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Background: Most evaluations of task-shifting have focused on common mental disorders. Much less work has been done on severe mental neurological and substance use (MNS) disorders, such as chronic psychosis and epilepsy. Given the high burden associated with severe MNS and the lack of mental health professionals in low and middle income countries, evaluations on the impact of task-shifting for these disorders are important. Methods:In a rural district of Nepal, a community mental health program, based on World Health Organization's Mental Health Gap Action Programme guidelines, was evaluated using a cohort study design. People with epilepsy and psychotic disorders were interviewed at treatment initiation and at 12-month follow-up. We also compared a group that was offered a comprehensive package of care (medication combined with psychosocial interventions, such as counselling and peer support groups) to a group that received medication only.Results: One-hundred nineteen persons were enrolled in the epilepsy cohort (EC) and 85 in the psychosis cohort (PC). The patients were enrolled in either the comprehensive package (n = 157) or medication only (n = 47). There was significant improvement (P < 0.0001) in psychosis symptoms (PC: Z = 6.78, r = 0.80) and depressive symptoms (EC: Z = 7.43, r = 0.73; PC: Z = 6.02, r = 0.70), seizures (EC: Z = 6.78), functional disability (EC: Z = 6.38, r = 0.67; PC: Z = 4.60, r = 0.57), family and caregiver burden (EC: Z = 8.09, r = 0.85; PC: Z = 6.81, r = 0.84), and social behaviour (PC: Z = 5.94, r = 0.84). There was greater risk reduction for recent seizures among people with epilepsy in the comprehensive treatment package vs. medication only (risk ratio = 0.52, 95% CI 0.29-0.95; P = 0.03); no other significant differences were observed between treatment arms. Conclusions:A community mental health program in Nepal, implemented by non-specialists, resulted in moderate to large effects among people with epilepsy or psychosis. A comprehensive package of care, including counselling and patient support groups, appears to offer added clinical benefits for patients with epilepsy. For people with psychosis, the basic package of care (i.e., psychotropic medications) performed similar to the comprehensive package, suggesting a less resource-intensive package may offer comparable results.

Background Large scale efforts to expand access to mental healthcare in low-and middle-income countries have focused on integrating mental health services into primary care settings using a task sharing approach delivered by non-specialist health workers. Given the link between mental disorders and risk of suicide mortality, treating common mental disorders using this approach may be a key strategy to reducing suicidality. Methods and findings The Programme for Improving Mental Health Care (PRIME) evaluated mental health services for common mental disorders delivered by non-specialist health workers at ten primary care facilities in Chitwan, Nepal from 2014 to 2016. In this paper, we present the indirect impact of treatment on suicidality, as measured by suicidal ideation, among treatment and comparison cohorts for depression and AUD using multilevel logistic regression. Patients in the treatment cohort for depression had a greater reduction in ideation relative to those in the comparison cohort from baseline to three months (OR = 0.16, 95% CI: 0.05-0.59; p = 0.01) and twelve months (OR = 0.31, 95% CI: 0.08-1.12; p = 0.07), with a significant effect of treatment over time (p = 0.02). Among the AUD cohorts, there were no significant differences between treatment and comparison cohorts in the change in ideation from baseline to three months (OR = 0.64, 95% CI: 0.07-6.26; p = 0.70) or twelve months (OR = 0.46, 95% CI: 0.06-3.27; p = 0.44), and there was no effect of treatment over time (p = 0.72). Conclusion The results provide evidence integrated mental health services for depression benefit patients by accelerating the rate at which suicidal ideation naturally abates over time. Integrated services do not appear to impact ideation among people with AUD, though baseline levels of ideation were much lower than for those with depression and may have led to floor

Background Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups—consumers, providers, organization leaders, and policy makers—with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. Methods We compiled secondary data from seven studies across six LMIC—Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia—to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. Results All but one scale within the Provider and Consumer versions had Cronbach’s alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings (R2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. Conclusion We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.