among community members; and (5) reduced conflict in families. Community members and IPT-G facilitators suggested that as depression remitted, IPT-G participants became more hopeful, motivated and productive.
Results suggest that providing treatment for depression in communities with high depression prevalence rates may lead to positive changes in a range of non-mental health outcomes.
Conflict-affected communities face poverty and mental health problems, with sexual violence survivors at high risk for both given their trauma history and potential for exclusion from economic opportunity. To address these problems, we conducted a randomized controlled trial of a group-based economic intervention, Village Savings and Loans Associations (VSLA), for female sexual violence survivors in the Democratic Republic of Congo.
In March 2011, 66 VSLA groups, with 301 study participants, were randomized to the VSLA program or a wait-control condition. Data were collected prior to randomization, at 2-months post-program in June 2012, and 8-months later for VSLA participants only. Outcome data included measures of economic and social functioning and mental health severity. VSLA program effect was derived by comparing intervention and control participants' mean changes from baseline to 2-month follow-up.
At follow-up, VSLA study women reported significantly greater per capita food consumption and significantly greater reductions in stigma experiences compared with controls. No other study outcomes were statistically different. At 8-month follow-up, VSLA participants reported a continued increase in per capita food consumption, an increase in economic hours worked in the prior 7 days, and an increase in access to social resources.
While female sexual violence survivors with elevated mental symptoms were successfully integrated into a community-based economic program, the immediate program impact was only seen for food consumption and experience of stigma. Impacts on mental health severity were not realized, suggesting that targeted mental health interventions may be needed to improve psychological well-being.
To discuss the potential usefulness of a public health approach for ‘mental health and psychosocial support’ (MHPSS) interventions in humanitarian settings.
Building on public mental health terminology in accordance with recent literature on this topic and considering existing international consensus guidelines on MHPSS interventions in humanitarian settings, this paper reflects on the relevance of the language of promotion and prevention for supporting the rationale, design and evaluation of interventions, with a particular focus on populations affected by disasters and conflicts in low- and middle-income countries.
A public mental health approach and associated terminology can form a useful framework in the design and evaluation of MHPSS interventions, and may contribute to reducing a divisive split between ‘mental health’ and ‘psychosocial’ practice in the humanitarian field. Many of the most commonly implemented MHPSS interventions in humanitarian settings can be described in terms of promotion and prevention terminology.
The use of a common terminology across health, protection, education, nutrition and other relevant sectors providing humanitarian interventions has the potential to allow for integration of MHPSS activities in one overall framework, with diverse humanitarian practitioners working to achieve a common goal.
There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.
Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq.
This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al. 2014a), informed by the Assessment–Decision–Administration-Production–Topical experts–Integration–Training–Testing (ADAPT–ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting.
Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT–ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility.
BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.