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There is limited research on the gap between the burden of mental disorders and treatment use in low- and middle-income countries. The aim of this study was to assess the treatment gap among adults with depressive disorder (DD) and alcohol use disorder (AUD) and to examine possible barriers to initiation and continuation of mental health treatment in Nepal. A three-stage sampling technique was used in the study to select 1,983 adults from 10 Village Development Committees (VDCs) of Chitwan district. Presence of DD and AUD were identified with validated versions of the Patient Health Questionnaire (PHQ-9) and Alcohol Use Disorder Identification Test (AUDIT). Barriers to care were assessed with the Barriers to Access to Care Evaluation (BACE). In this sample, 11.2% (N = 228) and 5.0% (N = 96) screened positive for DD and AUD respectively. Among those scoring above clinical cut-off thresholds, few had received treatment from any providers; 8.1% for DD and 5.1% for AUD in the past 12 months, and only 1.8% (DD) and 1.3% (AUD) sought treatment from primary health care facilities. The major reported barriers to treatment were lacking financial means to afford care, fear of being perceived as \"weak\" for having mental health problems, fear of being perceived as \"crazy\" and being too unwell to ask for help. Barriers to care did not differ based on demographic characteristics such as age, sex, marital status, education, or caste/ethnicity. With more than 90% of the respondents with DD or AUD not participating in treatment, it is crucial to identify avenues to promote help seeking and uptake of treatment. Given that demographic characteristics did not influence barriers to care, it may be possible to pursue general population-wide approaches to promoting service use.

Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting. We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, \"heart-mind\" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have \"heart-mind\" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information. In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants. ClinicalTrials.gov NCT03747055.

Depression and anxiety are prevalent worldwide, yet fewer than 20% of individuals in low- and middle-income countries receive appropriate care. Cultural norms play a significant role in how symptoms are expressed and how individuals seek help. In Nepal, traditional healers are often preferred over mental health specialists. This qualitative study explored how symptom presentation and perceived causes impact treatment-seeking behaviour among adults receiving care for depression or anxiety. Twenty-four participants (13 with depression, 9 with anxiety, and 2 with both conditions) were recruited from Jhapa, Chitwan, and Kailali districts through primary healthcare providers, psychosocial counselors, and mental health specialists. Individual interviews were conducted using the adapted McGill Illness Narrative Interview (MINI) to explore symptom experiences, illness narratives, perceived causes, and help-seeking patterns. Thematic analysis of the data was done using NVIVO software. Participants reported a range of emotional, cognitive, and physical symptoms including fear, anxiety, restlessness, irritability, sadness, and hopelessness. Somatic complaints like headaches, fatigue, and gastrointestinal issues were often interpreted as consequences of psychological stress. Some participants described dissociative experiences, such as detachment, amnesia, or perceptual distortions, leading to panic or self-harm. Stressors mentioned included financial hardships, bereavement, family conflicts, trauma, and culturally ingrained fears. Most participants initially sought help from biomedical providers like private clinics, hospitals, health centers, or health camps with some also consulting traditional healers. Education and caste played a significant role in treatment choices, with individuals with higher education and from higher castes more likely to seek biomedical care first. Gender and age had minimal impact. The study underscores the importance of culturally sensitive, community-based mental health programs to reduce stigma and ensure equitable access to care for depression and anxiety in Nepal.

Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing. A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment. These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).

Background Depression and anxiety are prevalent mental health issues globally, yet many individuals in low- and middle-income countries lack access to treatment. Limited research exists on mental health service utilization in these regions. Understanding the factors that affect access to care and treatment pathways can improve mental health services. This study examines the factors that facilitate the initiation and continuation of treatment for depression or anxiety in Nepal. Methods The study was conducted in three districts in Nepal: Jhapa, Chitwan, and Kailali districts, representing the eastern, central, and far-western regions. The participants were adults receiving treatment for depression or anxiety from various healthcare providers. A total of 24 participants were purposively recruited, including 13 with symptoms of depression, 9 with symptoms of anxiety, and 2 with both conditions. We utilized the McGill Illness Narrative Interview, a semi-structured protocol commonly used in mental health research, to collect detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors. Data analysis was performed using a framework and thematic analysis approach with NVIVO software. Results Treatment pathways for depression and anxiety in Nepal are complex, involving multiple service providers and recurrent treatment from the same providers. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (11.7%), and private clinics (8.0%). Traditional healers were the most popular choice for initial visits, followed by private clinics and government hospitals. Factors such as service quality, provider behavior, availability of trained providers, appointment process, confidentiality, and types of services offered influenced care-seeking decisions. Support from family or friends, awareness of mental health issues, and recommendations from trusted individuals also played a significant role. Conclusion Treatment pathways for depression and anxiety disorders are complex, often involving multiple sessions with various service providers and a combination of services. It is crucial to improve healthcare providers' behavior, appointment scheduling, and consultation quality to encourage individuals to seek care. Raising awareness about mental health conditions and available services through different channels and training traditional healers in mental health could help enhance access to care.

A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda. 8036 adults residing in these districts between May 2013 and May 2014. Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans.

