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      The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies

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          Abstract

          Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.

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          Most cited references106

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          Undertreatment of people with major depressive disorder in 21 countries.

          Major depressive disorder (MDD) is a leading cause of disability worldwide.
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            Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature

            Few individuals living with mental disorders around the globe have access to mental health care, yet most have access to a mobile phone. Digital technology holds promise for improving access to, and quality of, mental health care. We reviewed evidence on the use of mobile, online, and other remote technologies for treatment and prevention of mental disorders in low-income and middle-income countries. Of the 49 studies identified, most were preliminary evaluations of feasibility and acceptability. The findings were promising, showing the potential effectiveness of online, text-messaging, and telephone support interventions. We summarised the evaluations as: technology for supporting clinical care and educating health workers, mobile tools for facilitating diagnosis and detection of mental disorders, technologies for promoting treatment adherence and supporting recovery, online self-help programmes for individuals with mental disorders, and programmes for substance misuse prevention and treatment. Continued research is needed to rigorously evaluate effectiveness, assess costs, and carefully consider potential risks of digital technology interventions for mental disorders, while determining how emerging technologies might support the scale-up of mental health treatment and prevention efforts across low-resource settings.
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              Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial.

              Despite the importance of mental illness in Africa, few controlled intervention trials related to this problem have been published. To test the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction and to evaluate the feasibility of conducting controlled trials in Africa. For this cluster randomized, controlled clinical trial (February-June 2002), 30 villages in the Masaka and Rakai districts of rural Uganda were selected using a random procedure; 15 were then randomly assigned for studying men and 15 for women. In each village, adult men or women believed by themselves and other villagers to have depressionlike illness were interviewed using a locally adapted Hopkins Symptom Checklist and an instrument assessing function. Based on these interviews, lists were created for each village totaling 341 men and women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression or subsyndromal depression. Interviewers revisited them in order of decreasing symptom severity until they had 8 to 12 persons per village, totaling 284. Of these, 248 agreed to be in the trial and 9 refused; the remainder died or relocated. A total of 108 men and 116 women completed the study and were reinterviewed. Eight of the 15 male villages and 7 of the 15 female villages were randomly assigned to the intervention arm and the remainder to the control arm. The intervention villages received group interpersonal psychotherapy for depression as weekly 90-minute sessions for 16 weeks. Depression and dysfunction severity scores on scales adapted and validated for local use; proportion of persons meeting DSM-IV major depression diagnostic criteria. Mean reduction in depression severity was 17.47 points for intervention groups and 3.55 points for controls (P<.001). Mean reduction in dysfunction was 8.08 and 3.76 points, respectively (P<.001). After intervention, 6.5% and 54.7% of the intervention and control groups, respectively, met the criteria for major depression (P<.001) compared with 86% and 94%, respectively, prior to intervention (P =.04). The odds of postintervention depression among controls was 17.31 (95% confidence interval, 7.63-39.27) compared with the odds among intervention groups. Results from intention-to-treat analyses remained statistically significant. Group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction. A clinical trial proved feasible in the local setting. Both findings should encourage similar trials in similar settings in Africa and beyond.
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                Author and article information

                Journal
                Int J Environ Res Public Health
                Int J Environ Res Public Health
                ijerph
                International Journal of Environmental Research and Public Health
                MDPI
                1661-7827
                1660-4601
                16 June 2018
                June 2018
                : 15
                : 6
                : 1279
                Affiliations
                [1 ]Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC 20037, USA; abhardwa@ 123456alumni.unc.edu (A.B.); gapedersen@ 123456gwu.edu (G.A.P.)
                [2 ]Division of Epidemiology and Public Health, University of Nottingham, NG7 2RD, UK; laura.asher@ 123456nottingham.ac.uk
                [3 ]Department of Psychiatry, University of Oxford, Warneford Lane, OX1 2JD, UK; mina.fazel@ 123456psych.ox.ac.uk
                [4 ]Center for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; mark.jordans@ 123456kcl.ac.uk (M.J.D.J.); abhijit.nadkarni@ 123456kcl.ac.uk (A.N.)
                [5 ]War Child, Research and Development, 1098 LE, Amsterdam, The Netherlands
                [6 ]Butabika National Mental Hospital, 2 Kirombe-Butabika Road, P.O. Box 7017 Kampala, Uganda; byamamutamba@ 123456yahoo.com
                [7 ]YouBelong, P.O. Box 36510 Kampala, Uganda
                [8 ]Sangath, Socorro, Porvorim, Goa 403501, India
                [9 ]Department of Psychiatry, Sinai Health System & University of Toronto, Toronto, ON M5G 1X5, Canada; daisy.singla@ 123456utoronto.ca
                [10 ]Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA 02115, USA; vikram_patel@ 123456hms.harvard.edu
                [11 ]Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA
                Author notes
                [* ]Correspondence: bkohrt@ 123456gwu.edu
                [†]

                All authors contributed equally and are presented in alphabetical order.

                Author information
                https://orcid.org/0000-0002-3829-4820
                https://orcid.org/0000-0001-5832-5236
                https://orcid.org/0000-0003-3427-3464
                Article
                ijerph-15-01279
                10.3390/ijerph15061279
                6025474
                29914185
                32c432f2-5a93-4f18-9671-6988e6582a9e
                © 2018 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 09 May 2018
                : 14 June 2018
                Categories
                Review

                Public health
                community,global health,low- and middle-income countries,mental disorders,meta-review,paraprofessionals,psychological treatments

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