AMARI: African Mental Health Research Initiative

The African Mental Health Research Initiative (AMARI) was initially funded 2015-2021 by the Wellcome Trust programme Developing Excellence in Leadership, Training and Science (DELTAS) in Africa. The overall goal of AMARI was to build an African-led network of 47 research fellows in mental, neurological and substance use research in Ethiopia, Malawi, South Africa, and Zimbabwe. The Director of AMARI is Dr Dixon Chibanda who founded the pioneering Friendship Bench program. The program is led by the University of Zimbabwe. Prof Melanie Abas is AMARI co-investigator and lead for King’s College London. KCL is a key partner through membership of the AMARI steering committee, by providing external PhD supervision for 15 PhD fellows; by hosting an annual webinar series for three years; and leading training in research career development through the Academic Competencies Series (ACES) course. From 2015 – 2020, AMARI competitively recruited 47 fellows, at MPhil, PhD and postdoc levels across four countries, to receive research training, and supervision (Chibanda et al., 2020). All were registered at universities in African countries. King’s College London’s developed and ran the Academic Competencies Series (ACES) course for all the PhD and post-doc fellows. ACES is a pioneering capacity-building training series based on the Institute of Psychiatry Psychology and Neuroscience (IoPPN) Thrive, co-adapted to fit the needs of early career African Mental Health Researchers (Merritt et al., 2019; Okewole et al., 2020). The training focused on equipping researchers with the necessary skills to lead high quality research in their home countries, with workshops focusing on three broad topics: self-development, engagement and witing skills. Testimonials from AMARI-I showed fellows perceived ACES as very useful and applicable to their professional lives, including a “Train the Trainers” teaching approach to systematic reviewing, where AMARI alumni have been trained to train junior researchers in their home countries(Jack et al., 2020). The second phase of AMARI (AMARI-II) will run from 2021 – 2024. It will build on the findings and achievements of AMARI-I, to further drive forward strategies for culturally appropriate and sustainable research that will lead to lasting career pipelines. AMARI-II will provide 96 fellowships to African mental health scholars through nesting training opportunities within existing African-based research projects. A key role for KCL will be training African champions across three hubs in East, West, and Southern Africa to run the ACES course sustainably, and the addition of a leadership training course component led by the KCL African Leadership Centre. We envisage lasting impact from our approach to sustainable research training and partnership in African countries.

Find out more about the AMARI project

ASSET: Health System Strengthening in Sub-Saharan Africa

The ASSET research project aims to improve the quality and outcomes of surgical, maternal and integrated primary health care through health system strengthening interventions in Ethiopia, South Africa, Sierra Leone and Zimbabwe. ASSET brings together surgeons, obstetricians, midwives, psychiatrists, public health dentists, palliative care and general healthcare specialists to work with social scientists, health economists, information technologists and implementation scientists, and is looking for practical ways, through health system strengthening interventions, to improve the coverage and quality of care. Some of the methods ASSET is using include the introduction of evidence-based care pathways; essential health management information systems data to monitor the quality of continuing care and its outcomes; peer-driven quality improvement cycles; workforce strengthening to prepare for necessary organisational changes and foster non-technical skills (leadership, teamwork, communication, counselling, and stress management); and person-centred care. The health system strengthening interventions will be adapted to local contexts, piloted and refined, and then applied as a package of measures to improve care delivery.

Find out more about the ASSET project

Catalyst: Better mental health for young Mozambican mothers

Dr Tatiana Taylor Salisbury, Lecturer in Global Mental Health, King’s College London, is one of 35 awardees receiving an initial grant under the Bill and Melinda Gates Foundation’s Grand Challenges Explorations initiative. The award will fund the Catalyst project, which aims to adapt existing, evidence-based interventions for use among young mothers (aged 16-24 years) in Mozambique to improve their mental wellbeing before and after birth. Young women, their families, community leaders, service providers and government officials will partner with the research team to identify challenges to wellbeing and design and test potential solutions. This 18-month project is a collaboration between researchers from King’s College London, the Centro de Investigação em Saúde de Manhiça (Manhiça Health Research Centre) and the Royal College of Art. The project is nested within the PRECISE Network led by Prof Laura Magee and Prof Peter von Dadelszen, Department of Women and Children’s Health, King’s College London.

