Melanie A Abas | King's College London (original) (raw)

Papers by Melanie A Abas

IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized ... more IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. OBJECTIVE To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.

objective To document the lived experiences of people with both poor mental health and suboptimal... more objective To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings. methods In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team. results The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care. conclusions Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor a... more Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy (ART) and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire - 4.7 points in PST-AD arm versus control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.

IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized ... more IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. OBJECTIVE To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor a... more Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy (ART) and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire - 4.7 points in PST-AD arm versus control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted... more Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The intervention consisted of a single, 50-minute problem-solving cognitive-behavioural intervention session with four skill-based booster sessions, delivered by four lay adherence counsellors in the context of HIV care. Adaptation followed a theoretically driven approach to intervention adaptation, Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT), and included modifications to language, session length, tailoring content for delivery by lay counsellors and inclusion of culturally competent probes. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n = 4) and patients (n = 15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6 months. Next steps from this study include conducting a randomised control trial to evaluate the adapted intervention compared to standard of care in a larger sample over a long-term follow-up.

British Journal of Psychiatry, 2009

Health and Quality of Life Outcomes, 2009

Background There has been very little research on wellbeing, physical impairments and disability ... more Background There has been very little research on wellbeing, physical impairments and disability in older people in developing countries. Methods A community survey of 1147 older parents, one per household, aged sixty and over in rural Thailand. We used the Burvill scale of physical impairment, the Thai Psychological Wellbeing Scale and the brief WHO Disability Assessment Schedule. We rated received and perceived social support separately from children and from others and rated support to children. We used weighted analyses to take account of the sampling design. Results Impairments due to arthritis, pain, paralysis, vision, stomach problems or breathing were all associated with lower wellbeing. After adjusting for disability, only impairment due to paralysis was independently associated with lowered wellbeing. The effect of having two or more impairments compared to none was associated with lowered wellbeing after adjusting for demographic factors and social support (adjusted difference -2.37 on the well-being scale with SD = 7.9, p < 0.001) but after adjusting for disability the coefficient fell and was non-significant. The parsimonious model for wellbeing included age, wealth, social support, disability and impairment due to paralysis (the effect of paralysis was -2.97, p = 0.001). In this Thai setting, received support from children and from others and perceived good support from and to children were all independently associated with greater wellbeing whereas actual support to children was associated with lower wellbeing. Low received support from children interacted with paralysis in being especially associated with low wellbeing. Conclusion In this Thai setting, as found in western settings, most of the association between physical impairments and lower wellbeing is explained by disability. Disability is potentially mediating the association between impairment and low wellbeing. Received support may buffer the impact of some impairments on wellbeing in this setting. Giving actual support to children is associated with less wellbeing unless the support being given to children is perceived as good, perhaps reflecting parental obligation to support adult children in need. Improving community disability services for older people and optimizing received social support will be vital in rural areas in developing countries.

Aging & Mental Health, 2009

Objectives: To assess the concurrent and the construct validity of the Euro-D in older Thai perso... more Objectives: To assess the concurrent and the construct validity of the Euro-D in older Thai persons. Method: Eight local psychiatrists used the major depressive episode section of the Mini International Neuropsychiatric Interview to interview 150 consecutive psychiatric clinic attendees. A trained interviewer administered the Euro-D. We used receiver operating characteristic (ROC) analysis to assess the overall discriminability of the Euro-D scale and principal components factor analysis to assess its construct validity. Results: The area under the ROC curve for the Euro-D with respect to major depressive episode was 0.78 [95% confidence interval (CI) 0.70–0.90] indicating moderately good discriminability. At a cut-point of 5/6 the sensitivity for major depressive episodes is 84.3%, specificity 58.6%, and kappa 0.37 (95% CI 0.22–0.52) indicating fair concordance. However, at the 3/4 cut-point recommended from European studies there is high sensitivity (94%) but poor specificity (34%). The principal components analysis suggested four factors. The first two factors conformed to affective suffering (depression, suicidality and tearfulness) and motivation (interest, concentration and enjoyment). Sleep and appetite constituted a separate factor, whereas pessimism loaded on its own factor. Conclusion: Among Thai psychiatric clinic attendees Euro-D is moderately valid for major depression. A much higher cut-point may be required than that which is usually advocated. The Thai version also shares two common factors as reported from most of previous studies.

Harvard Review of Psychiatry, 2003

... From the Sections of Old Age (Dr. Abas) and Community Psychia-try (Dr. Broadhead), Institute ... more ... From the Sections of Old Age (Dr. Abas) and Community Psychia-try (Dr. Broadhead), Institute of Psychiatry, London; City of Harare Health Department (Dr. Mbengeranwa); and Departments of Ob-stetrics and Gynaecology (Dr. Mbengeranwa) and Psychiatry (Dr. Chagwedera ...

Psychiatric Services, 2008

Australian and New Zealand Journal of Psychiatry, 2003

Social Psychiatry and Psychiatric Epidemiology, 2001

Background: This paper explores the applicability of a psychosocial model of depression in an A... more Background: This paper explores the applicability of a psychosocial model of depression in an African setting. Method: Of a random sample of women (n=172) from a Zimbabwean township, 79 had a severe life event in the year before interview. Twenty-nine who had an onset of depression were compared with 50 who did not. Results: Having crisis support following a severe life event reduced the risk of onset of depression. The effect of crisis support was confounded by the number of severe events in the study year, but just persisted following adjustment for number of severe events and for socio-demographic factors. Women received crisis support more often from relatives than from partners or friends. The following variables were independently associated with onset of depression following a severe life event: number of life events in the previous 6 months, age, being in formal employment, having crisis support and separation from mother in childhood. Conclusion: This study supports the ubiquity of the social support construct. For Zimbabwe, the data suggest that crisis support from family members may be of particular importance in protecting against onset of depression.

Psychological Medicine, 1997

Australian and New Zealand Journal of Psychiatry, 2003

British Journal of Psychiatry, 1994

Psychological Medicine, 1998

IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized ... more IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. OBJECTIVE To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.

objective To document the lived experiences of people with both poor mental health and suboptimal... more objective To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings. methods In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team. results The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care. conclusions Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor a... more Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy (ART) and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire - 4.7 points in PST-AD arm versus control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.

IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized ... more IMPORTANCE Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. OBJECTIVE To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor a... more Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy (ART) and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire - 4.7 points in PST-AD arm versus control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted... more Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The intervention consisted of a single, 50-minute problem-solving cognitive-behavioural intervention session with four skill-based booster sessions, delivered by four lay adherence counsellors in the context of HIV care. Adaptation followed a theoretically driven approach to intervention adaptation, Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT), and included modifications to language, session length, tailoring content for delivery by lay counsellors and inclusion of culturally competent probes. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n = 4) and patients (n = 15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6 months. Next steps from this study include conducting a randomised control trial to evaluate the adapted intervention compared to standard of care in a larger sample over a long-term follow-up.

British Journal of Psychiatry, 2009

Health and Quality of Life Outcomes, 2009

Background There has been very little research on wellbeing, physical impairments and disability ... more Background There has been very little research on wellbeing, physical impairments and disability in older people in developing countries. Methods A community survey of 1147 older parents, one per household, aged sixty and over in rural Thailand. We used the Burvill scale of physical impairment, the Thai Psychological Wellbeing Scale and the brief WHO Disability Assessment Schedule. We rated received and perceived social support separately from children and from others and rated support to children. We used weighted analyses to take account of the sampling design. Results Impairments due to arthritis, pain, paralysis, vision, stomach problems or breathing were all associated with lower wellbeing. After adjusting for disability, only impairment due to paralysis was independently associated with lowered wellbeing. The effect of having two or more impairments compared to none was associated with lowered wellbeing after adjusting for demographic factors and social support (adjusted difference -2.37 on the well-being scale with SD = 7.9, p < 0.001) but after adjusting for disability the coefficient fell and was non-significant. The parsimonious model for wellbeing included age, wealth, social support, disability and impairment due to paralysis (the effect of paralysis was -2.97, p = 0.001). In this Thai setting, received support from children and from others and perceived good support from and to children were all independently associated with greater wellbeing whereas actual support to children was associated with lower wellbeing. Low received support from children interacted with paralysis in being especially associated with low wellbeing. Conclusion In this Thai setting, as found in western settings, most of the association between physical impairments and lower wellbeing is explained by disability. Disability is potentially mediating the association between impairment and low wellbeing. Received support may buffer the impact of some impairments on wellbeing in this setting. Giving actual support to children is associated with less wellbeing unless the support being given to children is perceived as good, perhaps reflecting parental obligation to support adult children in need. Improving community disability services for older people and optimizing received social support will be vital in rural areas in developing countries.

