Although recent reports suggest that service users in West African psychiatric facilities are exposed to poor quality of care and human rights violations, evidence is lacking on the extent and profile of specific deficits in the services provided to persons with mental health conditions.

To evaluate the quality of care and respect of human rights in psychiatric facilities in four West African countries, The Gambia, Ghana, Liberia and Sierra Leone, using the World Health Organization QualityRights Toolkit.

Trained research workers collected information through observation, review of records and interviews with service users, caregivers and staff. Independent panels of assessors used the information to assign scores to the criteria, standards and themes of the QualityRights Toolkit.

The study revealed significant gaps in these facilities. The rights to an adequate standard of living and to enjoyment of the highest attainable standard of health were poorly promoted. Adherence to the right to exercise legal capacity and the right to personal liberty and security was almost absent. Severe shortcomings in the promotion of the right to live independently and be included in the community were reported.

Inadequate appreciation of service users’ rights, lack of basic approaches to protect them and the non-promotion of rights-based services in these facilities are major problems that need to be addressed. Although it recognises the resource constraints and need for more human and financial resources, the study also identifies critical areas and challenges that require significant changes at the facility level.

There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).

To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.

Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.

Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.

Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.

None.

Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.

To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.

Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).

There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.

Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.

None.

Large-scale community studies of the prevalence of mental disorders using standardised assessment tools are rare in sub-Saharan Africa.

To conduct such a study.

Multistage stratified clustered sampling of households in the Yoruba-speaking parts of Nigeria. Face-to-face interviews used the World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI).

Of the 4984 people interviewed (response rate 79.9%), 12.1% had a lifetime rate of at least one DSM–IV disorder and 5.8% had 12-month disorders. Anxiety disorders were the most common (5.7% lifetime, 4.1% 12-month rates) but virtually no generalised anxiety or post-traumatic stress disorder were identified. Of the 23% who had seriously disabling disorders, only about 8% had received treatment in the preceding 12 months. Treatment was mostly provided by general medical practitioners; only a few were treated by alternative practitioners such as traditional healers.

The observed low rates seem to reflect demographic and ascertainment factors. There was a large burden of unmet need for care among people with serious disorders.

The improvement of community tolerance of people with mental illness is important for their integration. Little is known about the knowledge of and attitude to mental illness in sub-Saharan Africa.

To determine the knowledge and attitudes of a representative community sample in Nigeria.

A multistage, clustered sample of household respondents was studied in three states in the Yoruba-speaking parts of Nigeria (representing 22% of the national population). A total of 2040 individuals participated (response rate 74.2%).

Poor knowledge of causation was common. Negative views of mental illness were widespread, with as many as 96.5% (s.d.=0.5) believing that people with mental illness are dangerous because of their violent behaviour. Most would not tolerate even basic social contacts with a mentally ill person: 82.7% (s.e.=1.3) would be afraid to have a conversation with a mentally ill person and only 16.9% (s.e.=0.9) would consider marrying one. Socio-demographic predictors of both poor knowledge and intolerant attitude were generally very few.

There is widespread stigmatisation of mental illness in the Nigerian community. Negative attitudes to mental illness may be fuelled by notions of causation that suggest that affected people are in some way responsible for their illness, and by fear.