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Background Low- and middle-income countries (LMICs) allocate a disproportionately small fraction of their healthcare budgets to mental health, leading to a treatment gap exceeding 75%. To address this disparity, the World Health Organization (WHO) introduced the Mental Health Gap Action Programme (mhGAP), aiming to integrate mental healthcare into primary and community care settings. Central to this initiative is task-sharing: empowering non-specialist healthcare providers to detect and treat mental disorders. Adaptation and modification of mhGAP to the national and local contexts is an integral aspect of the guidelines. Methods This systematic review of reviews employs the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to document and characterize modifications to mhGAP implementation in LMICs. The databases searched included Embase, PubMed, PsycINFO, CINAHL, Google Scholar, Cochrane, and Web of Science. Reviews selected in stage 1 were used to find empirical studies from which relevant data was extracted. Results Narrative synthesis suggests that modifications primarily focus on content, delivery, and training methods, with limited attention to scaling up. Modifications adopt top down, yet consultative and participatory approaches. There is a notable lack of reporting on challenges, processes, and outcomes. Recommendations have been made to expand FRAME, namely, sources of knowledge, financial and temporal resources employed during the process of modification. Conclusion Modifications are essential for adapting interventions to diverse settings, yet they are often researcher-led with limited stakeholder involvement. Better documentation—particularly on challenges and outcomes—is needed. Strengthening frameworks like FRAME can improve reporting, optimize resources, and enhance implementation and scale-up in similar contexts.

Background Non-specialists’ involvement in mental health care is encouraged in the field of global mental health to address the treatment gap caused by mental illness, especially in low- and middle-income countries. While primary care physicians (PCPs) are involved in mental health care in Tunisia, a lower-middle-income country in North Africa, it is unclear to what extent they are prepared and willing to address mental health problems, substance use disorders, and suicide/self-harm. In this context, we aim (1) to report on mental health knowledge, attitudes, and self-efficacy among a sample of PCPs working in the Greater Tunis area, prior to the implementation of a mental health training program developed by the World Health Organization ; and (2) to identify what characteristics are associated with these competencies. Methods In total, 112 PCPs completed questionnaires related to their socio-demographic and practice characteristics, as well as their mental health knowledge, attitudes, and self-efficacy. Descriptive analyses and regression models were performed. Findings PCPs had more knowledge about depression, symptoms related to psychosis, and best practices after a suicide attempt; had favourable attitudes about distinctions between physical and mental health, learning about mental health, and the acceptance of colleagues with mental health issues; and believed most in their capabilities related to depression and anxiety. However, most PCPs had less knowledge about substance use disorders and myths about suicide attempts; had unfavorable attitudes about the dangerousness of people with mental health problems, personal disclosure of mental illness, non-specialists’ role in assessing mental health problems, and personal recovery; and believed the least in their capabilities related to substance use disorders, suicide/self-harm, and psychosis. Participation in previous mental health training, weekly hours (and weekly hours dedicated to mental health), weekly provision of psychoeducation, and certain work locations were associated with better mental health competencies, whereas mental health knowledge was negatively associated with weekly referrals to specialized services. Conclusions Findings suggest that PCPs in our sample engage in mental health care, but with some gaps in competencies. Mental health training and increased interactions/involvement with people consulting for mental health issues may help further develop non-specialists’ mental health competencies, and integrate mental health into primary care settings.

Background Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists’ mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper’s objective is to fill that lack. Methods We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis. Results Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP- based training’s expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions. Conclusions Findings highlight the complexity of implementing a mhGAP -based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP- based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.