CHANCES: Poverty reduction, mental health and the chances of young people: understanding mechanisms through analyses from 6 low- and middle-income countries

Poverty and mental health are closely linked. In low- and middle-income countries (LMICs), young people in poverty have a high risk of developing or maintaining mental health problems. The stress and environmental conditions associated with poverty increase the risk of mental health problems. Additionally, the disability and high costs faced by people with mental illness can maintain poverty. Currently, most evaluations of antipoverty interventions focus on socioeconomic or general wellbeing outcomes, but rarely examine the effects on mental health. At the same time, the main focus in the field of global mental health has been to improve access to treatment, but with little focus on the impact of interventions on future life chances and poverty. This study aims to (1) understand the mental health impact of antipoverty policies and (2) how mental health interventions influence the life chances and risk of poverty amongst young people. To do this, we will use multiple interdisciplinary methods to understand the costs and the impact of potential interventions and associated pathways to improved life chances. We will analyse seven different datasets from six low- and middle-income countries. We will also collect qualitative data from interviews and focus groups with young people from economically deprived circumstances. Qualitative data will provide information on: (i) experiences and meaning of poverty and mental health problems, (ii) personal experiences of being involved in antipoverty programmes or receiving mental health interventions, (iii) challenges or barriers to engaging with the antipoverty and mental health interventions and (iv) ideas for future interventions. Additionally, from the start of the project, we will work together with community members: young people from deprived circumstances, service users, health practitioners and policymakers. Workshops will help us to gather insights into how our findings can be used to develop and test new interventions, for example by combining mental health and poverty programmes. Mental health problems are common among young people from economically deprived circumstances in LMICs and it is known that experience of poverty and mental health problems can have long-lasting effects into adulthood. Providing more effective intervention during this period could be help reduce the impact of poverty and/or prevent mental health problems early in life, thus increasing future life chances, including opportunities for education and employment.

Counselling on Wheels Nigeria; Developing a framework for Africa-wide response to mental health challenges in communities affected by Violent Extremism

The Neem foundation is a non-governmental organisation set up in response to the problems associated with the Boko Haram conflict. Neem offers a range of psychosocial services to communities in north-east Nigeria, focusing on mental health interventions and peacebuilding initiatives. They seek to engage communities, facilitate dialogue between stakeholders and promote rehabilitation and reintegration of those affected by the insurgency. One of their initiative, the Counselling on Wheels (CoW) Programme, focuses on the psychosocial aspects of the crisis through an innovative mobile counselling. CoW has two main components: peacebuilding activities and psychological therapy services. Unlike standalone mental health services or peacebuilding initiatives, Neem’s unique approach emphasises individual psychological wellbeing as the foundation of collective resilience to conflict and peacebuilding. King’s College London conducted an independent evaluation of the programme to assess effectiveness and implementation outcomes, with a main focus on therapy services. The analysis was done on a sample of 3,091 participants, comparing pre- and post-scores on three psychological scales - Vulnerability to Violent Extremism (VVES); Depression, Anxiety and Stress Scale (DASS-21); and Post-Traumatic Stress Disorder Scale (PTSD-8). Significant reductions in scores for all three scales were seen, indicating that therapy delivered by the COW program improved mental well-being and reduced vulnerability to violent extremism. The programme was broadly found to be acceptable and feasible for delivery in the setting by both beneficiaries and service providers at a comparatively low cost (of US$ 56 per beneficiary starting in group therapy treatment). This indicates that, with appropriate adaptations, the intervention has potential for sustainable delivery and scale up within Nigeria and in other post-conflict settings. Discussions are currently underway with the United Nations about next steps for potential implementation and research. KCL Evaluation Team: Professor Melanie Amna Abas, Professor ‘Funmi Olonisakin, Natasha Chilambo, Sarah Derveeuw, Dr Chris Merritt, Dr Patrick Smith, Prof Richard Sullivan, Prof Preeti Patel, Dr Kimberley Goldsmith. Neem Foundation Project Partners: Dr Fatima Akilu, Dr Abiye Iruayenama, Ashraf Usman. Co-Investigators: Dr Kelly Rose-Clarke, Dr Ekaette Ikpe, Dr Olawale Ismail, Dr Sharli Paphitis, Dr Petr Slovak. Funder: King’s Together Strategic Award.

