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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 Grounded in the Integrated Promoting Action on Research Implementation in Health Services framework (i-PARIHS) and the Replicating Effective Programs framework (REP), the goal is to determine if the use of theory, data and end-user perspectives to guide an adaptation of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TSC) yields better outcomes and improves the “fit” of TSC to community mental health centers (CMHCs), relative to the standard version. Methods Ten counties in California were cluster-randomized by county to Adapted or Standard TSC. Within each county, adults who exhibited sleep and circadian dysfunction and serious mental illness (SMI) were randomized to immediate TSC or Usual Care followed by Delayed Treatment with TSC (UC-DT). Facilitation was the implementation strategy. The participants were 93 CMHC providers who delivered TSC (Standard = 30; Adapted = 63) and 396 CMHC patients (Standard = 74; Adapted = 124; UC-DT = 198). Patient assessments were completed at pre-treatment, post-treatment, and six months after treatment (6FU). Provider assessments were completed at post-training, mid-treatment, and post-treatment. Results TSC (combining Adapted and Standard), relative to UC-DT before delayed treatment with TSC, was associated with improvement from pre- to post-treatment in sleep disturbance ( b  = -10.91, p  < 0.001, d  = -1.52), sleep-related impairment ( b  = -9.52, p  < 0.001, d  = -1.06), sleep health composite ( b  = 1.63, p  < 0.001, d  = 0.95), psychiatric symptoms ( b  = -6.72, p  < 0.001, d  = -0.52), and overall functional impairment ( b  = -5.12, p  < 0.001, d  = -0.71). TSC’s benefits for functional impairment and psychiatric symptoms were mediated by improvements in sleep and circadian problems. Adapted versus Standard TSC did not differ on provider ratings of fit and better fit did not mediate the relation between TSC condition and patient outcome. Conclusions TSC can be delivered by CMHC providers. Adapted and Standard TSC both fit the CMHC context. These findings are interpreted through the lens of the four core constructs of the i-PARIHS framework. Trial registration Clinicaltrials.gov identifier: NCT04154631. Registered on November 6, 2019. https://clinicaltrials.gov/ct2/show/NCT04154631

Background There is a shortage of trained mental health workers in spite of the significant contribution of psychiatric disorders to the global disease burden. Task shifting, through the delegation of health care tasks to less specialised health workers such as community health workers (CHWs), is a promising approach to address the human resource shortage. CHWs in the Western Cape province of South Africa provide comprehensive chronic support which includes that for mental illness, but have thus far not received standardized mental health training. It is unknown whether a structured mental health training programme would be acceptable and feasible, and result improved knowledge, confidence and attitudes amongst CHWs. Methods We developed and piloted a mental health training programme for CHWs, in line with the UNESCO guidelines; the WHO Mental Health Gap Action Programme and the South African National framework for CHW training. In our quasi-experimental (before-after) cohort intervention study we measured outcomes at the start and end of training included: 1) Mental health knowledge, measured through the use of case vignettes and the Mental Health Knowledge Schedule; 2) confidence, measured with the Mental Health Nurse Clinical Confidence Scale; and 3) attitudes, measured with the Community Attitudes towards the Mentally Ill Scale. Knowledge measures were repeated 3 months later. Acceptability data were obtained from daily evaluation questionnaires and a training evaluation questionnaire, while feasibility was measured by participant attendance at training sessions. Results Fifty-eight CHWs received the training, with most ( n  = 56, 97.0%) attending at least 7 of the 8 sessions. Most participants ( n  = 29, 63.04%) demonstrated significant improvement in knowledge, which was sustained at 3-months. There was significant improvement in confidence, along with changes in attitude, indicating improved benevolence, reduced social restrictiveness, and increased tolerance to rehabilitation of the mentally ill in the community but there was no change in authoritarian attitudes. The training was acceptable and feasible. Conclusions Mental health training was successful in improving knowledge, confidence and attitudes amongst trained CHWs. The training was acceptable and feasible. Further controlled studies are required to evaluate the impact of such training on patient health outcomes. Trial registration PACTR PACTR201610001834198 , Registered 26 October 2016.

Background Untreated mental illness poses a significant threat to achieving global mental health targets. The increasing incidence of common mental disorders in India exacerbates the treatment gap. Structural fragmentation prevents effective screening and treatment, despite several policies and programs. The study presents a culturally tailored mental health campaign developed within a service design paradigm for mental health screening. Methods The campaign had three phases: formation of a multidisciplinary service design team, modelling of an intervention, and implementing activities across three levels- macro, meso, and micro- to be implemented by educated youth, utilizing task-sharing strategies. Additionally, the study tested the feasibility of a mental health screening using student volunteers through a cross-sectional door-knock survey that assessed the prevalence of depression, alcohol consumption, and drug abuse among 2,263 community residents from randomly selected geographical locations in Kerala, India. Standardized scales were used to measure the variables. Results The youth-led community screening is promising, as the detected incidence rate was comparable to that of screening performed by experts. Participants ( n  = 2263) from the cross-sectional survey comprised 52% males and 48% females. The study revealed the prevalence rates of moderate and above depression (9.1%), harmful alcohol use, including alcohol use disorder (6.2%), and drug abuse (8.9%). Lower economic attainment was a vulnerability for mental disorders in both genders, with females demonstrating a higher incidence of depression and males with higher alcohol and drug abuse. Compared to males from Above Poverty Line (APL) households, females from Below Poverty Line (BPL) households had an 80% higher likelihood of depression. Conclusion The service design team, representing a microcosm of the population, developed culturally appropriate mental health campaigns. The act-reflect-act framework within the Service Design Model integrated need-based services to bring together multiple healthcare stakeholders and ecosystem tiers, facilitated by public private partnership (PPP) to improve coverage and address barriers to accessing public mental health services. The stability of the referral model was ensured through long term initiatives, including establishment of mental health clinics and senior daycare centres.

Background Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States. Methods Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014–2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state. Results From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (− 0.52, 95% CI − 1.08 to 0.03; p  = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths. Conclusions State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary-care settings in Goa, India. Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy and/or antidepressants by lay health workers. Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months. Complete data, from all three follow-ups, were collected from 1243 (75.4%) and 938 (81.7%) of the subjects enrolled in the study facilities from the public and private sectors, respectively. Within the public facilities, subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm. Time costs were also significantly lower in the intervention arm than in the control arm, whereas health system costs in the two arms were similar. Within the private facilities, however, the effectiveness and costs recorded in the two arms were similar. Within public primary-care facilities in Goa, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving.

Counselling Ideologies draws our attention to the dilemmas inherent within the therapeutic ideologies commonly subscribed to by psychotherapists and counsellors working with those who challenge heteronormative models and approaches. Identifying the modernist, heteronormative understandings of the world implicit in the more popular models, this book employs queer theory to challenge these ideologies, drawing on disciplines both within and outside of counselling and psychology, as well as sociology, cultural studies and various ethnographic accounts. It highlights the dilemmas faced by those who may wish to practise as 'queer therapists', addressing not only therapeutic dilemmas, but also issues such as: identity, race, coming-out experiences, 'internalised homophobia', 'empathy', 'ethical issues', bisexuality and pathologisation. Comprising contributions from both academic experts and practitioners from the UK, USA and Australia, this book represents a new approach to counselling and psychotherapy that will appeal not only to sociologists and those working in the field of mental health, but also to scholars of race and ethnicity, gender, queer studies and queer theory.