Giuseppe Raviola

In 2014, the Islamic State of Iraq and Syria targeted the Yazidi ethno-religious minority in Sinjar, northern Iraq, abducting Yazidi boys aged 8 to 14 who endured violence, family separation and significant trauma exposure. Upon return, these children needed mental health care. This study investigates the availability of mental health services for male Yazidi former CAAFAGs (children associated with armed forces and armed groups) and discusses their rights under international legal frameworks. The study used a convergent mixed-methods design involving male Yazidi former CAAFAGs and mental health providers in the Sinjar district and the Duhok governorate. Quantitative data were collected through a descriptive survey of thirty CAAFAGs and ten providers. Qualitative insights from semi-structured interviews with ten CAAFAGs and ten providers expanded on these findings, and the results were integrated into a joint display for interpretation. Among the thirty CAAFAGs, 70% had not received any mental health care since their captivity. After captivity, 33% wanted (personal desire) mental health care; of those who wanted care, 80% received services through non-governmental organizations (NGOs). In contrast to this “personal desire” for care, 96.7% of male Yazidi former CAAFAGs acknowledged that they are in need of mental health care, yet only one is currently seeking it. Qualitative data revealed a gap in mental health and psychosocial support (MHPSS) services specifically for male CAAFAGs, as NGOs focused more on female survivors. It also identified financial, personnel and logistical challenges for NGOs, as well as discrepancies between CAAFAGs and providers regarding perceived willingness to receive mental health care. CAAFAGs and providers recognize an urgent need for tailored, trauma-informed MHPSS and reintegration services for male Yazidi former CAAFAGs. While NGOs play an essential role in delivering mental health care, their focus is primarily on female survivors, leaving a gap in support for male CAAFAGs. International legal frameworks protecting child victims’ rights remain inadequately respected in practice. Addressing these gaps is crucial for CAAFAGs’ successful reintegration and rehabilitation.

This chapter explores the foundational knowledge essential to training in humanitarian mental health response and mental health systems strengthening. This knowledge includes familiarity with international standards of psychosocial, psychological, and psychiatric care and support in the context of both humanitarian crises and also in developing standing sustainable services; elements of health systems and clinical services design; quality improvement methods and elements of training systems design; and key concepts in social medicine as they apply to ethical delivery of mental health care. Global mental health educators and practitioners can deploy their expertise in developing clinical trainings, sustaining supervision, and managing teams in order to develop effective systems to support communities affected by crises, as well as to build long-term clinical capacities and contribute to overall health systems strengthening. Training curricula should be informed by a proposed care system that can be strengthened and developed according to existing resources—with both theory of change and value chain approaches—and should elaborate how care delivery platforms link district hospital, primary care, and community-based components of service delivery following a humanitarian crisis. Integration of planning for both humanitarian crisis response and subsequent mental health system reform can produce optimal outcomes in settings with constrained resources for mental healthcare delivery.

Background: The COVID-19 pandemic caused considerable burden on mental health worldwide. To address this emergency in Peru, Socios en Salud (SES) implemented an innovative digital system for the diagnosis and psychological therapy in vulnerable populations. We describe the development, implementation, and participant outcomes of this intervention.Methods: We conducted an intervention in a general population of Lima, Peru using a digital tool, ChatBot-Juntos, incorporating the abbreviated Self-Reporting Questionnaire (SRQ) to screen psychological distress. Participants positive for psychological distress received remote Psychological First Aid (PFA) and grief therapy if needed. Participants with a mental health condition or safety concern were referred to mental health services. SRQ scores were collected 3 months after PFA sessions. Differences between screening and follow-up scores were compared using Wilcoxon sign-rank test.Results: In total, 2027 people were screened; 1581 (77.9%) screened positive for psychological distress. Nine hundred ninety-seven (63%) people with psychological distress received PFA, and 320 (32.1%) of those were also referred for mental health care. At 3 months after follow-up, SRQ scores were collected for 579 (58%) participants. Significant reduction in SRQ scores was observed 3 months after PFA [median SRQ score changed from 9 to 5 (p < 0.001)], and after PFA plus referral to mental health services [median SRQ score changed from 11 to 6 (p < 0.001)].Conclusion: Digital technology can be used to screen for psychological distress and deliver mental health support for populations affected by the COVID-19 pandemic. More research is needed to determine whether technology contributes to improved mental health outcomes.

