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Despite progress in the development and evaluation of evidence-based primary mental health interventions in low-income and middle-income countries, implementation and scale-up efforts have had mixed results. Considerable gaps remain in the effective translation of research knowledge into routine health system practices, largely due to real-world contextual constraints on implementation and scale-up efforts. The Southern African Research Consortium for Mental Health Integration (S-MhINT) programme used implementation research to strengthen the implementation of an evidence-based integrated collaborative depression care model for primary healthcare (PHC) services in South Africa. To facilitate the scale-up of this model from a testing site to the whole province of KwaZulu-Natal, a capacity building programme was embedded within the Alliance for Health Policy and Systems Research (AHPSR) learning health systems (LHS) approach. The paper discusses efforts to scale up and embed case finding and referral elements of the S-MhINT package within routine PHC. Data from semistructured interviews, a focus group discussion, proceedings from participatory workshops and outputs from the application of continuous quality improvement (CQI) cycles were thematically analysed using the AHPSR LHS framework. Learning particularly occurred through information sharing at routine participatory workshops, which also offered mutual deliberation following periods of applying CQI tools to emergent problems. Individual-level, single-loop learning seemed to be particularly observable elements of the AHPSR LHS framework. Ultimately, our experience suggests that successful scale-up requires strong and sustained relationships between researchers, policy-makers and implementers, investments into learning platforms and organisational participation across all levels to ensure ownership and acceptance of learning processes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges., Methods: A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field., Results: In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs., Conclusions: These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multi-country initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention., Objective: This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa., Methods: Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team., Results: The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur., Conclusions: The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in low-to-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.

Background: Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness., Methods: A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline)., Results: From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support., Conclusions: These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.

Against the backdrop of mounting calls for the global scaling-up of mental health services - including quality care and prevention services - there is very little guidance internationally on strategies for scaling-up such services. Drawing on lessons from scale-up attempts in six low- and middle-income countries, and using exemplars from the front-lines in South Africa, we illustrate how health reforms towards people-centred chronic disease management provide enabling policy window opportunities for embedding mental health scale-up strategies into these reforms. Rather than going down the oft-trodden road of vertical funding for scale-up of mental health services, we suggest using the policy window that stresses global policy shifts towards strengthening of comprehensive integrated primary health care systems that are responsive to multimorbid chronic conditions. This is indeed a substantial opportunity to firmly locate mental health within these horizontal health systems strengthening funding agendas. Although this approach will promote systems more enabling of scaling-up of mental health services, implications for donor funders and researchers alike is the need for increased time commitments, resources and investment in local control.

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: It is widely recognised that mental health policies should be developed in consultation with those tasked with their implementation and the users affected by them. In the South African legislative context public participation in policymaking is assumed, with little guidance on how to conduct consultation processes, nor how to use consultation inputs in policy decisions., Methods: The South African Mental Health Policy Framework and Strategic Plan was adopted in 2013 after an extensive consultation process. Focussing on the 2012 provincial and national consultation summit, this case-study conducted key informant interviews and undertook documentary analysis to explore the process through which consultation inputs were-or were not-transferred to inform this policy. Between 2013 and 2016 seven interviews were conducted, and 11 documents (policy drafts and summit outputs) and transcripts of 23 audio-recorded sessions from the national summit were analysed., Results: Findings revealed that no substantive changes were made to the mental health policy following the consultation summits. There do not seem to have been systematic processes for facilitating and capturing knowledge inputs, or for transferring these inputs between provincial and national levels. There was also no further consultation regarding priorities identified for implementation prior to finalisation of the policy, with participants highlighting concerns about policy implementation at local levels as a result. This represents a lost opportunity for greater involvement of service users in policy development., Conclusions: Together with poor service-user representation, the format of the consultation process limited participant interaction and the possibility for engagement with, or uptake of, more experiential forms of knowledge. Several procedural elements were found to limit the elicitation and transference of consultation contributions for uptake into policy. Recommendations for future policy consultations include adapting the format of participatory processes to enable optimal use of participant knowledge, as well as greater service-user participation., Competing Interests: The authors have declared that no competing interests exist.

AimsSuicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC., Methods: Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder., Results: We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5-11.1% in community samples and 5.0-14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries., Conclusion: The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.

