Mozambique was recently estimated to have the highest suicide rate in Africa. Global modeling exercises estimate that depression is one of the leading causes of disability nationally, yet our pilot studies suggest depression is not often identified or treated. Given limited specialist human resources and reach of the current mental health system, the Ministry of Health has targeted mental health service integration with primary care as a high priority. However, there is currently no primary care integration, with all mental healthcare occurring at district-level specialized psychiatric services. The goal of this award is to broaden the candidate?s expertise to conduct independent mental health systems research focused on the integration of mental health in global primary care settings. Through research, coursework, structured mentorship, and conference attendance, the candidate will develop new competencies in mental health systems research, including: (1) content knowledge on the evidence-base for integrating mental healthcare in primary care; (2) mixed-methods techniques for pragmatic randomized trials in low- and middle-income country (LMIC) health systems; (3) ethical conduct of clinical research in LMICs; and (4) professional development to become an independent NIH-funded investigator. Drs. Deepa Rao, Kenneth Sherr, Jrgen Untzer, Inge Petersen, Palmira dos Santos, and Vasco Cumbe will mentor and advise the candidate in these four objectives. The research will be conducted in Sofala, Mozambique in partnership with the Mozambican Ministry of Health. The candidate will determine the optimal screening cut- off for the Patient Health Questionnaire-9 and conduct the first-ever study of prevalence, associated factors, and care-seeking for depressive symptoms (including suicidal ideation) among primary care patients in Sofala, Mozambique (Aim 1). These data, combined with semi-structured key-informant interviews of existing practices and perceptions of supply/demand side barriers (Aim 2), will be used to inform the design and implementation of mental health integration guidelines and decision-support tools. Last, the candidate will implement and pilot- test the feasibility of depression care integration within public clinics in Sofala, Mozambique. The candidate will collect mixed-methods pilot data of input variables, implementation outcomes, and patient outcomes, paired with the Consolidated Framework for Implementation Research (CFIR) to systematically assess intervention characteristics, outer/inner setting, and processes (Aim 3). Pilot effectiveness data, along with analyses of CFIR constructs affecting implementation, will help identify factors distinguishing between facilities achieving high and low implementation success, and inform implementation strategies for a follow-on NIH grant testing impact and implementation strategies in an adequately-powered cluster randomized trial. In Mozambique, this research will contribute to scalable mental health integration models that promote integrated care for depressive symptoms. More generally, we anticipate our mixed-methods data, including the CFIR constructs of implementation success, will be of interest to the larger global community looking to close mental health treatment gaps in LMICs.

Public Health Relevance

) Mozambique was recently estimated to have the highest suicide rate in Africa, and depression is estimated through global modeling exercises as one of the leading causes of disability nationwide. Currently, few people have access to care for depression or suicidal thoughts in the public-sector health system and there are few previous peer-reviewed studies on these topics. Additionally, there is currently no integration of mental healthcare with primary care services, with all mental healthcare occurring at separate district-level specialized psychiatric services. This research project will study depressive symptoms and suicidal thoughts among primary care patients in Mozambique and will develop and pilot-test an evidence-based package of care to more effectively identify and treat depression and suicidal thoughts in primary care settings across the country.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Scientist Development Award - Research & Training (K01)
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Mental Health Services Research Committee (SERV)
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Amarreh, Ishmael G
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University of Washington
Public Health & Prev Medicine
Schools of Public Health
United States
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Fabian, Katrin; Fannoh, Josiah; Washington, George G et al. (2018) ""My Heart Die in Me"": Idioms of Distress and the Development of a Screening Tool for Mental Suffering in Southeast Liberia. Cult Med Psychiatry 42:684-703