Introduction Evidence-based low-intensity psychological interventions such as Problem Management Plus (PM+) have the potential to expand treatment access for depression and anxiety, yet these interventions are not yet effectively implemented in rural, public health systems in resource-limited settings. In 2017, Partners In Health adapted PM+ for delivery by primary care nurses in rural Rwanda and began integrating PM+ into health centres in collaboration with the Rwandan Ministry of Health, using established implementation strategies for mental health integration into primary care (Mentoring and Enhanced Supervision at Health Centers for Mental Health (MESH MH)). A gap in the evidence regarding whether low-intensity psychological interventions can be successfully integrated into real-world primary care settings and improve outcomes for common mental disorders remains. In this study, we will rigorously evaluate the delivery of PM+ by primary care nurses, supported by MESH MH, as it is scaled across one rural district in Rwanda. Methods and analysis We will conduct a hybrid type 1 effectiveness-implementation study to test the clinical outcomes of routinely delivered PM+ and to describe the implementation of PM+ at health centres. To study the clinical effectiveness of PM+, we will use a pragmatic, randomised multiple baseline design to determine whether participants experience improvement in depression symptoms (measured by the Patient Health Questionnaire-9) and functioning (measured by the WHO-Disability Assessment Scale Brief 2.0) after receiving PM+. We will employ quantitative and qualitative methods to describe and evaluate PM+ implementation outcomes using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, using routinely collected programme data and semistructured interviews. Ethics and dissemination This evaluation was approved by the Rwanda National Ethics Committee (Protocol #196/RNEC/2019) and deemed exempt by the Harvard University Institutional Review Board. The results from this evaluation will be useful for health systems planners and policy-makers working to translate the evidence base for low-intensity psychological interventions into practice.

Background: The Zanmi Lasante Depression Symptom Inventory (ZLDSI) is a screening tool for major depression used in 12 primary care clinics in Haiti’s Central Plateau. Although previously validated in a clinic-based sample, the present study is the first to evaluate the validity and clinical utility of the ZLDSI for depression screening in a school-based population in central Haiti. Methods: We assessed depressive symptoms in a school-based sample of transitional age youth (18–22 years; n = 120) with the ZLDSI. Other mental health-related assessments included a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) for current Major Depressive Episode, the Center for Epidemiologic Studies Depression Scale, and selected items adapted from the Global School-Based Health Survey mental health module. Diagnostic assignments of major depressive episode (MDE) were based on modified SCID interviews. Results: The ZLDSI demonstrated good overall accuracy in identifying current MDE (Area under the Curve = .92, 95% CI = .86, .98, p < .001). We ascertained ≥12 as the optimal cut-off point to screen for depression with a sensitivity of 100% and a specificity of 73.9%. In addition, the ZLDSI was associated with other measures of depressive symptoms, suggesting that it demonstrates construct validity. Conclusions: Study findings support that the ZLDSI has clinical utility for screening for depression among school-going transitional age youth.

Between 2010 and 2019 the international health care organization Partners In Health (PIH) and its sister organization Zanmi Lasante (ZL) mounted a long-term response to the 2010 Haiti earthquake, focused on mental health. Over that time, implementing a Theory of Change developed in 2012, the organization successfully developed a comprehensive, sustained community mental health system in Haiti's Central Plateau and Artibonite departments, directly serving a catchment area of 1.5 million people through multiple diagnosis-specific care pathways. The resulting ZL mental health system delivered 28 184 patient visits and served 6305 discrete patients at ZL facilities between January 2016 and September 2019. The experience of developing a system of mental health services in Haiti that currently provides ongoing care to thousands of people serves as a case study in major challenges involved in global mental health delivery. The essential components of the effort to develop and sustain this community mental health system are summarized.

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing—engaging non-specialist providers—to deliver mental health care.