Opportunities for Integrating Mental Health into HIV, MCH, and Other Health Service Platforms - Joy Baumgartner

1. ​Opportunities for Integrating Mental Health into
HIV, MCH, and Other Health Service Platforms
Joy Noel Baumgartner, PhD, MSSW
Assistant Professor of Global Health
Director, Evidence Lab
Duke Global Health Institute
CORE Group Fall 2016 Conference
October 14, 2016

2. NCDs, Mental Disorders & DALYs
Depression is the 3rd leading cause of disability adjusted life years, 2nd for YLD.
Cost of MNS is $2.5 Trillion = 3x the cost of heart disease (World Economic Forum, 2013)
Global burden (HIC+LMIC), Figure from
Prince et al. 2007, Lancet

3. Magnitude of depression in LMICs
• Mental disorders account for 11% of
the total burden of disease in
LMICs with depression being the
leading neuropsychiatric cause
• Leading global policy, practice and
research organizations are
increasingly taking notice and
prioritizing mental health
World Bank & WHO, April 2016
A global community of
mental health innovators
http://mhinnovation.net/

4. Global burden of suicide
WHO 2014, Preventing Suicide

5. Moderate-Severe Depression (mhGAP-IG)
• Experiences depressed
mood, loss of interest and
enjoyment, and reduced
energy leading to
diminished activity for at
least 2 weeks. Many people
with depression also suffer
from anxiety symptoms
and medically unexplained
somatic symptoms
• Has difficulties carrying out
his or her usual work,
school, domestic or social
activities due to symptoms
of depression
WHO, 2010

6. Depression Treatment (mhGAP-IG)
• Basic Psychosocial treatment for depression
– Psychoeducation
– Addressing current psychosocial stressors (e.g. domestic violence)
– Reactivate social networks
– Structured physical activity program
– Follow-up (re-assess)
* Medication as indicated
• Advanced psychosocial interventions
– Defined as an intervention that takes more than a few hours of a health-care
provider’s time to learn and typically more than a few hours to implement. Such
interventions can be implemented in non-specialized care settings, but only
when sufficient human resource time is made available. Eg…
• Cognitive behavioural therapy (CBT)
• Interpersonal psychotherapy (IPT)
• Problem-solving counselling or therapy

7. Depression and HIV in LMICs
• Depression is more common among people living with HIV (PLWH) than
general population in high-income countries (~5%–20% prevalence); data
from LMICs indicates even higher prevalence levels (~7-30% prevalence)
• Poor mental health affects disability and quality of life for PLWH and it also
impacts their ability to engage with HIV care and treatment services
including adherence to antiretroviral therapy (ART)
• Evidence that mental disorders also associated with HIV risk behaviors such
as substance abuse, multiple sexual partners and unprotected sex
• Addressing depression among both general populations and higher risk
populations such as PLWH is paramount

8. Burden of maternal mental health
• Common perinatal mental disorders (CPMDs), which
includes depression, anxiety and somatic disorders, are a
major cause of disability during and after pregnancy
• Burden of perinatal depression (pregnancy period + 12
months postpartum) is high globally but even higher in
LMICs with estimates from 18% to 25%
• Burden of CPMDs can be reduced through mental health
interventions delivered by supervised non-specialists
• Implementation of depression interventions in primary
care settings is cost-effective
• Addressing maternal mental health benefits women,
children and their families
Key References:
Fisher et al., Bull World Health Organ 2012;90:139G–49G; Rahman et al., Bull World Health Organ 2013;91:593–601I ; Chisholm et al, BJP; 2004, 184(5):393-
403; Araya et al., Am J Psychiatry 2006; 163:1379–1387.;Siskind et al., J Mental Health Policy Econ; 2008;11(3):127-33.
Risk factors for CPMDs
• Poverty
• Gender-based violence
• Lack of reproductive
autonomy
• Having an unintended
pregnancy
• Lack of social support

9. Impact of perinatal depression
Impact on Mother
• Disability, poor quality of life
• Poor social functioning
• Decreased productivity
• Negative cognitions
• Suicidal ideation
Impact on Child
• Undernutrition, stunting, diarrhea
• Problems in breastfeeding
• Low academic achievement
• Socio-emotional and cognitive delays
• Childhood depression
• Behavior problems
Wachs, et al. (2009). Maternal Depression: A global threat to children’s health, development,
and behavior and to human rights. Child Development Perspectives 3(1):51-59.
Fisher, et al. (2012). Prevalence and determinants of common perinatal mental disorders in
women in LMICs: a systematic review. Bull World Health Org 90:139-149G.
Rahman, et al. (2013). Grand Challenges: Integrating Maternal Mental Health into Maternal
and Child Health Programmes. PLoS Med 10(5).