Background The barriers and facilitating factors for integrating mental health into primary health care have been well documented in the literature, but little is known about the perspectives of primary health care workers (who provide integrated mental health care) on barriers and facilitating factors of the health system for scaling up mental health interventions in low and middle income countries. This study aimed to explore these perspectives of primary health care workers within the health system, and identify possible strategies to optimize the integration of mental health in primary health care. Methods The study was conducted in the Chitwan district of Nepal with 55 purposively selected primary health care workers representing prescribers ( N  = 35), non-prescribers ( N  = 12) and Female Community Health Volunteers ( N  = 8). Using a semi-structured interview guide, experienced qualitative researchers collected data between September 2016 and May 2017. The interviews were audio-taped, transcribed and then translated into English. The transcripts were coded using Nvivo 10 software and themes were generated for the thematic analysis. Results According to the health workers, the facilitating factors for scaling up mental health services in primary health care setting in Nepal included; (1) availability of guidelines, protocols and awareness raising materials, (2) provision of supervision, (3) referral systems being in place, (4) patient record keeping, (5) community sensitizations and home visits, and (6) provision of psychosocial counseling. The barriers identified included; (1) shortage of psychotropic medicines, (2) lack of private space for counseling, (3) workload and health workers’ grievances regarding incentives, and (4) perceived stigma causing dropouts. Conclusions The findings suggest that implementation of mental health services through primary health care workers in resource-poor setting is possible when health system level barriers are addressed and facilitating factors are strengthened. In order to address these barriers the health workers suggested a few strategies which included; ensuring dedicated staff available at health facility, allocating dedicated and confidential space for counseling, improving on incentives and motivational benefits to existing health staff, organizing policy level advocacy for mental health, improving medicine supply chain management and strengthening systems for supervision, referral and mental health information management.

Background Depression is a prevalent mental health condition worldwide but there is limited data on its presentation and associated symptoms in primary care settings in low- and middle-income countries like Nepal. This study aims to assess the prevalence of depression, its hallmark and other associated symptoms that meet the Diagnostic and Statistical Manual (DSM-5) criteria in primary healthcare facilities in Nepal. The collected information will be used to determine the content of a mobile app-based clinical guidelines for better detection and management of depression in primary care. Methods A total of 1,897 adult patients aged 18–91 (63.1% women) attending ten primary healthcare facilities in Jhapa, a district in eastern Nepal, were recruited for the study between August 2, 2021, and March 25, 2022. Trained research assistants conducted face-to-face interviews in private spaces before the consultation with healthcare providers. Depression symptoms, including hallmark symptoms, was assessed using the validated Nepali version of the Patient Health Questionnaire (PHQ-9). Results One in seven (14.5%) individuals attending primary health care facilities in Jhapa met the threshold for depression based on a validated cut-off score ( > = 10) on the PHQ-9. The most commonly reported depressive symptoms were loss of energy and sleep difficulties. Approximately 25.4% of women and 18.9% of men endorsed at least one of the two hallmark symptoms on the PHQ-9. Using a DSM-5 algorithm (at least one hallmark symptom and five or more total symptoms) to score the PHQ-9, 6.3% of women and 4.3% of men met the criteria for depression. The intra-class correlation coefficient for PHQ-9 total scores by health facility as the unit of clustering was 0.01 (95% confidence interval, 0.00-0.04). Conclusion Depression symptoms are common among people attending primary healthcare facilities in Nepal. However, the most common symptoms are not the two hallmark criteria. Use of total scores on a screening tool such as the PHQ-9 risks overestimating the prevalence and generating false positive diagnoses. Compared to using cut off scores on screening tools, training health workers to first screen for hallmark criteria may increase the accuracy of identification and lead to better allocation of treatment resources.

Background Depression is a common mental health issue that can be effectively managed in primary and community health care settings. However, there is a significant gap between the number of individuals in need of care and those who actually receive treatment, with the greatest gap in low- and middle-income countries (LMICs). Although efforts have been made in LMICs to improve access to mental health services by addressing supply-side barriers, there has been less attention to demand-side obstacles. On the demand side, factors such as stigma, negative attitudes, and limited awareness of available services lead to underutilization of mental health services. This protocol describes a study of active ingredients of a community-based intervention aimed at enhancing help-seeking for depression care in Nepal, a LMIC with low rates of mental health treatment seeking. Methods The study will take place in two municipalities in eastern Nepal, utilizing the Multiphase Optimization Strategy (MOST) with a 2 × 3 factorial randomized controlled trial design. Female Community Health Volunteers will be trained to identify individuals with depression using the Community Informant Detection Tool, a proven community-based strategy for proactive case detection, and subsequently implement the Gain Life intervention, which aims to promote help-seeking for depression care. The Gain Life intervention comprises four components: (i) information about depression, (ii) awareness of available services, (iii) stigma reduction by dispelling myths and facts about depression, and (iv) a life transformation story. The study will target the adult population, with eligibility criteria including being 18 years or older, residing in specific municipalities, meeting the CIDT threshold for depression, providing consent, and having proficiency in Nepali. The sample size will be 288, with the primary outcome being help-seeking behaviour. Discussion In this protocol paper, we outline how the MOST framework can optimize a community-based intervention aimed at improving help-seeking for depression care. The findings from this study will guide decisions on whether to proceed with a fully randomized controlled trial or conduct an additional optimization study to finalize the intervention components. Trial registration ClinicalTrials.gov NCT06574074. Registered on 27 August 2024.