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ObjectivesTuberculosis (TB) and mental illnesses are highly prevalent globally and often coexist. While poor mental health is known to modulate immune function, whether mental disorders play a causal role in TB incidence is unknown. This systematic review examines the association between mental health and TB disease risk to inform clinical and public health measures.DesignSystematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Search strategy and selection criteriaMEDLINE, PsycINFO and PsycEXTRA databases were searched alongside reference list and citation searching. Inclusion criteria were original research studies published 1 January 1970–11 May 2020 reporting data on the association between mental health and TB risk.Data extraction, appraisal and synthesisData were extracted on study design and setting, sample characteristics, measurement of mental illness and TB, and outcomes including effect size or prevalence. Studies were critically appraised using Critical Appraisal Skills Programme (CASP) and Appraisal Tool for Cross-Sectional Studies (AXIS) checklists.Results1546 records published over 50 years were screened, resulting in 10 studies included reporting data from 607 184 individuals. Studies span across Asia, South America and Africa, and include mood and psychotic disorders. There is robust evidence from cohort studies in Asia demonstrating that depression and schizophrenia can increase risk of active TB, with effect estimates ranging from HR=1.15 (95% CI 1.03 to 1.28) to 2.63 (95% CI 1.74 to 3.96) for depression and HR=1.52 (95% CI 1.29 to 1.79) to RR=3.04 for schizophrenia. These data align with evidence from cross-sectional studies, for example, a large survey across low-income and middle-income countries (n=242 952) reports OR=3.68 (95% CI 3.01 to 4.50) for a depressive episode in those with TB symptoms versus those without.ConclusionsIndividuals with mental illnesses including depression and schizophrenia experience increased TB incidence and represent a high-risk population to target for screening and treatment. Integrated care for mental health and TB is needed, and interventions tackling mental illnesses and underlying drivers may help reduce TB incidence globally.PROSPERO registration numberCRD42019158071.

Structural barriers perpetuate mental-health disparities for minoritized U.S. populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental-health-care access and relevance. Mutual capacity-building partnerships between low- and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and share GMH strategies through a case series of said partnerships between Kenya and North Carolina, South Africa and Maryland, and Mozambique and New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included qualitative formative work and partnership building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science—and facilitating learning across settings—can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Objective: To estimate the prevalence of major depressive episode (MDE) in patients with presumptive pulmonary tuberculosis (pre-PTB, defined by cough lasting ≥ 3 weeks) and compare it between patients with pulmonary tuberculosis (PTB) and without PTB. Methods: Patients with pre-PTB (n=260) were screened for depression using the Patient Health Questionnaire (PHQ-9). Those individuals with scores ≥ 10 were subsequently assessed with the depression module of the Mini International Neuropsychiatric Interview (MINI-Plus) to confirm diagnosis. Associations of categorical variables with PTB and MDE were calculated using the chi-square test and OR. Results: PTB was confirmed in 98 patients (37.7%). A high proportion of both groups (active PTB and no PTB) screened positive for depression (60.2 vs. 62.1%, respectively). Among 159 patients who screened positive for depression, a subset of 97 (61.0%) were further evaluated with the MINI-Plus; current MDE was confirmed in 54.6% (53/97). On univariate and multivariate analysis, female sex was the only factor associated with the diagnosis of current MDE (p = 0.04). Conclusion: The prevalence of MDE was high among individuals with prolonged respiratory symptoms, independent of PTB diagnosis. This is consistent with other studies of depression in primary care in Brazil.

Introduction Unhealthy alcohol use (UAU) is a major public health challenge, particularly in low- and middle-income countries. Mozambique is the fourth poorest country in the world where half of the population lives below the poverty line. UAU is frequent among drinkers in Mozambique; however, resources and infrastructure to treat UAU are very limited. This paper examines how task-shifting and a provider-facing mobile health application are being used to improve access to care. In this paper, the feasibility, acceptability and appropriateness of a provider-facing mobile health application being used under a task-shifting model to identify UAU and provide a four-session brief motivational interviewing intervention are described. Method The study used a sequential exploratory mixed-methods design with a QUAL → quan structure. First, 15 psychiatric technicians and primary care providers in Mozambique's Nampula Province participated in semi-structured interviews. These interviews were recorded and transcribed. Then, 45 providers completed a 12-item quantitative survey on tablets. Quantitative analysis used descriptive statistic calculation and qualitative analysis used thematic analysis. Results Nonspecialized providers found the mobile health app to be acceptable, appropriate, and feasible when delivering a 4-session brief motivational intervention under a task-shifting model. Central benefits of the technology were enhanced standardization and efficiency of sessions as well as feelings of legitimacy when interacting with patients. Main concerns were feasibility of implementing the intervention due to time constraints of workload and internet connectivity issues. Conclusions Provider-facing technology shows promise in supporting task-shifting models that can expand alcohol intervention services and increase access to care in low- and middle-income countries. Providers without specialized training in behavioral health interventions can provide critical services to patients with UAU and provider-facing mobile health applications may help bring such models to scale.