The Life Esidimeni tragedy in South Africa showed that, despite significant global gains in recognizing the salience of integrated public mental health care during the past decade, crucial gaps remain. State and non-state mental health service collaboration is a recognized strategy to increase access to care and optimal use of community resources, but little evidence exist about how it unfolds in low- to middle-income countries. South Africa's Mental Health Policy Framework and Strategic Plan 2013-20 (MHPF) underlines the importance of collaborative public mental health care, though it is unclear how and to what extent this happens. The aim of the study was to explore the extent and nature of state and non-state mental health service collaboration in the Mangaung Metropolitan District, Free State, South Africa. The research involved an equal status, sequential mixed methods design, comprised of social network analysis (SNA) and semi-structured interviews. SNA-structured interviews were conducted with collaborating state and non-state mental health service providers. Semi-structured interviews were conducted with collaborating partners and key stake holders. Descriptive network analyses of the SNA data were performed with Gephi, and thematic analysis of the semi-structured interview data were performed in NVivo. SNA results suggested a fragmented, hospital centric network, with low average density and clustering, and high authority and influence of a specialist psychiatric hospital. Several different types of collaborative interactions emerged, of which housing and treatment adherence a key point of collaboration. Proportional interactions between state and non-state services were low. Qualitative data expanded on these findings, highlighting the range of available mental health services, and pointed to power dynamics as an important consideration in the mental health service network. The fostering of a well-integrated system of care as proposed in the MHPF requires inter-institutional arrangements that include both clinical and social facets of care, and improvements in local governance.

Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using framework analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries., (© The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: UK Dementia Strategies prioritise fair access to mental and physical healthcare. We investigated whether there are inequalities by deprivation or gender in healthcare received by people with dementia, and compared healthcare received by people with and without dementia., Methods: we investigated primary care records of 68,061 community dwelling dementia patients and 259,337 people without dementia (2002-13). We tested hypotheses that people with dementia from more deprived areas, and who are women receive more psychotropic medication, fewer surgery consultations, are less likely to receive annual blood pressure, weight monitoring and an annual review, compared with those from less deprived areas and men., Results: only half of people with dementia received a documented annual review. Deprivation was not associated with healthcare received. Compared to men with dementia, women with dementia had lower rates of surgery consultations (adjusted incidence rate ratio (IRR) 0.90, 95% CI 0.90-0.91), of annual blood pressure monitoring (adjusted IRR 0.96, 95% CI 0.95-0.97) and of annual weight monitoring (adjusted IRR 0.91, 95% CI 0.90-0.93). Men with dementia were less likely to be taking psychotropic medication than women with dementia. People with dementia had fewer surgery consultations and were less likely to have their weight and blood pressure monitored at least annually, compared to the non-dementia group., Conclusions: people with dementia, in particular women, appear to receive less primary healthcare, but take more psychotropic medication that may negatively impact their physical health. Reducing these inequalities and improving access of people with dementia to preventative healthcare could improve the health of people with dementia., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Aims: In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia., Methods: The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework., Results: Three main themes were identified. (1) Focused on 'Restoring the person's life', including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting., Conclusions: Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.

High-quality information to measure the need for, and the uptake, cost, quality and impact of care is essential in the pursuit of scaling up mental health care in low- and middle-income countries (LMIC). The aim of this study was to identify indicators for the measurement of effective coverage of mental health treatment. We conducted a two-round Delphi study (n = 93 experts from primarily LMIC countries Ethiopia, India, Nepal, Nigeria, South Africa and Uganda), in order to generate and prioritize a set of indicators. First, 52 unique indicators were generated (based on a total of 876 responses from participants). Second, the selected indicators were then scored for significance, relevance and feasibility. Mean priority scores were calculated per indicator (score range, 1-5). All 52 indicators had a weighted mean score that ranged from 3.20 for the lowest ranked to 4.27 for the highest ranked. The 15 highest ranked indicators cover the different domains of measuring effective mental health treatment coverage. This set of indicators is highly stable between the different groups of experts, as well as between the different participating countries. This study provides data on how mental health service and financial coverage can be assessed in LMIC. This is an important element in the move to scale-up mental health care., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings., Aims: To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME)., Method: ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13-22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members., Results: One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts., Conclusions: ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation., (© The Royal College of Psychiatrists 2016.)

