AMARI: African Mental Health Research Initiative

The African Mental Health Research Initiative (AMARI) is part of the Wellcome Trust's programme for Developing Excellence in Leadership, Training and Science (DELTAS) in Africa. AMARI is a consortium of four African universities, supported by three UK universities, whose overall goal is to build an Africa-led network of future leaders in mental, neurological and substance use (MNS) research in Ethiopia, Malawi, South Africa and Zimbabwe. It will achieve this by recruiting nearly 50 fellows across MPhil, PhD and Post-doc programmes, and intensively training and supporting these researchers. AMARI aims to equip researchers to lead high quality mental health research programmes that meet the needs of their countries, and to establish a sustainable career path for these researchers. A particular focus is on integrating MNS research into existing programmes such as HIV/AIDS, maternal and child health work.

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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.

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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 well-being 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.

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 as prescribed on time each day is critical for viral suppression and survival. However, there are many barriers to good adherence and one of the most impactful is depression. Worldwide, depression is twice as common in those living with HIV as in those not infected with this virus. 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. The TENDAI study 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 improving mental health. 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 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 well-being 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 randomized 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