Background Social anxiety disorder (SAD) is one of the most prevalent anxiety disorders in Canada. Viable therapy options for the treatment of SAD include CBT being delivered virtually. In Australia, an innovative internet-delivered cognitive-behavioral therapy (iCBT) program for social anxiety has been developed, implemented, and demonstrated as effective. To make available high-quality and real-time evidence in response to the crucial need to access psychological services to meet population mental health needs, we propose to conduct a Canadian adaptation of the iCBT Shyness Program and to examine the program’s effectiveness, and implementation in two Canadian provinces (Quebec and Ontario). Methods The overall study design is a hybrid effectiveness-implementation study of a quasi-experimental parallel group trial. Prior to implementing the iCBT Shyness Program, it will undergo an initial adaptation to the Canadian context and focus groups will be conducted with key actor groups to discuss the adaptations to the graphics, narration of the lessons, and this to better reflect varying socio-cultural context among Canadian French- and English-speaking populations. We will evaluate the effectiveness of the program in three parallel pathways reflecting real-world pathways: (1) self-refer to the intervention; (2) recommended by a health professional without guidance; and (3) recommended by a health professional, with low-intensity guidance. Data collection will be carried out at baseline, at the beginning of each lesson, 12-week and 6-month follow-up. Outcomes measured will include anxiety and depressive symptoms, psychological distress, disability, as well as health service utilization and satisfaction. Semi-structured interviews will then be conducted with study participants and health care providers to explore facilitating factors and barriers to the implementation of the iCBT adapted program. Discussion This study will provide evidence on the effectiveness, barriers and facilitating factors to implementing a low-intensity iCBT in the Canadian context for SAD, which will bridge an important care gap for undeserved populations in Canada with SAD. Findings will inform the eventual scaling up of the program in community-based primary care across Canada. This would improve equity of the health care system by helping a large number of Canadians to timely access to mental health services. Trial registration clinicaltrials.gov NCT06403995. Prospectively registered on 05/03/2024.

Objectives Using Andersen’s model of health care seeking behavior, we examined the predisposing, enabling, and need factors associated with mental health service use (MHSU) during the first wave of the COVID-19 pandemic across Canada. Methods The sample included n = 45,542 participants in the 5 established regional cohorts of the Canadian Partnership for Tomorrow’s Health (CanPath) and who responded to the CanPath COVID-19 health survey (May-December 2020), with complete data on MHSU. Multivariable logistic regression analyses were carried out to study MHSU as a function of predisposing, enabling, and need factors. Analyses were stratified by regional cohort. Results Among the need factors, individuals reporting moderate/severe symptoms of depression and anxiety and poorer self-rated mental health were more likely to report MHSU. Among the enabling factors, receipt of informational/financial/practical support was associated with increased MHSU. While income was not consistently associated with MHSU, reported decrease in income was marginally associated with reduced MHSU. Among the predisposing factors, identifying as female or other gender minority was associated with increased MHSU, as was the presence of past-year cannabis use. In contrast, older age and alcohol consumption were associated with reduced MHSU. Conclusion Need factors were consistently associated with MHSU. Although income inequities in MHSU were not observed, changes such as reduced income during the pandemic may lead to barriers in accessing mental health services. Future research should focus on better identifying contextual enabling factors and policies that overcome financial barriers to MHSU.

Background In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services ( Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care ( Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models’ similarities and differences. Methods We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators ( n  = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS’s components included in the initially designed program, Mitchell and Lewis (2003)’s logic model framework, and Chaudoir and colleagues (2013)’s framework on contextual factors’ influence on an innovation’s implementation. Results Findings show the APSS-CRDS program’s regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists’ availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors’ influence, like ministerial and medical associations’ involvement, collaborations, the context’s implementation readiness, physician practice characteristics, and the program’s adaptability. Interpretation Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

QuestionThere is a large worldwide gap between the service need and provision for mental, neurological and substance use disorders. WHO’s Mental Health Gap Action Programme (mhGAP) intervention guide (IG), provides evidence-based guidance and tools for assessment and integrated management of priority disorders. Our 2017 systematic review identified 33 peer-reviewed studies describing mhGAP-IG implementation in low-income and middle-income countries.Study selection and analysisWe searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, 3ie, Google Scholar and citations of our review, on 24 November 2020. We sought evidence, experience and evaluations of the mhGAP-IG, app or mhGAP Humanitarian IG, from any country, in any language. We extracted data from included papers, but heterogeneity prevented meta-analysis.FindingsOf 2621 results, 162 new papers reported applications of the mhGAP-IG. They described mhGAP training courses (59 references), clinical applications (n=49), research uses (n=27), contextual adaptations (n=13), economic studies (n=7) and other educational applications (n=7). Most were conducted in the African region (40%) and South-East Asia (25%). Studies demonstrated improved knowledge, attitudes and confidence post-training and improved symptoms and engagement with care, post-implementation. Research studies compared mhGAP-IG-enhanced usual care with task-shared psychological interventions and adaptation studies optimised mhGAP-IG implementation for different contexts. Economic studies calculated human resource requirements of scaling up mhGAP-IG implementation and other educational studies explored its potential for repurposing.ConclusionsThe diverse, expanding global mhGAP-IG literature demonstrates substantial impact on training, patient care, research and practice. Priorities for future research should be less-studied regions, severe mental illness and contextual adaptation of brief psychological interventions.

