In 2014, the World Health Organisation (WHO) declared the 2014–2016 West African Ebola outbreak as a “public health emergency of international concern”, an epidemic that eventually engulfed three West African countries of Guinea, Sierra Leone, and Liberia, infected 28,616 persons, led to 11,310 deaths and left over 10,000 survivors (1). Ebola Virus Disease (EVD) is now considered a threat to public health in the heavily populated regions of east, central and west Africa where since 1976 at least 35 EVD outbreaks have been reported (2). To-date, Uganda has had 7 Ebola outbreaks with the most recent having occurred between 20th September 2022 to the 11th of January 2023, affected 9 districts (Mubende district was the epicentre), infected 164 persons (142 confirmed and 22 probable), led to 55 confirmed deaths, with 87 survivors and 4,000 contacts (3).
EVD is not only associated with a high mortality and physical morbidity, but also with mental health disorders. EVD related mental health disorders do not only affect EVD survivors, but also frontline health workers and volunteers and members of the affected communities (2, 4–8). Ebola survivors have been reported to develop the mental health problems of depression, anxiety, post-traumatic stress disorder (PTSD) and insomnia. These occur as a result of a number of factors including the trauma associated with the EVD illness experience (including the manner of evacuation from home that involves destruction of personal effects to prevent transmission of disease, and the harrowing experience in the Ebola treatment unit), being infected with a highly fatal disease, loss of loved ones, rejection, isolation stigmatisation by the community, and possibly as a result of secondary central nervous system (CNS) viral invasion with recent evidence pointing towards clinical and imaging features indicative of meningoencephalitis and meningitis (2, 4–8). For healthcare workers, providing medical care for EVD infected patients is mentally very stressful due to treating very sick patients, the high mortality in the Ebola treatment units, extended work shift times, risk of infection, fear of infecting family members, witnessing the death of colleagues, and having to wear personal protective equipment (which is uncomfortable, impairs communication and performance of diagnostic and therapeutic procedures). These all contribute to predisposing frontline health workers and volunteers to anxiety, depression, PTSD, fatigue and social isolation (9, 10). For members of Ebola affected communities, loss of loved ones, having loved ones isolated in Ebola treatment units and isolation centres, rejection and stigmatisation, threatened violence and sometimes actual violence and economic and social disruption associated with community lockdowns all contribute to mental health disorders (5, 10, 11). EVD associated mental health disorders if not treated have been reported to have a tendency to chronicity with Kelly et al., (2019) in a follow-up study of EVD survivors of the 1995 Ebola Outbreak in Kikwit, DRC reporting persistence of depressive and anxiety symptoms two decades after the outbreak (2).
Despite this demonstrated need, the implementation of community mental health services in EVD affected communities remains poor (12). This has been attributed to a number of reasons that include: affected communities are often remote and suffer from chronic war conflict; health systems in many sub-Saharan African countries are fragile as demonstrated during the 2014–2016 West African Ebola outbreak where a 2015 World Bank report noted that at the time of the West African Ebola outbreak, the number of mental health workers (including psychiatrist) in the local population was as low as 1 in 6 million in Sierra Leone and 1 in 25,000 in Liberia (13); a lack of prioritisation of mental health by international humanitarian donor agencies in preference for biomedical interventions (14, 15). Therefore, there is an urgent need to commit more resources to mental health care in vulnerable regions including developing novel approaches to addressing this mental health burden.
One endeavour in this direction is being undertaken by the Mental Health Focus Area of the Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit (MRC/UVRI & LSHTM Uganda Research Unit) in partnership with the Ministry of Health of Uganda, entitled, ‘Proposal to address the medium- to long-term EBOLA associated psychological Distress and psychosocial problems in Mubende District in central Uganda (Ebola + D Project)’. The Ebola + D Study will be undertaken in Mubende District in central Uganda (the epicentre of recent Uganda EVD outbreak). This protocol describes the process that will be employed to develop, and pilot test the Ebola + D mental health intervention model to address the mental health problems of the Ebola affected Mubende district.
Mental health care in the Mubende district at the time of the 2022–2023 Ebola outbreak
Mubende district (population 720,000) at the time of the Ebola outbreak had limited mental health services that primarily consisted of 1 mental health department at Mubende Regional Referral Hospital. The entire district mental health work force consisted of only 12 mental health workers (1 psychiatrist, 2 psychiatric clinical officers and 9 psychiatric nurses) all based at the regional referral hospital with no primary mental health services at the more than 42 public health facilities in the district (Dr Kenneth Kalani, field coordinator of the Ebola MHPSS response- personal communication December 2022). Following the Ebola outbreak in Mubende district on the 20th September 2022, the Ministry of Health of Uganda, established an Ebola National Task Force that had as one of its sub-pillars the Ebola Mental Health and Psychosocial Support Services (MHPSS). The MHPSS sub-pillar outlined three objectives: i) enhance the capacity of health workers and community volunteers to offer mental health and psychosocial support, ii) extend mental health and psychosocial support services to various segments of the community including EVD survivors and members of the affected community, and iii) provide mental health and psychosocial support services specifically tailored for frontline health workers. In the immediate aftermath of the outbreak, Mubende district saw an influx of psychosocial workers who supported the district to address the immediate mental health and psychosocial effects of EVD. In preparation for the scale down of MHPSS, the Ministry of Health with support of partners trained 90 members of the Village Health Team (VHT; the first level of primary health care in the Uganda health system; 10 VHTs per sub-county) to provide continued mental health and psychosocial support to the district. However, no mechanism was put in place to provide continued support for the trained VHTs and for upward linkage of referrals to the Mental Health Department at Mubende Regional Referral Hospital.