Background: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa., Methods/design: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17., Discussion: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa., Trial Registration: Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013.

Background: Maternal mental health care is a neglected area in low and middle income countries (LAMIC) such as South Africa, where maternal and child health care priorities are focused on reducing maternal and infant mortality and promoting infant physical health. In the context of a paucity of mental health specialists, the aim of this study was to understand the explanatory models of illness held by women with maternal depression with the view to informing the development of an appropriate counselling intervention using a task sharing approach., Methods: Twenty semi-structured qualitative interviews were conducted with mothers from a poor socio-economic area who were diagnosed with depression at the time of attending a primary health care facility. Follow-up interviews were conducted with 10 participants in their homes., Results: Dimensions of poverty, particularly food and financial insecurity and insecure accommodation; unwanted pregnancy; and interpersonal conflict, particularly partner rejection, infidelity and general lack of support were reported as the causes of depression. Exacerbating factors included negative thoughts and social isolation. Respondents embraced the notion of task sharing, indicating that counselling provided by general health care providers either individually or in groups could be helpful., Conclusion: Counselling interventions drawing on techniques from cognitive behavioural therapy and problem solving therapy within a task sharing approach are recommended to build self-efficacy to address their material conditions and relationship problems in poorly resourced primary health care facilities in South Africa.

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Nearly one in three South Africans will suffer from a mental disorder in his or her lifetime, a higher prevalence than many low- and middle-income countries. Understanding the economic costs and consequences of prevention and packages of care is essential, particularly as South Africa considers scaling-up mental health services and works towards universal health coverage. Economic evaluations can inform how priorities are set in system or spending changes., Objective: To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use (MNS) disorders and the cost-effectiveness of treatment interventions., Design: Narrative overview methodology., Results and Conclusions: Reviewed studies indicate that integrating mental health care into existing health systems may be the most effective and cost-efficient approach to increase access to mental health services in South Africa. Integration would also direct treatment, prevention, and screening to people with HIV and other chronic health conditions who are at high risk for mental disorders. We identify four major knowledge gaps: 1) accurate and thorough assessment of the health burdens of MNS disorders, 2) design and assessment of interventions that integrate mental health screening and treatment into existing health systems, 3) information on the use and costs of traditional medicines, and 4) cost-effectiveness evaluation of a range of specific interventions or packages of interventions that are tailored to the national context.

There is new policy commitment to mental health in South Africa, demonstrated in the national mental health summit of April 2012. This provides an opportunity to take stock of our mental health services. At primary care level key challenges include- training and supervision of staff in the detection and management of common mental disorders, and the development of community-based psychosocial rehabilitation programmes for people with severe mental illness (in collaboration with existing non-governmental organizations). At secondary level, resources need to be invested in 72-hour observation facilities at designated district and regional hospitals, in keeping with the Mental Health Care Act. At tertiary level, greater continuity of care with primary and secondary levels is required to prevent "revolving door" patterns of care. There are major challenges and also opportunities related to the high level of comorbidity between mental illness and a range of other public health priorities, notably HIV/AIDS, cardiovascular disease and diabetes. The agenda for mental health services research needs to shift to a focus on evaluating interventions. With current policy commitment, the time to act and invest in evidence-based mental health services is now.

Within the context of a large treatment gap for depression and a scarcity of specialist resources, there is a need for task shifting to scale up mental health services to address this gap in South Africa. This study assessed the feasibility of an adapted manualized version of grouped based Interpersonal Therapy (IPT) for use by supervised community health workers through a pilot study on 60 primary health care clinic users screened as having moderate to severe depression. Retention was good and participants in the group-based IPT intervention showed significant reduction in depressive symptoms on completion of the 12-week intervention as well as 24 weeks post baseline compared to the control group. Qualitative process evaluation suggests that improved social support, individual coping skills and improved personal agency assisted in the reduction of depressive symptoms.