More information on the NEEM Foundation

Counselling on Wheels Documentary

Creative Arts Hub Zimbabwe - United to Overcome HIV in Young People

Creative Arts Hub Zimbabwe uses a combination of music, dance, drama and meditation to build self-confidence and social support, and encourage self-expression, for vulnerable young people living with HIV and poor mental health. The creative arts sessions are combined with group adherence counselling, with the aim of improving engagement in HIV care. The sessions are led by a professional Zimbabwean musician, Tariro neGitare and clinical psychologist Tarisai Bere. The creative arts hub was established through a partnership between a government health clinic, performing artists, and mental health practitioners, funded by a King’s College London Cultural Grant. Prof Melanie Abas from King's College London is the academic lead. A delegation from the BRIT School in Croydon travelled to support the programme in the dance and film-making aspects. The BRIT students worked with Zimbabwean artists and the young people themselves to create a dance workshop and make a film about Creative arts hub Zimbabwe. The film was made to show the impact of taking part in the Hub sessions, on the young people’s wellbeing. This video can viewed through the link below. The young people attending the Creative Arts Hub reported low self-esteem and hopelessness before engaging in the project. All the participants were struggling with taking their life-saving HIV medication, with many extremely ill. Qualitative interviews following their participation in the session reveal the programme was a ‘fun’ new experience, facilitating social skills and peer support. The arts-based sessions built self-esteem, and confidence, and encouraged participants to focus on their future including engaging with their HIV treatment. Five young people from the Creative Arts Hub have been trained to co-facilitate the sessions for a second group of vulnerable young people living with HIV. These sessions are currently ongoing in Harare, Zimbabwe.

The Creative Arts Hub Zimbabwe (video link)

ImpleMentAll: Towards evidence-based tailored implementation strategies for eHealth

ImpleMentAll is a European collaboration of 13 countries that aims to develop, apply, and evaluate tailored implementation strategies of on-going eHealth implementation initiatives for depression. The project is funded by the European Commission. For more information about the ImpleMentAll Project, please contact Arlinda Cerga Pashoja at arlinda.cerga-pashoja@lshtm.ac.uk.

LATIN–MH: Latin America Treatment & Innovation Network in Mental Health

The increasing availability and decreasing costs of new communication technologies, such as smartphones, in Latin America have opened new opportunities for the delivery of interventions at a much larger scale than ever considered possible. Latin-MH created a technological platform (CONEMO) to deliver a behavioural activation intervention for patients with hypertension and/or diabetes who also presented clear depressive symptoms. CONEMO is an 18-session intervention, based on behavioural activation principles, delivered by a smartphone application and supported by non-specialist health workers through a tablet-based dashboard. We conducted two multicentre RCTs, in Brazil (n=880), and Peru (n=432) with adults presenting with depressive symptoms and comorbid hypertension or diabetes, attending Family Health Units in São Paulo and public outpatient healthcare services in Lima. The participants were randomly assigned to receive either enhanced usual care or the CONEMO intervention. The primary outcome was a reduction of 50% or more in depressive symptoms measured by the PHQ-9. The secondary outcomes included measures of behavioural activation, quality of life, disability, and health services usage. Overall, the intervention proved to be clinically effective in both settings, with a difference of 11% in São Paulo and 20% in Lima in favour of CONEMO. The platform is currently being tested in two other regional countries. This is the first RCT of a technology-based system to treat depression with a psychological intervention among people with co-morbid chronic diseases. Depression is common and disabling and there is a massive treatment gap in most low-and-middle income countries. There is a lack of trained human resources to deliver psychological treatments in most LMICs. Technology supported and delivered interventions can be accessed by a large proportion of the population, something that was unthinkable before. There are plans to implement this intervention at a much larger scale in both countries.