Introduction When tuberculosis (TB) and depression co-occur, there is greater risk for comorbidities, disability, suffering, and health-related costs. Depression is also associated with poor treatment adherence in patients with TB. The major aim of this study was to assess the symptoms of depression and associated factors among TB patients currently receiving directly observed treatment short-course (DOTS) treatment. Methods A cross-sectional study was conducted among TB patients currently undergoing treatment in 27 DOTS centers in three districts of Kathmandu Valley. The study included 250 TB patients within 2 months of treatment initiation, aged 18 years and above. The previously validated Nepali Patient Health Questionnaire (PHQ-9) was used to screen for depression and semi-structured interviews were conducted to collect socio-demographic information and other factors related to TB and/or depression. Data analysis was conducted using IBM SPSS Statistics version 20. Results The study found the mean PHQ Score to be 2.84 (s.d. 4.92, range 0–25). Among the respondents, 10% (n = 25) had PHQ-9 scores ⩾10, suggestive of probable depression. Multivariate linear regression indicated that depressive symptoms were significantly associated with being separated/widowed/divorced (p = 0.000) and having lower education (0.003). In addition, smoking (p = 0.02), alcohol use (p = 0.001), and experience of side effects from TB medications (p = 0.001) were risk factors for higher PHQ-9 scores. Conclusions Our findings suggest that patients on TB treatment have higher risk of depression and efforts should be made by the National Tuberculosis Program to address this issue.

Background The South African National Mental Health Policy Framework and Strategic Plan 2013–2020 was adopted to address the country’s substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa. Methods Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services. Results A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population. Conclusions Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.

Background: In sub-Saharan Africa, mental and substance-related disorders account for 19% of all years lived with disability, yet the intersection between poverty and mental distress is poorly understood since most psychiatric research is conducted in high-income countries. Aims: To examine the prevalence of and associations between food insecurity, mental distress and suicidal ideation in three rural village clusters in sub-Saharan Africa. Method: Cross-sectional multivariate analysis of sociodemographic variables associated with mental distress and suicidal ideation in three countries. The sample included 1,142 individuals from three rural village clusters in Nigeria ( n = 380), Uganda ( n = 380) and Ghana ( n = 382). Food insecurity was measured based on the number of months in the previous year that the respondent’s family reported being ‘unable to eat two square meals per day’. Mental distress was assessed using the Kessler non-specific psychological distress scale (K6) and suicidal ideation was measured using an item from PRIME-MD. Other sociodemographic variables included gender, age, literacy and occupation. Results: The prevalence of individuals with moderate or severe mental distress in Nigeria, Uganda and Ghana were higher than previously reported in the literature: 35.5%, 30.8% and 30.4%, respectively, and suicidal ideation rates were 29.7%, 21.3% and 10.9%. No differences were observed in mental distress between men and women in any of the sites. Being a farmer (vs student or other) was protective for mental distress in two sites (Uganda and Ghana) but no other social indicators, such as age, gender, literacy and food insecurity, were significantly associated with mental distress. Risk for suicidal ideation differed across sites: it was associated with food insecurity in Nigeria, female gender in Uganda, and older age in Uganda. Conclusions: Mental distress and suicidal ideation were highly prevalent in three settings of extreme poverty across all groups, in ways that were not always consistent with the global literature. These findings suggest that more research is needed in to better understand the social etiology of mental distress in sub-Saharan Africa.