BACKGROUND A recent situational analysis suggests that post-apartheid South Africa has made some gains with respect to the decentralization and integration of mental health into primary health care. However, service gaps within and between provinces remain, with rural areas particularly underserved. Aim This study aims to calculate and cost a hypothetical human resource mix required to populate a framework for district adult mental health services. This framework embraces the concept of task shifting, where dedicated low cost mental health workers at the community and clinic levels supplement integrated care. METHOD The expected number and cost of human resources was based on: (a) assumptions of service provision derived from existing services in a sub-district demonstration site and a literature review of evidence-based packages of care in low- and middle-income countries; and (b) assumptions of service needs derived from other studies. RESULTS For a nominal population of 100 000, minimal service coverage estimates of 50% for schizophrenia, bipolar affective disorder, major depressive disorder and 30% for post-traumatic stress disorder and maternal depression would require that the primary health care staffing package include one post for a mental health counsellor or equivalent and 7.2 community mental health worker posts. The cost of these personnel amounts to £28 457 per 100 000 population. This cost can be offset by a reduction in the number of other specialist and non-specialist health personnel required to close service gaps at primary care level. CONCLUSION The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries.

Objectives: To identify progress and challenges in mental healthcare in South Africa, as well as future mental health services research priorities., Method: A systematic review of mental health services research. Literature searches were conducted in Medline, PsychInfo and Sabinet databases from January 2000 to October 2010 using key phrases. Hand searches of key local journals were also conducted. Of 215 articles retrieved, 92 were included. Data were extracted onto a spreadsheet and analysed thematically., Results: While progress in epidemiological studies has been good, there is a paucity of intervention and economic evaluation studies. The majority of studies reviewed were on the status of mental healthcare services. They indicate some progress in decentralised care for severe mental disorders, but also insufficient resources to adequately support community-based services, resulting in the classic revolving-door phenomenon. Common mental disorders remain largely undetected and untreated in primary healthcare. Cross-cutting issues included the need for promoting culturally congruent services as well as mental health literacy to assist in improving help-seeking behaviour, stigma reduction, and reducing defaulting and human rights abuses., Conclusion: While there has been some progress in the decentralisation of mental health service provision, substantial gaps in service delivery remain. Intervention research is needed to provide evidence of the organisational and human resource mix requirements, as well as cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.

Purpose of Review: Against the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs., Recent Findings: Key strategies and actions are as follows: (i) the adoption of a decentralized stepped care approach embracing task shifting to nonspecialists for those disorders for which it has been shown to be effective; (ii) ensuring adequate numbers of mental health specialists to provide a supportive supervisory framework and referral pathways; (iii) ensuring adequate infrastructure to support decentralized care; (iv) promoting mental health literacy; (v) adoption of a social inclusion and developmental model of disability in caring for people with chronic mental illness; and (vi) embracing a multisectoral community collaborative approach., Summary: Optimizing mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions. Studies demonstrating the cost-effectiveness of integrated stepped packages of care embracing a task-shifting approach, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors, can assist this process. Specialist mental health training programmes in LMICs also need to be responsive to the changing demands on service providers, incorporating a public health approach and equipping specialists for diversification of their roles within the task shifting model.

Integrating mental health into primary health care is widely promoted for a host of reasons, chief among which is providing a more comprehensive health care service. However, only a few countries have adequate mental health resources to undertake the integration of mental health into primary health care in a uniform manner, with wide variations among countries. This paper examines the extent to which two low-income countries (Ghana and Uganda) and one middle-income country (South Africa) are managing the integration of mental health into primary health care using the recommendations of the WHO World Health Report, 2001. Primary and secondary data sources from a situational analysis of mental health services in the three countries were analysed. The findings indicate that significant challenges remain in integrating mental health care into primary health care. Poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons advanced. Aside from better human resource planning for mental health, integration may be advanced by the development of packages of care which adopt a task-shifting approach suited to a country's needs.

Intersectoral action is increasingly recognized as necessary to address the social determinants of mental health. This study aims to assess South Africa's progress in intersectoral collaboration for mental health, and provide recommendations for intersectoral collaboration, to generate lessons for other low- and middle-income countries. We conducted a survey of the existing mental health system in South Africa using the World Health Organization Assessment Instrument for Mental Health Systems. We also conducted 96 semi-structured interviews and 12 focus group discussions with a range of stakeholders at national, provincial and district level. Data were analysed thematically to understand the roles and responsibilities of different sectors in realizing the right to mental health. A range of key sectors were identified as having roles in mental health promotion, illness prevention and service delivery. In discussing South Africa's progress, respondents gave several suggestions about how to formulate an intersectoral response in this context, including increasing high level political commitment, and using leadership from the health sector. We outline roles and responsibilities for various sectors and lessons that can be learnt from this context. These include the importance of developing programmes alongside legislation, employing targeted awareness-raising to engage sectors, and developing a structured approach to intersectoral action.

