This review suggests that psychosocial factors, namely, depression and alcohol may have adverse effects upon HIV-related outcomes. However, further large, high-quality studies examining outcomes other than adherence are needed. There is also an urgent need for randomized controlled trials of interventions for mental disorder and a need to investigate their impact upon HIV-related outcomes.

BackgroundUnderstanding co-morbidity of depression and tuberculosis (TB) has been limited by challenges in measurement of depression due to overlapping symptoms, use of small hospital samples and uncontrolled analysis. This study was conducted to better understand the burden and presentation of depression, and associated factors in people with TB in primary care settings in Ethiopia.MethodsWe conducted a cross-sectional survey among 657 people newly diagnosed with TB. Symptoms of depression were measured using the Patient Health Questionnaire (PHQ-9). TB symptoms and other factors were captured using standardised questionnaires. The factor structure of PHQ-9 was examined. Multivariable analysis was carried out to estimate prevalence ratios.ResultsThe prevalence of probable depression was 54.0%. The PHQ-9 had one factor structure (alpha = 0.81). Little interest or pleasure in doing things (73.0%) was the commonest depressive symptom. Older age (Adjusted Prevalence ratio (APR) = 1.19; 95%CI = 1.06, 1.33), female sex (APR = 1.23; 95%CI = 1.18, 1.27), night sweating (APR = 1.25; 95%CI = 1.16, 1.35), pain (APR = 1.69; 95%CI = 1.24, 2.29), being underweight (APR = 1.10; 95%CI = 1.07, 1.13), duration of illness (APR = 1.35; 95%CI = 1.22, 1.50), level of education (APR = 0.93; 95%CI = 0.90, 0.95), and social support (APR = 0.89; 95%CI = 0.85, 0.93) were independently associated with probable depression.ConclusionsDepression appears highly prevalent in people with TB and PHQ-9 seems to be a useful instrument to detect depression in the context of TB. The frequency of depressive symptoms would suggest that the occurrence of the symptoms in people with TB is in the usual manifestation of the disorder. Prospective studies are needed to understand the longitudinal relationship between TB and depression.

ObjectiveTo investigate the association between comorbid depression and tuberculosis treatment outcomes, quality of life and disability in Ethiopia.MethodsThe study involved 648 consecutive adults treated for tuberculosis at 14 primary health-care facilities. All were assessed at treatment initiation (i.e. baseline) and after 2 and 6 months. We defined probable depression as a score of 10 or above on the nine-item Patient Health Questionnaire. Data on treatment default, failure and success and on death were obtained from tuberculosis registers. Quality of life was assessed using a visual analogue scale and we calculated disability scores using the World Health Organization’s Disability Assessment Scale. Using multivariate Poisson regression analysis, we estimated the association between probable depression at baseline and treatment outcomes and death.ResultsUntreated depression at baseline was independently associated with tuberculosis treatment default (adjusted risk ratio, aRR: 9.09; 95% confidence interval, CI: 6.72 to 12.30), death (aRR: 2.99; 95% CI: 1.54 to 5.78), greater disability (β: 0.83; 95% CI: 0.67 to 0.99) and poorer quality of life (β: −0.07; 95% CI: −0.07 to −0.06) at 6 months. Participants with probable depression had a lower mean quality-of-life score than those without (5.0 versus 6.0, respectively; P < 0.001) and a higher median disability score (22.0 versus 14.0, respectively; P < 0.001) at 6 months.ConclusionUntreated depression in people with tuberculosis was associated with worse treatment outcomes, poorer quality of life and greater disability. Health workers should be given the support needed to provide depression care for people with tuberculosis.

Well-designed epidemiological research is relatively lacking in low and middle income countries where two-thirds of the world’s estimated 24 million people with dementia live. The 10/66 Dementia Research Group has sought since 1998 to redress this imbalance. Pilot studies to develop and validate dementia diagnostic measures and study care arrangements in 26 centers worldwide were followed by one phase cross-sectional catchment area surveys in eight Latin American countries, China, India, Nigeria and South Africa. The protocol includes assessment of sociodemographics, disability, care arrangements, physical and mental health, and dementia diagnosis with (more restrictive) DSM-IV and (less restrictive) 10/66 dementia criteria. An incidence phase is underway in eight countries. 10/66 dementia prevalence is generally double that of DSM-IV dementia. DSM-IV dementia is particularly rare in India, attributable to the small proportion of family informants confirming cognitive decline and social impairment. Carer psychological and economic strain is as high as in the developed world, despite traditional family care arrangements. A significant minority of people with dementia are vulnerable due to lack of family support and economic resources. Earlier studies probably underestimated dementia prevalence in regions with very low awareness of this emerging public health problem. More research is needed to delineate the impact of dementia relative to other chronic diseases, and secular trends in countries experiencing rapid demographic ageing and health transition. Packages of care are also a priority - healthcare services and governments have not responded to families’ complex needs for support in their long-term care role.