Objective: This opinion piece encourages mental health researchers and clinicians to engage with mental health issues among tuberculosis patients in the Asia-Pacific region in a culturally appropriate and ethical manner. The diversity of cultural contexts and the high burden of tuberculosis throughout the Asia-Pacific presents significant challenges. Research into tuberculosis and mental illness in this region is an opportunity to develop more nuanced models of mental illness and treatment, while simultaneously contributing meaningfully to regional tuberculosis care and prevention. Conclusions: We overview key issues in tuberculosis and mental illness co-morbidity, highlight ethical concerns and advocate for a regional approach to tuberculosis and mental health that is consistent with the transnational challenges presented by this airborne infectious disease. Integrating tuberculosis and mental health services will go a long way to addressing the needs of vulnerable populations and stopping the transmission of one of the world’s biggest infectious killers.

Tuberculosis (TB) and depression act synergistically via social, behavioral, and biological mechanisms to magnify the burden of disease. Clinical depression is a common, under-recognized, yet treatable condition that, if comorbid with TB, is associated with increased morbidity, mortality, community TB transmission, and drug resistance. Depression may increase risk of TB reactivation, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment because of poverty, undernutrition, immunosuppression, and/or negative coping behaviors, including substance abuse. Tuberculous infection and/or disease reactivation may precipitate depression as a result of the inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Clinical depression may also be triggered by TB-related stigma, exacerbating other underlying social vulnerabilities, and/or may be attributed to the side effects of anti-tuberculosis treatment. Depression may negatively impact health behaviors such as diet, health care seeking, medication adherence, and/or treatment completion, posing a significant challenge for global TB elimination. As several of the core symptoms of TB and depression overlap, depression often goes unrecognized in individuals with active TB, or is dismissed as a normative reaction to situational stress. We used evidence to reframe TB and depression comorbidity as the 'TB-depression syndemic', and identified critical research gaps to further elucidate the underlying mechanisms. The World Health Organization's Global End TB Strategy calls for integrated patient-centered care and prevention linked to social protection and innovative research. It will require multidisciplinary approaches that consider conditions such as TB and depression together, rather than as separate problems and diseases, to end the global TB epidemic.

In 2007, Nigeria made history by launching the Conditional Grants Scheme CGS, one of the world's largest poverty elimination campaigns aimed at achieving the Millennium Development Goals MDGs by 2015. As part of CGS, the Office of the Senior Special Assistant to the President of Nigeria on the MDGs OSSAP-MDGs collaborated with The Earth Institute, Columbia University to develop the Nigeria MDG Information System NMIS, a web-based platform designed to support data-driven decision-making, local-level planning, and budgeting by Local Government Areas. This paper discusses the evolution of NMIS as a data repository and describes its uses. NMIS maps and visually displays school-related data that can be used for education planning. NMIS illustrates the integration of educational and technological innovations and demonstrates ways in which challenges related to Education Management Information Systems can be overcome. NMIS could serve as a good example for other developing countries that seek to create large databases for public planning. This paper shares lessons learned in terms of the content, design, and potential uses of such information systems for local-level education planning. This paper concludes by highlighting that a data system alone is not sufficient to ensure effective analysis and use of data and multiple rounds of end-user training and case studies must accompany the system.

BACKGROUND: Despite being one of the leading causes of disability worldwide, fewer than 10% of depressed individuals in low-resource settings have access to treatment. Mounting evidence suggests that nonspecialist workers are capable of providing counseling and case management at the community level. They often use brief psychiatric screening instruments as clinical tools to identify cases and monitor symptoms over time. In order for such tools to be used in diverse settings, they must demonstrate adequate reliability and validity in addition to cross-cultural relevance. To be used to guide routine care they also need to be flexibly adapted and sensitive to change. The goal of this paper is to assess the cross-cultural validity of brief psychiatric screening instruments in sub-Saharan Africa, identify best practices, and discuss implications for clinical management and scale-up of mental health treatment in resource-poor settings. METHOD: Systematic review of studies assessing the validity of screening instruments for depression, anxiety, and mental distress in sub-Saharan Africa using Medline and PsycINFO. RESULTS: Sixty-five studies from 16 countries assessing the validity of brief screening instruments for depression, anxiety, and/or mental distress. CONCLUSIONS: Despite evidence of underlying universality in the experience of depression and anxiety in sub-Saharan Africa, differences in the salience, manifestation, and expression of symptoms suggest the need for the local adaptation of instruments. Rapid ethnographic assessment has emerged as a promising, low-cost, and efficient strategy for doing so. Language: en