The EMR has developed a regional framework that identifies feasible and cost-effective solutions to better mental health care, including the further integration of mental health into primary care settings (4) through, for example, the involvement of primary care physicians (PCPs) in mental health care (5). The training has been used in the Region to enhance the mental health capacity of for example physicians, social workers, nurses, community health workers, family volunteers, psychosocial staff of humanitarian agencies, and pregnant women (13-20). [...]Tunisian experts are elaborating a national strategy for the early detection of autism spectrum disorders by PCPs. [...]the accompanying training material for the mhGAP module on conditions specifically related to stress (23) was not available in the working languages of Tunisia during the first mhGAP-based implementation (21).

Training based on the Mental Health Gap Action Programme (mhGAP) is being increasingly adopted by countries to enhance non-specialists' mental health capacities. However, the influence of these enhanced capacities on referral rates to specialised mental health services remains unknown. We rely on findings from a longitudinal pilot trial to assess the influence of mental health knowledge, attitudes and self-efficacy on self-reported referrals from primary to specialised mental health services before, immediately after and 18 months after primary care physicians (PCPs) participated in an mhGAP-based training in the Greater Tunis area of Tunisia. Participants included PCPs who completed questionnaires before (n = 112), immediately after (n = 88) and 18 months after (n = 59) training. Multivariable analyses with linear mixed models accounting for the correlation among participants were performed with the SAS version 9.4 PROC MIXED procedure. The significance level was α < 0.05. Data show a significant interaction between time and mental health attitudes on referrals to specialised mental health services per week. Higher scores on the attitude scale were associated with more referrals to specialised services before and 18 months after training, compared with immediately after training. Findings indicate that, in parallel to mental health training, considering structural/organisational supports to bring about a sustainable change in the influence of PCPs' mental health attitudes on referrals is important. Our results will inform the scale-up of an initiative to further integrate mental health into primary care settings across Tunisia, and potentially other countries with similar profiles interested in further developing task-sharing initiatives.

The World Health Organization (WHO)'s Mental Health Gap Action Programme (mhGAP)-Intervention Guide (IG) aims to integrate mental health into primary care/community-based settings by equipping non-specialists with tools, training, and support to deliver evidence-based interventions. With the growing popularity of the mhGAP-IG, a systematic review was conducted by Keynejad and colleagues (2018) to identify articles reporting on evidence generated from the implementation and evaluation of the mhGAP-IG in low- and middle-income countries (LMICs). Their review identified peer-reviewed articles and one thesis. In this current review, we report on the implementation and use of mhGAP-IG documented in the grey literature, an important and accessible channel to share information for LMICs. We searched grey literature databases for documents that reported on the implementation and/or use of the mhGAP-IG or its training modules: ProQuest Dissertations & Theses Global, the Mental Health Innovation Network (MHIN) database, the WHO website, the mhGAP Newsletter, and the first 10 pages of Google search results. Authors developed and adapted search strategies according to database characteristics. Database searches were completed by November 12, 2019. One hundred and fifty-one (n = 151) documents were included in our review. We report on where the mhGAP-IG has been implemented and/or used worldwide. Many types of personnel were trained in the mhGAP-IG and/or used it in clinical practice. Contextual barriers and facilitators may influence the implementation and/or use of the mhGAP-IG, and we organized these according to structural, organizational, provider, patient, and innovation characteristics. Some information on evaluating the mhGAP-IG was documented in the grey literature. Outcomes included: feasibility of implementing and/or using the mhGAP-IG, its coverage, its impact on the capacities of personnel, patient outcomes, and policies, as well as program costs. This review of the grey literature provides rich experiential knowledge that can complement information documented in the peer-reviewed literature. It is important for researchers conducting reviews on global health/global mental health topics to consider incorporating grey literature search strategies in their reviews. This may not only help to acknowledge the research/dissemination realities of many LMICs, but also to generate findings that reinforce and/or expand those documented in peer-reviewed articles.