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Background: There is an absence of mental health services within general hospitals in Gaza. As part of the Ministry of Health plan to develop mental health liaison services, a cross-sectional survey of the prevalence of and risk factors for psychological distress in attendees at two general hospitals was undertaken to estimate and highlight the need for establishing such services., Methods: 20 volunteers aged 24-30 years with a degree in psychological or social science from a university accredited by the Palestinian Ministry of Education and Higher Education, and with experience in field data collection for studies in mental health, were selected and trained in the use of the Arabic version of the 12-item General Health Questionnaire (GHQ-12), an internationally and well validated tool for measuring psychological distress in adults. The volunteers were supervised as they screened adult attendees at emergency rooms, inpatient wards and outpatient departments, and women attending the maternity units at two of the largest general hospitals in Gaza (Nasser and Indonesian) over seven consecutive days (March 18-23, 2018). Attendees at emergency and outpatient departments were included if they were on repeat visits with medically unexplained somatic complaints, if they attended with complaints resulting from any kind of social problem, physical or sexual violence, or had a history of any kind of chronic disease. All patients from the internal medicine and inpatient departments were included. The data from the questionnaires were collated and analysed with descriptive and inferential statistics., Findings: 1789 attendees (791 men and 998 women) were screened using the GHQ-12. Of these attendees, 23·8% (426 of 1789) had a GHQ-12 score of 6 or 7, indicating the presence of significant psychological distress with a high possibility of caseness (ie, meeting the diagnostic threshold for clinical depression). 36·2% (648 of 1789) scored 8 or above, indicating the presence of moderate to severe depression or anxiety disorders that require immediate clinical intervention. For all of the hospital departments surveyed, individuals with scores of 6 or greater made up a large proportion of the attendees (385 of 660 [58·3%] in emergency rooms, 197 of 306 [64·4%] in inpatient wards, 430 of 711 [60·5%] in outpatient departments, and 62 of 112 [55·4%] in maternity units), in both hospitals. In addition, a set of risk factors were found to be significantly associated with GHQ-12 scores of 6 or greater. These were being a woman (p=0·020), living in villages adjoining the most conflict prone areas (p<0·0001), no or low formal education (p<0·0001), being divorced (p<0·001) or widowed (p<0·0001), being unemployed (p<0·0001), and low family income (monthly income of <1000 ILS; p<0·0001). On further stepwise regression analysis, unemployment and low family income were found to be the most important risk factors associated with GHQ-12 scores of 6 or greater., Interpretation: In general hospital attendees there was a very high rate of significant psychological distress. Given the absence of mental health services within general hospitals in Gaza, the findings indicate an urgent need to make mental health interventions routinely available through general hospital liaison units in Gaza. The risk factors that were identified indicate that psychosocial interventions and access to developmental support are key components of such clinical services, and will be required to reduce the very large, and mostly unmet, population burden of mental health problems in Gaza., Funding: WHO, occupied Palestinian territory, as part of the EU project "Building Palestinian resilience: improving psychosocial and mental health responses in emergency"., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middle-income countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care., Methods: We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16-60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013., Findings: 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference -3.75, 95% CI -7.92 to 0.42; p=0.08; IDEAS -0.95, -1.68 to -0.23; p=0.01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0.89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (-9.29, -15.41 to -3.17; p=0.003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease., Interpretation: The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas., Funding: Wellcome Trust., (Copyright © 2014 Chatterjee et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd. All rights reserved.)

Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders., Methods: In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407., Findings: 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide., Interpretation: A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities., Funding: The Wellcome Trust., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.