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Psychiatric disorders are among the leading cause of disability worldwide, yet fewer than 25 % of affected individuals are estimated to have access to treatment. In many low-income settings, it is estimated that less than 10 % of affected individuals are able to access basic mental health care and, even when they do, it is often below minimum ethical and clinical standards [1]. The discipline of global mental health is dedicated to reducing mental health disparities within and between countries by preventing mental disorders and improving access to psychiatric treatment, particularly in low-resource settings [2]. The study of cross-cultural mental health dates back to the late 1800s, when European psychiatrists and anthropologists began to identify and document locally specific mental diseases in their colonies [3]. Transcultural psychiatry branched into two research traditions: “relativists,” who were focused on characterizing culture-bound syndromes, and “universalists,” who sought to identify universality across cultures in the manifestation of mental disorders [2]. Both research traditions emerged from a colonial paradigm, wherein Western researchers studied the non-Western “other.” Whereas relativists relied primarily on qualitative and ethnographic methods [4], universalists employed epidemiological methods to estimate the cross-cultural prevalence of mental disorders, as defined by Western criteria. Cross-cultural mental health research has evolved significantly from its colonial roots to what is now a global partnership model emphasizing interdependency, bi-directional knowledge generation and transfer, and shared ownership (see Fig. 1). Though the relativist and universalist perspectives still exist, most global mental health researchers have gravitated towards an integrationist perspective, recognizing both broad universality in mental disorders across cultures as well as meaningful cross-cultural variation. Global mental health research now requires an interdisciplinary approach to bridge multiple perspectives and address complex questions related to cultural adaptation, effectiveness, dissemination, and implementation. It is grounded in the social justice and human rights perspective that all people have the right to health and mental health [5], with an emphasis on creating sustainable interventions to reduce mental health disparities. This paradigm shift has many implications for the training of the next generation of global mental health researchers, including both identifying and developing critical new skill sets to propel the field forward. Fig. 1 History and evolution of global mental health research and training

Depression is a common comorbid condition for patients with tuberculosis (TB) (1–3), and is associated with higher morbidity and mortality (4,5), antibiotic drug resistance (1,3,6), and community transmission. Depressed individuals with TB are less likely to seek care promptly, if at all, and once in treatment are significantly less likely to take medications consistently and/or completely (2,4,7). These treatment irregularities can lead to drug resistance, morbidity and mortality. Therefore, depression may be an unrecognized driver of the TB and multidrug resistant TB (MDR-TB) epidemics. MDR-TB treatment is significantly more expensive, takes approximately four times as long to complete, and produces acute physical and psychiatric side effects, which makes treatment adherence and completion a considerable challenge. Since few low-income settings have the resources or capacity to deliver the specialized care that is required, ensuring prompt and complete TB management in all settings is critical to curb the global TB and emerging MDR-TB epidemics. Using a two-stage snowbalxfl approach to reviewing the literature, first searching MEDLINE (1946-2013), PubMed (196-2013), and PsycINFO (1806-2013) databases with key relevant search terms, then reviewing the references of those articles, we identified 31 studies from 11 countries that assessed depression prevalence among individuals with active TB. These included one low-income (Kenya), three lower-middle income (India, Nigeria, Pakistan), five upper-middle income (South Africa, Peru, Romania, Russia, Turkey), and two high-income countries (Greece, United States). The studies were of mixed methodological quality. A majority of them relied on brief screening instruments to identify probable cases of depression, seven used clinical diagnostic interviews, and two did not specify the method of assessment. Only two studies included a healthy comparison group. Sample sizes ranged from 30 to 691 (mean 158, median 100). Two-thirds were conducted among outpatient populations and the remaining among inpatients in hospitals. The current prevalence of depression among individuals receiving treatment for TB ranged from 11.3% to 80.2%, with a mean weighted prevalence of 48.9% (95% CI 48.3%-49.6%). In the two studies that compared the prevalence of depression among TB outpatients to healthy controls, that prevalence was three to six times higher among the former. Though we expected to find consistent rates within or between countries of similar income levels, a great deal of variability was observed. The widest variation occurred within countries (India, Nigeria, Pakistan, Peru and Russia). However, in these cases, the weighted mean prevalence within countries revealed relatively narrow confidence intervals with a strong central tendency. There was little difference in rates between studies using structured diagnostic interviews versus brief screening instruments, and no single screening instrument produced higher or lower rates than any other used. The most commonly used brief screening tool, adopted in eight studies, was the Beck Depression Inventory. Though available evidence is of mixed methodological quality, it suggests that the prevalence of depression among individuals with active TB may be equally high or higher than in people with other chronic medical conditions. However, more research is sorely needed to estimate the true community prevalence of depression among individuals with TB. Treating comorbid depression has been associated with better TB outcomes, including medication adherence, treatment completion, and cure. A prospective controlled study in India found that TB patients who received individual psychotherapy during treatment were significantly more likely to adhere to and complete treatment and, thus, be cured of their disease (8). In rural Ethiopia, the organization of peer-led “TB clubs” increased clinic attendance and adherence, case detection, and community awareness about TB (9). In Peru, a psychosocial support group intervention was developed for MDR-TB patients which improved treatment adherence and completion, as well as social rehabilitation after treatment (1). Finally, antidepressants, in isolation or in conjunction with other therapies, have also been effectively used to treat depression among patients with TB (10). Though TB disproportionately affects individuals in low-resource settings with few mental health specialists, a growing body of evidence suggests that non-specialist health workers can be trained to deliver basic mental health care, including case detection, symptom management and triage, and such strategies may be very useful and relevant in the context of TB.