Find out more about the LATIN-MH project

LIFE2YEARS - 10/66 ten years on

Population ageing and the transition from infectious to chronic diseases is occurring more rapidly in middle than it did in high income countries. Chronic diseases are already leading causes of death in all regions, but the focus on preventing premature mortality neglects the societal impact of the emerging epidemic on disability/dependence, particularly in older people. The focus for this project is the potential to modify trajectories of ageing through prevention and targeted intervention. Whether, in ageing societies, we can add ‘life to years’ as well as ‘years to life’ is an unresolved question. The project will delineate secular trends (2005-2015) in the health of older people by completing a third prevalence wave survey in catchment areas previously surveyed in 2004-2006 and 2007-2009. Health expectancies (HE), summarising effects of morbidity and mortality, provide evidence of direct policy relevance on the impact of population ageing on health. Inequalities in HE (disability-free and dependence free life expectancies) will be evaluated within and between countries. Multistate analyses will assess their determinants, unpacking influences of socioeconomic position, chronic disease and underlying frailty on incidence of disability and care-dependence, recovery and mortality, thus identifying priorities for prevention and intervention. Knowledge from the population research will be translated during the project into development of a simple practice-based multidimensional risk assessment tool, suitable for use in planned field trials of the implementation of a new WHO guideline (co-developed by the PI) for prevention/ management of care dependence in frail older people in resource poor settings.

PROACTIVE: Cluster randomised controlled trial (RCT) for late life depression in socioeconomically deprived areas of São Paulo, Brazil

PROACTIVE is a two-arm cluster randomised controlled trial comparing the cost-effectiveness of a psychosocial, community-based intervention with usual care to reduce depressive illness among adults aged 60 years or older from poor backgrounds in Guarulhos, São Paulo, Brazil. PROACTIVE consists of 8 to 11 home sessions delivered in a stepped-care fashion by Community Health Workers equipped with tablet computers with a pre-installed software that assist with the delivery of the intervention. The study will screen 24,000 elderly people and recruit 1,440 participants from 20 primary health care clinics. We will compare recovery across arms at 8 and 12 months after entering the trial. Secondary outcomes will also include quality of life and levels of functioning. Direct and indirect costs will be measured to undertake a cost-effectiveness analysis. Two additional sub-studies will be undertaken: 1) a study to test a ‘minimal’ intervention for people with sub-threshold depression; and 2) a study to test if the PROACTIVE intervention will also have an effect on lowering blood pressure among individuals with depression and hypertension. With the rapid growth of the elderly population in low- and middle-income countries, and the limited resources to cater for the needs of this subpopulation, mental health problems are usually neglected. Depression is one of the most challenging problems experienced by older adults who present other co-morbid physical chronic conditions and social neglect. This is the first RCT of an intervention for elderly depressed people in Latin America. The main short-term impact of this project will benefit depressed elderly people, who will receive improved treatment, as well as the community health workers empowered with new skills to improve their professional practice. If this intervention proves to be cost-effective, it is likely to be implemented at a larger scale by the Brazilian Unified Health System (SUS) to alleviate the suffering of millions of people who currently receive little or no help for their mental health problems. This study will provide unique and important information to Brazilian policymakers and those from other countries experiencing similar problems.

TENDAI Study: Task shifting to treat depression and HIV medication nonadherence in low resource settings

For people living with HIV, taking antiretroviral medication on time each day is critical to suppress the amount of virus in the blood to prevent illness and progression to AIDS.. Depression is a major barrier to adherence to antiretroviral medication. Worldwide, depression is twice as common in those living with HIV as in those not living with HIV. A particular obstacle to depression in low-resource settings is the lack of mental health specialists and treatments. However, there is a well-established infrastructure for HIV care in sub-Saharan Africa which could provide an excellent platform to integrate mental health care, building on the skills of existing HIV care staff. ENDAI is a clinical trial which aims to demonstrate how people living with HIV can achieve viral suppression through better approaches to adherence counselling, and through treatment for depression. Problem-solving therapy for adherence and depression (PST-AD), is delivered over six weekly sessions. It has a motivational approach and teaches people to become good problem solvers and to apply these skills to their barriers to adherence and to improve their ability to cope with stressful life experiences. The intervention prioritises task-shifting, with existing counsellors and nurses as interventionists trained specifically in the intervention. If successful, TENDAI could make a critical difference to the health, quality of life, and survival of people managing the challenges of HIV treatment in Zimbabwe, and potentially other countries in sub-Saharan Africa. The team’s work is already having policy impact, being included in the December 2018 Joint United Nations Programme on HIV/AIDS (UNAIDS) report about HIV and mental well-being. TENDAI research was mentioned in the context of the UNAIDS 90-90-90 goals which aim to bring an end to the global AIDS epidemic by 2030. TENDAI is also highly relevant the current policy and funding priority, to improve the quality of life for people living with HIV. Principal Investigator: Prof Melanie Abas. Co-Investigators: Dr Kimberley Goldsmith, Dr Barbara Barrett. Trial manager: Rebecca Jopling.

