Specialised mental health (MH) care providers are often absent or scarcely available in low resource and humanitarian settings (LRHS), making MH training and supervision for general health care workers (using task-sharing approaches) essential to scaling up services and reducing the treatment gap for severe and common MH conditions. Yet, the diversity of settings, population types, and professional skills in crisis contexts complicate these efforts. A standardised, field tested instrument for clinical supervision would be a significant step towards attaining quality standards in MH care worldwide.

A competency-based clinical supervision tool was designed by Médecins Sans Frontières (MSF) for use in LRHS. A systematic literature review informed its design and assured its focus on key clinical competencies. An initial pool of behavioural indicators was identified through a rational theoretical scale construction approach, tested through waves of simulation and reviewed by 12 MH supervisors in seven projects where MSF provides care for severe and common MH conditions.

Qualitative analysis yielded two sets of competency grids based on a supervisee's professional background: one for ‘psychological/counselling’ and another for ‘psychiatric/mhGAP’ practitioners. Each grid features 22–26 competencies, plus optional items for specific interventions. While the structure and content were assessed as logical by supervisors, there were concerns regarding the adequacy of the tool to field reality.

Humanitarian settings have specific needs that require careful consideration when developing capacity-building strategies. Clinical supervision of key competencies through a standardised instrument represents an important step towards ensuring progress of clinical skills among MH practitioners.

Understanding how and under what circumstances a highly effective psychological intervention, improved symptoms of depression is important to maximise its clinical effectiveness.

To address this complexity, we estimate the indirect effects of potentially important mediators to improve symptoms of depression (measured with the Patient Health Questionnaire (PHQ-9)) in the Healthy Activity Program trial.

Interventional in(direct) effects were used to decompose the total effect of the intervention on PHQ-9 scores into the direct and indirect effects. The following indirect effects were considered: characteristics of sessions, represented by the number of sessions and homework completed; behavioural activation, according to an adapted version of the Behavioural Activation for Depression Scale – Short Form; and extra sessions offered to participants who did not respond to the intervention.

Of the total effect of the intervention measured through the difference in PHQ-9 scores between treatment arms (mean difference: −2.1, bias-corrected 95% CI −3.2 to −1.5), 34% was mediated through improved levels of behavioural activation (mean difference: −0.7, bias-corrected 95% CI −1.2 to −0.4). There was no evidence to support the mediating role of characteristics of the sessions nor the extra sessions offered to participants who did not respond to the treatment.

Findings from our robust mediation analyses confirmed the importance of targeting behavioural activation. Contrary to published literature, our findings suggest that neither the number of sessions nor proportion of homework completed improved outcomes. Moreover, in this context, alternative treatments other than extra sessions should be considered for patients who do not respond to the intervention.

In Chiapas, Mexico, it is estimated that 1,356 million people suffer from depression; there are about 210 psychologists (1/24,847 people) and 4 psychiatrists (1/1,304 people). Collaborative task sharing, which engages nonspecialists in mental health care delivery, is essential to address the large global burden of mental illness. The collaborative care model (CoCM), a specific type of task-sharing strategy, incorporates a team-based approach with: a primary care provider (PCP); a behavioral health professional, who is the care manager (CM); and a consulting psychiatrist. CoCM has shown improved outcomes for both mental and general health, expanded access to care, and cost-effectiveness.

Our objective is to implement one of the arms of the phased model and CoCM, through supervision and training of health professionals not specialists in Mental Health, in different clinical spaces of community primary care, by specialists.

We implemented a training program taught by psychiatrists and psychologists for health workers in communities of La Sierra Madre in Chiapas, which includes: training of intern nurses, training and supervision of intern doctors and on-site supervision and training of community mental health workers (CMHW); all undergoing a process of monitoring, evaluation and quality.

Of the patients that were treated (202; 89% women), more than 80% had a diagnosis of anxiety and depression. The most notable clinical improvement (measured with the PHQ-9 depression scale) occurred in the intervention group of CMHW + interns (reduction PHQ-9 58%).

This strategy seems acceptable to address the large gaps in the availability of mental health providers in low-income countries.

No significant relationships.

Because of the high burden of untreated mental illness in humanitarian settings and low- and middle-income countries, scaling-up effective psychological interventions require a cultural adaptation process that is feasible and acceptable. Our adaptation process incorporates changes into both content and implementation strategies, with a focus on local understandings of distress and treatment mechanisms of action.

Building upon the ecological validity model, we developed a 10-step process, the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) procedure, and piloted this approach in Nepal for Group Problem Management Plus (PM+), a task-sharing intervention, proven effective for adults with psychological distress in low-resource settings. Detailed documentation tools were used to ensure rigor and transparency during the adaptation process.

The mhCACI is a 10-step process: (1) identify mechanisms of action, (2) conduct a literature desk review for the culture and context, (3) conduct a training-of-trainers, (4) translate intervention materials, (5) conduct an expert read-through of the materials, (6) qualitative assessment of intervention population and site, (7) conduct practice rounds, (8) conduct an adaptation workshop with experts and implementers, (9) pilot test the training, supervision, and implementation, and (10) review through process evaluation. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of ‘tension’; modification of recruitment procedures to assure fit; and development of a skills checklist.

A 10-step mhCACI process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation.

There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.

In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.

Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35–0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13–0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.

An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.