Backgroundempirical evidence from high-income countries suggests that self-rated health (SRH) is useful as a brief and simple outcome measure in public health research. However, in many low- and middle-income countries (LMIC) there is a lack of evaluation and the cross-cultural validity of SRH remains largely untested. This study aims to explore the prevalence of SRH and its association with mortality in older adults in LMIC in order to cross-culturally validate the construct of SRH.Methodspopulation-based cohort studies including 16,940 persons aged ≥65 years in China, India, Cuba, Dominican Republic, Peru, Venezuela, Mexico and Puerto Rico in 2003. SRH was assessed by asking ‘how do you rate your overall health in the past 30 days’ with responses ranging from excellent to poor. Covariates included socio-demographic characteristics, use of health services and health factors. Mortality was ascertained through a screening of all respondents until 2007.Resultsthe prevalence of good SRH was higher in urban compared to rural sites, except in China. Men reported higher SRH than women, and depression had the largest negative impact on SRH in all sites. Without adjustment, those with poor SRH showed a 142% increase risk of dying within 4 years compared to those with moderate SRH. After adjusting for all covariates, those with poor SRH still showed a 43% increased risk.Conclusionour findings support the use of SRH as a simple measure in survey settings to identify vulnerable groups and evaluate health interventions in resource-scares settings.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurseled service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

IntroductionDepression is commonly comorbid with chronic physical illnesses and is associated with a range of adverse clinical outcomes. Currently, the literature on the role of depression in determining the course and outcome of tuberculosis (TB) is very limited.AimOur aim is to examine the relationship between depression and TB among people newly diagnosed and accessing care for TB in a rural Ethiopian setting. Our objectives are to investigate: the prevalence and determinants of probable depression, the role of depression in influencing pathways to treatment of TB, the incidence of depression during treatment, the impact of anti-TB treatment on the prognosis of depression and the impact of depression on the outcomes of TB treatment.Methods and analysisWe will use a prospective cohort design. 703 newly diagnosed cases of TB (469 without depression and 234 with depression) will be consecutively recruited from primary care health centres. Data collection will take place at baseline, 2 and 6 months after treatment initiation. The primary exposure variable is probable depression measured using the Patient Health Questionnaire-9. Outcome variables include: pathways to treatment, classical outcomes for anti-TB treatment quality of life and disability. Descriptive statistics, logistic regression and multilevel mixed-effect analysis will be used to test the study hypotheses.Ethics and disseminationEthical approval has been obtained from the Institutional Review Board (IRB) of the College of Health Sciences, Addis Ababa University. Findings will be disseminated through scientific publications, conference presentations, community meetings and policy briefs.Anticipated impactFindings will contribute to a sparse evidence base on comorbidity of depression and TB. We hope the dissemination of findings will raise awareness of comorbidity among clinicians and service providers, and contribute to ongoing debates regarding the delivery of mental healthcare in primary care in Ethiopia.

Purpose of the studyPopulations in Latin America, Asia and sub-Saharan Africa are rapidly ageing. The extent to which traditional systems of family support and security can manage the care of increased numbers of older people with chronic health problems is unclear. Our aim was to explore the social and economic effects of caring for an older dependent person, including insight into pathways to economic vulnerability.Design & methodsWe carried out a series of household case studies across urban and rural sites in Peru, Mexico, China and Nigeria (n = 24), as part of a cross-sectional study, nested within the 10/66 Dementia Research Group cohort. Case studies consisted of in-depth narrative style interviews (n = 60) with multiple family members, including the older dependent person.ResultsGovernments were largely uninvolved in the care and support of older dependent people, leaving families to negotiate a ‘journey without maps’. Women were de facto caregivers but the traditional role of female relative as caregiver was beginning to be contested. Household composition was flexible and responsive to changing needs of multiple generations but family finances were stretched.ImplicationsGovernments are lagging behind sociodemographic and social change. There is an urgent need for policy frameworks to support and supplement inputs from families. These should include community-based and residential care services, disability benefits and carers allowances. Further enhancement of health insurance schemes and scale-up of social pensions are an important component of bolstering the security of dependent older people and supporting their continued social and economic participation.