Close to 14% of the global burden of disease can be attributed to neuropsychiatric disorders primarily related to the disabling nature of common mental disorders (CMDs), [1,2] which typically include depression, anxiety and psychoactive substance use or alcohol use disorder. A review and meta-analysis of studies between 1980 and 2013 established that 29.2% of individuals globally experienced CMDs at some point in their lifetime. [3] CMDs have been shown to contribute to the burden of disease in low-and middle-income countries, [4-6] and can variously compromise adherence to treatment, health behaviour change and self-management efforts. [7-9] In South Africa (SA), almost a third (30.3%) of the population has experienced a CMD in their lifetime, [10] with a 12-month prevalence estimate of 16.5% for CMDs (anxiety, mood and substance use disorders). [11] Although effective treatment for mental disorders is available [12,13] and can be delivered in routine primary healthcare (PHC), [14] only about half of patients with a depressive disorder in high-income settings are detected [15,16] and only 16.5% of all individuals with a 12-month major depressive disorder receive minimally adequate treatment. [17] In SA this gap is far greater, with only one in four people with a CMD reporting receiving treatment of any kind. [18] While integrating mental healthcare into existing health systems may be the most effective and cost-efficient approach to improve access to mental health services in SA, it requires addressing major knowledge gaps, inter alia the development and assessment of interventions that integrate mental health screening and treatment into existing health systems [8,19] as well as training lay counsellors in the identification of mental disorders. [20] However, screening that is integrated into routine care must use measures that can be administered by nonspecialist health staff, are brief and easy to administer, and promote high specificity given the meagre resources available to treat false positives. [21] Objectives This validation study was a substudy of the Southern African Mental Health Integration project on evaluating the scale-up of evidencebased packages for integration of mental healthcare in PHC settings for depression and alcohol use disorders into routine care that is part of the Mental Health Integration Programme (MhINT). Continuous This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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Objective: Integration of mental health and chronic disease services in primary care could reduce the mental health treatment gap and improve associated health outcomes in low-resource settings. Low rates of nurse identification and referral of patients with depression limit the effectiveness of integrated mental health care; the barriers to and facilitators of identification and referral in South Africa and comparable settings remain undefined. This study explored barriers to and facilitators of nurse identification and referral of patients with depressive symptoms as part of integrated mental health service delivery in KwaZulu-Natal, South Africa. Design: Triangulation mixed methods study incorporating qualitative and quantitative data. Methods: Data collection, analysis, and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Participants were professional nurses at ten primary health care facilities in Amajuba, KwaZulu-Natal, South Africa. Qualitative data collection involved semi-structured interviews targeting specific CFIR constructs with high- and low-referring nurses. Deductive and inductive coding were used to derive primary themes related to barriers and facilitators. Quantitative data collection involved a structured questionnaire assessing determinants explored in the interviews. Qualitative comparative analysis was used to identify the necessary or sufficient conditions for high and low nurse referral. Results: Twenty-two nurses were interviewed. Primary themes related to insufficient training, supervision, and competency; emotional burden; limited human and physical resources; perceived patient need for integrated services; and intervention acceptability. Sixty-eight nurses completed questionnaires. Quantitative results confirmed and expanded upon the qualitative findings. Low self-assessed competency was a consistent barrier to appropriate service delivery. Conclusions: To promote the success of integrated care in a context of severe staff shortages and over-burdened providers, implementation strategies including direct training, structured supervision, and routine behavioral health screening tools are warranted. Interventions to improve mental health literacy of patients as well as emotional support for nurses are also needed.

Background Integration of depression treatment into primary care could improve patient outcomes in low-resource settings. Losses along the depression care cascade limit integrated service effectiveness. This study identified patient-level factors that predicted detection of depressive symptoms by nurses, referral for depression treatment, and uptake of counseling, as part of integrated care in KwaZulu-Natal, South Africa. Methods This was an analysis of baseline data from a prospective cohort. Participants were adult patients with at least moderate depressive symptoms at primary care facilities in Amajuba, KwaZulu-Natal, South Africa. Participants were screened for depressive symptoms prior to routine assessment by a nurse. Generalized linear mixed-effects models were used to estimate associations between patient characteristics and service delivery outcomes. Results Data from 412 participants were analyzed. Nurses successfully detected depressive symptoms in 208 [50.5%, 95% confidence interval (CI) 38.9–62.0] participants; of these, they referred 76 (36.5%, 95% CI 20.3–56.5) for depression treatment; of these, 18 (23.7%, 95% CI 10.7–44.6) attended at least one session of depression counseling. Depressive symptom severity, alcohol use severity, and perceived stress were associated with detection. Similar factors did not drive referral or counseling uptake. Conclusions Nurses detected patients with depressive symptoms at rates comparable to primary care providers in high-resource settings, though gaps in referral and uptake persist. Nurses were more likely to detect symptoms among patients in more severe mental distress. Implementation strategies for integrated mental health care in low-resource settings should target improved rates of detection, referral, and uptake.

Background: People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low-and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa.