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There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings.
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).
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.
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.
ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.
Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.
To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.
Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.
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.
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.
Psychosocial interventions may contribute to reducing the burden of mental disorders in low- and middle-income (LAMI) countries by improving social functioning, but the evidence has not been systematically reviewed.
Systematic review and meta-analysis of the effect of psychosocial interventions on social functioning in people with depression and schizophrenia in LAMI countries.
Studies were identified through database searching up to March 2011. Randomised controlled trials were included if they compared the intervention group with a control group receiving placebo or treatment as usual. Random effects meta-analyses were performed separately for depressive disorders and schizophrenia and for each intervention type.
Of the studies that met the inclusion criteria (n=24), 21 had sufficient data to include in the meta-analysis. Eleven depression trials showed good evidence for a moderate positive effect of psychosocial interventions on social functioning (standardised mean difference (SMD)=0.46, 95% CI 0.24-0.69, n=4009) and ten schizophrenia trials showed a large positive effect on social functioning (SMD = 0.84, 95% CI 0.49-1.19, n=1671), although seven of these trials were of low quality. Excluding these did not substantially affect the size or direction of effect, although the precision of the estimate was substantially reduced (SMD = 0.89, 95% CI 0.05-1.72, n=863).
Psychosocial interventions delivered in out-patient and primary care settings are effective at improving social functioning in people with depression and should be incorporated into efforts to scale up services. For schizophrenia there is an absence of evidence from high-quality trials and the generalisabilty of the findings is limited by the over-representation of trials conducted in populations of hospital patients in China. More high-quality trials of psychosocial interventions for schizophrenia delivered in out-patient settings are needed.