Ebola + D Mental Health Intervention
To address the above identified gap, the Mental Health Focus Area of the MRC/UVRI & LSHTM Uganda Research Unit proposes to develop and pilot the Ebola + D mental health intervention model that would employ a collaborative stepped care approach modelled on the HIV + D mental health intervention (a depression integration model that has shown effectiveness against depression and anxiety disorder in adult HIV care in Uganda) (16) which was developed by the Mental Health Focus Area modelled on the MANAS mental health intervention that demonstrated effectiveness and cost-effectiveness in primary healthcare in India (17). The development of the Ebola + D intervention will be guided by four principles: i) the intervention should address the health system challenges in the district (low mental health literacy in the community, and inadequate knowledge and skills of non-specialist primary health care workers to identify and support patients with mental health issues; severe shortage of mental health workers in the district; shortage of other cadres of health care workers; a poor referral system in the district) (18, 19); ii) use the best global practices hence the task-shifting approach of using supervised trained lay health workers to deliver low intensity psychological treatments (17, 20, 21); iii) the selected clinical treatments should have been shown to be effective against the target mental disorders (depression, anxiety disorders and PTSD), hence the selection of the psychoeducation (22), the transdiagnostic Problem Solving Therapy (PST) (23), and the use of Selective-Serotonin Re-uptake Inhibitors (SSRIs) for depression, anxiety disorder and PTSD (24–26)), iv) and the intervention should be guided by the specific needs of the patient and aligned with the concepts of person-centred care (27). The overall goal of the Ebola + D intervention will be recovery from the mental health disorders (depression, anxiety and PTSD). This will be guided by two rules: allocation of the clinical treatments based on decision rules defined by severity of symptoms and response; and planned reviews of response at regular intervals (monthly until remission). The locally validated Luganda (Luganda is the predominant local language spoken in central Uganda) or English version of the WHO- Self Report Questionnaire (SRQ-20) (28, 29) will be used by the trained lay health workers (members of the Village Health Team) to screen members of the community for psychological distress. The SRQ-20 which was developed by the WHO specifically for low- and middle- income (LMIC) settings employs a yes/no answer format (which is amicable to lay health workers who often have low levels of literary) and is designed to detect non-specific psychological distress, including suicidality (28).
The Ebola + D intervention will be delivered by the health centre based medical team, in partnership with members of the village health team (VHT; the first level of the Ugandan health care system). The intervention will be coordinated by a designated mental health contact person at the participating Health Centre III or IV (either a general nurses or general clinician, working at the health facility), and will be supported by mental health professionals based at Mubende Regional Referral Hospital.
The Ebola + D intervention will involve 4 steps:
Step 1 (Initiation of treatment): Patients with SRQ-20 scores of ≥ 6) (demonstrated 84% sensitivity and 93% specificity) (28) are advised about their scores and offered Psychoeducation (undertaken by a lay health worker, member of the VHT)
Step 2: (Management of moderate to severe cases): Patients who remain symptomatic at follow up (SRQ-20 score ≥ 6, after 4 weeks) despite Step 1. These will be offered Problem Solving Therapy (PST; minimum 4 sessions, maximum 8 sessions) (undertaken by a lay health worker, member of the VHT).
Step 3: (Monitoring outcomes): If after 6 sessions of PST, SRQ-20 scores are still 6 and above, complete PST sessions and add Selective Serotonin Re-Uptake Inhibitor (SSRI; such as Fluoxetine 20mg/day for 6 months) (SSRI medication initiated by clinician).
Step 4: (Referral to Mental Health Specialist/ Clinician in charge of facility): If despite Step 3 there is no improvement (SRQ-20 scores 6 and above); or at initiation of treatment or during any phase of treatment, if someone is deemed to have a high suicide risk confirmed by the supervisor (contact general nurse or clinician), following a positive SRQ-20 item 16 (‘do you feel that you are a worthless person?’) or/and item 17 (‘has the thought of ending your life been in your mind?’) (28), then continue all existing treatment and refer to a specialised mental health worker (psychiatrist, psychiatric nurse or psychiatric clinical officer at Mubende Regional Referral Hospital).
The Ebola + D mental health intervention will be delivered at 11 public health care facilities (Health Centre IIIs and IVs) in the district of Mubende. At each of the 11 public health care facilities, this mental health intervention will be delivered by a team that will include: 2 trained lay health workers (selected from members of the Village Health Team); a supervisor (selected from the health centre), clinicians (from the health centre); and a visiting specialist mental health worker (psychiatric clinical officer or psychiatric nurse from Mubende Regional Referral Hospital).
To develop the Ebola + D mental health intervention, we shall employ the methodology developed by PREMIUM (Program for Effective Mental Health Interventions in Under-Resourced Health Systems) (30) where participatory, theory-informed approaches will be used. The Mental Health Focus Area of the MRC/UVRI & LSHTM Uganda Research Unit has previously employed this methodology to support the development of the HIV + D mental health intervention. This will involve the following: i) develop a Health Talk about the psychosocial and mental health problems associated with EVD to be delivered at the triage area where community members who have come to access health services at the public health care facilities are waiting (to increase mental health literacy, messages will be drawn from the WHO Psychological First Aid Manual) (31); ii) will develop the message that will be given in the Psychoeducation Session (1st step of care in the Ebola + D mental health intervention); iii) will undertake the local adaptation and translation of Problem Solving Therapy for Primary Care (PST-PC) treatment manual (32); iv) will undertake the training and supervision of lay health workers and their supervisors; v) will undertake the training of clinicians in mhGAP guidelines (including use of SSRIs) (33).