The shift in emphasis to universal primary health care in post-apartheid South Africa has been accompanied by a process of decentralization of mental health services to district level, as set out in the new Mental Health Care Act, no. 17, of 2002 and the 1997 White Paper on the Transformation of the Health System. This study sought to assess progress in South Africa with respect to deinstitutionalization and the integration of mental health into primary health care, with a view to understanding the resource implications of these processes at district level. A situational analysis in one district site, typical of rural areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). The findings suggest that the decentralization process remains largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilized chronic conditions. We suggest that, in a similar vein to other low- to middle-income countries, deinstitutionalization and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.

The purpose of the research programme introduced in this article is to provide new knowledge regarding comprehensive multisectoral approaches to breaking the negative cycle of poverty and mental ill-health. The programme undertakes an analysis of existing mental health policies in four African countries (Ghana, South Africa, Uganda, Zambia), and will carry out and evaluate interventions to assist in the development and implementation of mental health policies in those countries, over a five-year period. The four countries in which the programme is being conducted represent a variety of scenarios in mental health policy development and implementation.

Care for common mental health problems in medium-resourced countries has been conceptualized by the World Health Organization as needing to be provided by primary health care personnel, in particular primary health care nurses. This study, which comprised a file audit of a psychological referral service at primary level in South Africa, suggests that in contexts where specialized psychological services are lacking, the demand for mental health services includes that of psychometric assessment services for mental retardation and/or scholastic problems. It is argued that in these contexts, third generation health systems reforms should be applied to the provision of care for more common mental health problems as well as mental retardation and/or scholastic problems in medium-resourced countries. This would require the insertion of a 'package' comprised of both psychological assessment and intervention services. It is suggested that in South Africa, such a 'package' could be provided by the new professional category of 'counsellor', which the Professional Board of Psychology of the South African Health Professions Council has recently accredited.

While the vision for restructuring health care in South Africa is based on a comprehensive primary health care system, care at the primary level remains largely biomedical in orientation. Given this, I argue that whilst adding mental health care to primary level care may increase accessibility of psychiatric care. it will not, however, provide for comprehensive integrated primary mental health care as planned. This would require a paradigm shift towards a comprehensive discourse of care which includes mental health care. While efforts towards reorienting health care personnel in South Africa towards the primary health care approach have been initiated, an examination of the primary health care system in one sub-district in South Africa, reveals that the delivery of biomedical care is sustained by a number of factors within the primary health care system as well as within the macro-context. A shift in the paradigm of care provided would therefore require the transformation of the system on many fronts. Of central importance would be the restructuring of the primary health care system to be supportive of emotional labour, health promotion, empowerment of service users and of care which takes the subjectivity of the illness experience for the patient into account.

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.

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Aims.: The aim of this study was to identify the risk correlates for coexisting common mental disorders (CMDs) in the chronic care population in South Africa, with the view to identifying particularly vulnerable patient populations. Methods.: The sample comprised 2549 chronic care patients enrolled in the baseline and endline rounds of a facility detection survey conducted by the Programme for Improving Mental Health Care in three large facilities in the Dr Kenneth Kaunda district in the North West province of South Africa. Participants were screened for depression using the Patient Health Questionnaire (PHQ9) and for alcohol misuse using the Alcohol Use Disorders Identification Test (AUDIT). Data were analysed according to the number of morbidities, disorder type (physical or mental) and demographic variables. Multimorbidity was defined as the presence of two or more disorders (physical and/or mental). Results.: Just over one-third of the sample reported two or more physical conditions. Women were more at risk of being depressed than were men, with men more at risk of alcohol misuse. Those who were employed were at lower risk of having coexisting CMDs, while being younger, HIV positive, and food deprived were all found to be associated with higher risk for having coexisting CMDs. Conclusion.: In the face of the large treatment gap for CMDs in South Africa, and the role that coexisting CMDs can play in exacerbating the burden of chronic physical diseases, mental health screening and treatment interventions should target HIV-positive, younger patients living in circumstances where there is household food insecurity. [ABSTRACT FROM AUTHOR]