Aging & Mental Health, 2009

Objectives: To assess the concurrent and the construct validity of the Euro-D in older Thai perso... more Objectives: To assess the concurrent and the construct validity of the Euro-D in older Thai persons. Method: Eight local psychiatrists used the major depressive episode section of the Mini International Neuropsychiatric Interview to interview 150 consecutive psychiatric clinic attendees. A trained interviewer administered the Euro-D. We used receiver operating characteristic (ROC) analysis to assess the overall discriminability of the Euro-D scale and principal components factor analysis to assess its construct validity. Results: The area under the ROC curve for the Euro-D with respect to major depressive episode was 0.78 [95% confidence interval (CI) 0.70–0.90] indicating moderately good discriminability. At a cut-point of 5/6 the sensitivity for major depressive episodes is 84.3%, specificity 58.6%, and kappa 0.37 (95% CI 0.22–0.52) indicating fair concordance. However, at the 3/4 cut-point recommended from European studies there is high sensitivity (94%) but poor specificity (34%). The principal components analysis suggested four factors. The first two factors conformed to affective suffering (depression, suicidality and tearfulness) and motivation (interest, concentration and enjoyment). Sleep and appetite constituted a separate factor, whereas pessimism loaded on its own factor. Conclusion: Among Thai psychiatric clinic attendees Euro-D is moderately valid for major depression. A much higher cut-point may be required than that which is usually advocated. The Thai version also shares two common factors as reported from most of previous studies.

Harvard Review of Psychiatry, 2003

... From the Sections of Old Age (Dr. Abas) and Community Psychia-try (Dr. Broadhead), Institute ... more ... From the Sections of Old Age (Dr. Abas) and Community Psychia-try (Dr. Broadhead), Institute of Psychiatry, London; City of Harare Health Department (Dr. Mbengeranwa); and Departments of Ob-stetrics and Gynaecology (Dr. Mbengeranwa) and Psychiatry (Dr. Chagwedera ...

Psychiatric Services, 2008

Australian and New Zealand Journal of Psychiatry, 2003

Social Psychiatry and Psychiatric Epidemiology, 2001

Background: This paper explores the applicability of a psychosocial model of depression in an A... more Background: This paper explores the applicability of a psychosocial model of depression in an African setting. Method: Of a random sample of women (n=172) from a Zimbabwean township, 79 had a severe life event in the year before interview. Twenty-nine who had an onset of depression were compared with 50 who did not. Results: Having crisis support following a severe life event reduced the risk of onset of depression. The effect of crisis support was confounded by the number of severe events in the study year, but just persisted following adjustment for number of severe events and for socio-demographic factors. Women received crisis support more often from relatives than from partners or friends. The following variables were independently associated with onset of depression following a severe life event: number of life events in the previous 6 months, age, being in formal employment, having crisis support and separation from mother in childhood. Conclusion: This study supports the ubiquity of the social support construct. For Zimbabwe, the data suggest that crisis support from family members may be of particular importance in protecting against onset of depression.

Psychological Medicine, 1997

Australian and New Zealand Journal of Psychiatry, 2003

British Journal of Psychiatry, 1994

Psychological Medicine, 1998