Find out more about TENDAI Study

TENDAI-Together - Improving Mental Health and HIV outcomes for Expectant Couples in Malawi

The aim of this project is to develop and pilot test an intervention for expectant couples in Malawi where one or both partners are living with HIV, to reduce maternal depression, increase the wellbeing of both partners, and improve HIV viral suppression. TENDAI stands for Task-shifting to improve Depression and Adherence to HIV medication. The original intervention was developed in neighbouring Zimbabwe. It comprises a culturally adapted 6-session behavioural intervention. This consists of problem-solving therapy and positive activity scheduling for depression and other common mental disorders, with additional content adapted from LifeSteps for HIV medication adherence. This is delivered by primary care counsellors and encourages the client to generate solutions to problems underlying their depression and help them overcome their barriers to taking HIV medication. This project aims to adapt TENDAI for expectant couples in Malawi where one or both partners are living with HIV, and where the woman has depression. We expect the adapted intervention to include support to encourage self-testing for partners who do not know their HIV status, and extra education and support for serodiscordant couples, where only one member of the couple is living with HIV. Serodiscordancy is common in Malawi and increases stress and distrust in a relationship. Also, without intervention, HIV-negative partners acquire HIV at up to 12% per year. If the HIV-positive partner adheres well to antiretroviral therapy, the amount of virus in the blood is supressed to an undetectable level, so preventing onward transmission of HIV to sexual partners, and from mother to baby. This is known as undetectable = untransmissible (U=U). Messaging on U=U may ease concerns in couples and increase the wellbeing of both partners within a discordant couple. We will develop an SMS based intervention to deliver U=U messaging and motivate women’s partners to self-test for HIV. This project aims to carry out formative work and an exploratory trial to test feasibility and acceptability of TENDAI-Together, plus the feasibility of collecting clinical outcome measures. The expected findings for this study will include the acceptability and feasibility of the TENDAI- Together intervention. These will inform a future randomised controlled trial powered to determine the effectiveness of the stepped care TENDAI-Together intervention. This project will add to the growing evidence base on the importance of integrating mental health care into the management of HIV.

For more information about the project

The Friendship Bench

The Friendship Bench (FB) project is an evidence-based intervention developed in Zimbabwe to bridge the mental health treatment gap. The FB aims to enhance mental wellbeing and improve quality of life through the use of problem-solving therapy delivered by trained lay health workers, focussing on people who are suffering from common mental disorders, such as anxiety and depression. The Friendship Bench intervention has been developed over a twenty-year period from community research in Zimbabwe. It uses a cognitive behavioural therapy-based approach at primary care level to address 'kufungisisa' – the local word closest to depression (literally, “thinking too much” in Shona). Uniquely, the FB uses ‘grandmothers’ to deliver the therapy. These grandmothers are community volunteers, without any prior medical or mental health experience, who are trained to counsel patients usually for six structured 45-minute sessions, on wooden benches within the grounds of clinics in a discrete area. In 2016, the results from a FB randomised controlled trial were published in JAMA, showing that the group from the Friendship Bench had a significant decrease in depressive symptoms, compared to the control group. Since 2006, Dr Chibanda and his team have trained over 600 of the grandmothers in evidence-based talk therapy, which they deliver for free in more than 70 communities in Zimbabwe, and in 2017 alone 30,000 were seen on a Friendship Bench. The FB has now expanded beyond Zimbabwe; it is being used in Malawi and Zanzibar, and it has been adapted for New York City, highlighting that interventions created in low- and middle-income countries can be adapted for high-income countries. There are several FB studies currently underway including; The Youth Friendship Bench (YouFB), OptFB, FB Plus and Zvandiri.

Find out more about The Friendship Bench project

The Indigo Network

INDIGO is an international network of forty countries worldwide collaborating to build the evidence base of what works to reduce mental health related stigma and discrimination. It includes a current Medical Research Council five-year £2million Partnership Grant with staff in five countries. The MRC Indigo programme grant, led by Prof Sir Graham Thornicroft and Prof Norman Sartorius, will produce a harmonised set of metrics for international stigma research and will produce proof of concept studies for candidate interventions to reduce stigma and discrimination in low- and middle-income countries. Contact: graham.thornicroft@kcl.ac.uk.

Find out more about the INDIGO Network