This detailed case history traces the first 5 years of a psychosocial support group intervention aimed to improve adherence to individualized drug regimens for multidrug-resistant tuberculosis (MDR-TB) in Peru. A total of eight groups were established in metropolitan Lima and two provinces of Peru led by teams of psychiatrists and nurses. The intervention consisted of bi-monthly support groups, recreational excursions, symbolic celebrations, and periodic family workshops. Notably, of the 285 patients who participated in this intervention, only 3.5% defaulted from treatment. Details include the description of services, patient data, major psychosocial difficulties faced by this population, key challenges, and implications. Psychosocial support is a crucial component of treatment for MDR-TB in order to ensure completion of complicated treatment regimens and enable psychosocial rehabilitation after treatment.

Treatment of gestational multidrug-resistant tuberculosis (MDR-TB) is controversial. We describe follow-up of 6 children exposed to second-line antituberculous agents in utero. Each child (average age, 3.7 years) underwent comprehensive clinical evaluation. One child had MDR-TB diagnosed. There was no evidence of significant late-presentation toxicity among the children. The results suggest that aggressive management of gestational MDR-TB may benefit both mother and child.

Neuropsychiatric disorders are the leading cause of disability worldwide, accounting for 22.7% of all years lived with disability (YLDs). Despite this global burden, fewer than 25% of affected individuals ever access mental health treatment; in low-income settings, access is much lower, though non-allopathic interventions through traditional healers are common in many venues. Three main barriers to reducing the gap between individuals who need and those who have access to mental health treatment include stigma and lack of awareness, limited material and human resources, and insufficient research capacity. We argue that investment in dissemination and implementation research is critical to face these barriers. Dissemination and implementation research can improve mental health care in low-income settings by facilitating the adaptation of effective treatment interventions to new settings, particularly when adapting specialist-led interventions developed in high-resource countries to settings with few, if any, mental health professionals. In Mozambique, the World Health Organization estimates only 0.04 psychiatrists per 100,000 population, representing 30 times less than the global median, and more than 150 times lower than the median in high income countries. Emerging evidence from other low-income settings suggests that lay providers can be trained to detect mental disorders and deliver basic psychotherapeutic and psychopharmacological interventions when supervised by an expert. Mozambique has both the political commitment and available resources for mental health, but inadequate research capacity and workforce limits the country’s ability to assess local needs, adapt and test interventions, and identify implementation strategies that can be used to effectively bring evidence-based mental health interventions to scale within the public sector. Global training and research partnerships are critical to building capacity, promoting bilateral learning between and among low- and high-income settings, ultimately reducing the mental health treatment gap worldwide. Through new research partnership between Universidade Eduardo Mondlane (Mozambique), Columbia University (USA), Vanderbilt University (USA), and Universidade Federal de São Paulo (Brazil), we are working towards a North-South and South-South collaboration to build research capacity in Mozambique and other Portuguese-speaking African countries.