10. Global mental health policies
and guidance
Recommendation to assess
mother 10-14 days postpartum
for resolution of mild, transitory
postpartum depression
(“maternal blues”).
If symptoms persist, further
assessment and evaluation.

11. Evidence-based maternal mental health
interventions for low-resource settings
increasingly publicly available

12. Integration opportunities within
maternal health care continuum
• Mental health integrated into maternal health services
– Facility-level
• E.g. antenatal care, PMTCT, HIV care & treatment, family planning, and
well-child/immunization visits
– Community-level
• E.g. Screening and referral by health extension workers (Ethiopia) or
church-based lay counsellors within antenatal program (Nigeria)
• Integrating mental health requires health systems
strengthening (e.g. effective referral system is part of quality service
delivery yet many barriers to referral completion)

13. Maternal Mental Health in Ethiopia
• Population-based study assessed mental health among 1294
non-pregnant, postpartum women in Amhara region
• Results
– 1 in 5 women experiencing mental distress (SRQ-20)
– ~15% of surveyed women had had suicidal thoughts
– Poor health of last delivered child and inequitable gender
attitudes associated with poor mental health
– Social support from female friends was strongly protective
• Community mental health services could strengthen social
support between female friends with education and support
group facilitation by health extension workers
Baumgartner et al., 2016;
Baumgartner et al., 2014

14. Integrating mental health care into
HIV services platform
• Integration is a priority strategy for providing mental health services
• Requires a health systems strengthening approach
• Referrals are key component of integrated service delivery; however referral
follow-up is challenging across all health services
• Facilitated referrals are enhanced referrals that include components (e.g.
escorting client) that support referral completion by strengthening linkages
between two services or between community-based and facility-based services
• 7-step facilitated referral model for integrating family planning into HIV care
and treatment services tested in Tanzania; model can be applied for other
services integration
(Patel, et al. PLoS Med; 2013)

15. Facilitated Referrals to strengthen
integrated mental health services
1. Screen
2. Counsel
3. Refer
4. Record
5. Accompany
6. Access
7. Monitor
P
S
Y
C
H
I
V
Screen clients for mental health
problems
Provide minimal psychoeducation
and/or counselling
Refer clients with need to
clinic/service & Record referral
Accompany clients to psychiatric
nurse, social worker, or trained lay
counsellor
Clients with referrals access
psychiatric clinic or social work
services for follow-up
Monitor reduction in symptoms,
disability, quality of life
Baumgartner et al., 2014

16. Facilitated referrals for integrating NCD
services into HIV care and treatment in Zambia
• Quasi-experimental cohort study: 2 hospitals using facilitated referrals to support
services for depression and diabetes among patients in HIV clinics
• Screening for depression and diabetes within routine HIV care and treatment
service encounters
– Depression care by HIV counselors/psychiatric nurses trained on group intervention
[8-week group counseling intervention for depression among PLWH by Petersen et al
(2014) in South Africa]
– Diabetes care by clinical officers and nutritionists following MOH guidelines
(additional training needed)
• Study objectives
1. To determine the feasibility of integrating NCD care into HIV care and treatment by
tracking service indicators, and
2. To assess the impact of mental health care on both depression symptoms and ART
adherence (pre/post-intervention; 3 month follow-up)

17. Zambia: Ongoing study update
• Existing government mental health services (on which we need
to rely for referrals and supervision) need significant
strengthening
• Data are still being collected but thus far we see about ~10% of
HIV care and treatment clients are screening with high levels of
depression symptoms indicative of severe depression and
another ~10% with moderate depression
• Depression among both women and men, all ages, stresses of
supporting families and food insecurity

18. Global mental health integration…
Way forward
• Evidence-based and promising interventions developed for LMICs are becoming
publicly available (e.g. Thinking Healthy Programme; Friendship Bench) and WHO’s
mhGAP guidelines are increasingly being adapted for local contexts
• Integrating mental health care into other health services can also help advance
those health services priorities (HIV medication adherence; maternal and child
health outcomes, etc.)
• As MCH, HIV and other service platforms consider integrating and scaling up new
and adapted mental health interventions, sufficient attention and resources must
also be paid to strengthening health systems
– Task-shifting/sharing needs supportive supervision and monitoring
– Functioning referral systems and training for non-specialists to screen/refer/follow-up
– Incorporating mental health into HMIS
– Sensitization of communities as well as health financing stakeholders that mental disorders are
treatable and a good MCH or HIV investment

19. Acknowledgements
FHI 360 Team & Advisors for Zambia Study
• Namakau Nyambe
• Earnest Muyunda
• Pai Lien Chen
• Rebecca Dirks
• Mike Welsh
• Tim Mastro
Funding
• Zambia study: FHI Foundation
• Ethiopia study: USAID