The process of mastery of major stressors in children has been much less studied than similar processes in adults. The purpose of this pilot study was to develop and to conduct beginning testing of a new psychological measure to assess the construct of cognitive mastery of stressful events in children, i.e., the Child Cognitive Mastery Scale (CCMS). First, 22 situations involving forced-choice responses were developed around three previously-identified domains: safety and security, just and controllable world, and self-view and pictures portraying these situations were drawn. Then, 56 children, ages 6 to 11 were tested with the CCMS and a depression measure. Twenty-one children were re-tested 7 to 10 days later with the CCMS. Teachers provided ratings of school achievement and parents provided information regarding stressful life events and the child's overall behavior. Results showed evidence of overall test-retest reliability and beginning evidence of inter-administrator reliability. The results also identified some initial "hints" at discriminative and construct validity and seemed, for the most part, to confirm the projective assumption that the childrens' responses would reflect their own views of the world and of themselves. This initial pilot study provided some encouraging information regarding the psychometric properties of the CCMS as well as information regarding needed revisions and some directions for further evaluation and development.

acase@tulane.edu / BACKGROUND Malawi is one of the least developed countries in the world, where the government’s investment in the health care system, including mental health services is very low. As a result, there is limited access to mental health services and general health workers lack training to address mental health issues. Low detection rates of common mental disorders (CMDs) in Malawi suggest that a large percentage of people with CMDs are going unrecognized and untreated. Social capital is important in this context because it may improve mental health for men and women in rural, sub-Saharan settings, such as rural Malawi, where there is little or no mental health care. This dissertation presents three papers related to the relationship between social capital and mental health in rural Malawi. The first paper explores the social determinants of social capital, the second paper examines the relationship between social capital and mental health, and the final paper looks at the role of gender as a moderator in this relationship. METHODS The analyses in this dissertation use a subset of data from the 2008 and 2010 Malawi Longitudinal Study of Families and Health” (MLSFH). The study sample included 1523 females and 994 males who had both 2008 and 2010 SF-12 mental health scores. The seven social capital measures were financial and non-financial transfers given and received, financial and non-financial reciprocity, and social participation. The six mental health measures were the 2010 SF-12 mental health composite score (MCS-12); the 4 components/scales of the 2010 MCS-12 which includes role/emotional functioning, social functioning, vitality, and mental health functioning; and overall satisfaction as perceived by the respondent. Paper #1 used seven ordinary least squared multiple regression and ordered logistic regression models to determine the determinants of social capital in 2008. Paper #2 used six ordinary least squared multiple regression and logistic regression models to determine the association between 2008 social capital measures and mental health outcomes in 2010 from 2008 and 2010 longitudinal data. Paper #3 used six ordinary least squared multiple regression and logistic regression models stratified by sex to determine the association between 2008 social capital measures, 2008 gender attitudes and gender power, and mental health outcomes in 2010 for males and females. RESULTS Paper #1 found that none of the predictor variables were statistically significant for all seven social capital measures, although being from the Central region of Malawi and attending Church in the last week were associated with five out of seven measures. Paper #2 found only one measure of social capital had a positive association with a measure of mental health, while three other measures of social capital had a negative association with a mental health measure. Paper #3 found clear differences between men and women when examining the role of gender on the relationship between social capital and mental health. CONCLUSION These results will inform future studies seeking to measure social capital in rural, sub-Saharan African settings and will provide insights when planning interventions to increase social capital in order to improve mental health for men and women in resource-poor settings. The measures of social capital used in this study should be further explored further and validated in other rural, sub-Saharan African settings. / 1 / Stacy Wallick

Background: Drug use by young people is on the increase globally, regionally and locally, in Zimbabwe. Most of what is known about the risk and protective factors for drug use has been written from studies done in high income countries. Limited studies focused on the low to medium income countries. The available literature for Zimbabwe is a few quantitative studies, done nearly two decades ago. These might not still be relevant today because of the generational changes that have taken place in the society over time. Methods: A qualitative study was conducted in Mufakose, one of the low income high density suburbs of Harare, Zimbabwe. The aim of the study was to find out the reasons why young people in the community were using drugs while others within the same geographical area were not using. A purposive sampling method was used to recruit 40 young people aged between 18 and 24 years who were current drug users, past users and those who had never used drugs at all in their entire lifetime. Individual in-depth interviews and focus group discussions were conducted at two community centres in the community to elicit data from the participants. Data collected from the in-depth interviews and focus group discussions were analysed using NVivo using themes that were derived from literature. Results: Results showed that both risk and protective factors for drug use exist at three levels of human interaction: the micro, meso and macro levels. Micro level risk factors included stressors from the home or living arrangements or workplace, stress due to loss of a loved one, boredom due to unemployment and lack of activities, a lack of commitment to work, sport or school and one's beliefs. Meso level risk factors were exposure to the drug using behaviour by peers and bullying. At family level, exposure to drug use, family conflicts were reported as risk factors. At macro level, drug availability and cost and media influence were cited as risk factors for drug use among the group. For the protective factors leading to non-use, religion was the strongest protective factor at all the three levels. A commitment to work, sport or school was also protective at micro level. Non-exposure to drug using behaviour were protective at the meso level. Conclusion: The current social environment in Zimbabwe together with a breakdown of the country's institutions such as marriage due to death, divorce or migration to other countries. The breakdown has left some children in single parent families vulnerable to a life of drug use. Early initiation into drug use was reported to be through exposure from peers, families and other members of the community as young people in Mufakose are using drugs in-order to escape from the reality of life. Evidence based psychosocial interventions could be used to reduce the impact of drug use among this population.

Includes bibliographical references / Introduction: There is a large treatment gap for people with mental disorders in Africa and other low resourced countries, estimated to be between 70% and 90%. The treatment gap is mainly due to the lack of trained mental health professionals and inadequate mental health service resources in Africa. There has been a growing global movement championed by the World Health Organisation (WHO) to integrate mental health into primary health care as the most effective way of reducing this treatment gap. This study aimed to investigate the impact of WHO Mental Health Gap Action Programme (mhGAP) training and supervision on primary health workers' knowledge, attitudes, confidence and detection rate of major mental disorders in the district of Mulanje, Malawi. Method: The study was a quantitative evaluation using a quasi-experimental method (single cohort pre- and post-measures) and an interrupted time-series design. Forty-three primary healthcare workers from Mulanje, Malawi completed pre- and post- training questionnaires assessing knowledge, attitudes and confidence regarding the assessment and management of major mental disorders. Rates of diagnosis of major mental disorders were obtained from clinic registers for 5 months prior to and 7 months following training. Results: The results showed a significant change on knowledge and confidence scores but not attitudes. The mean knowledge score showed a statistically significantly increase from 11.8 (standard deviation [SD]: 0.33) before training to 15.1 (SD: 0.38) immediately after training; t(42) = 7.79, p <.01. Mean knowledge score was also significantly higher six month post training (13.9, SD: 2.52) than before training; t(42) = 4.57, p < .01. Similarly, the mean confidence score increased significantly from 39.9 (SD): 7.68) before training to 49.6 (SD: 06.14) immediately after training; t(84) = 8.43, p <.01. Mean confidence score was also significantly higher six month post training (46.8, SD: 6.03) than before training; t(84) = 6.60, p <.01. There was no overall significant difference in mean CAMI scores before, immediately after and 6 months after training in all four of the CAMI components. The F-test statistic and P-value for Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology were: F2, 126, 0.05 = 2.5; p =.09, F2, 126, 0.05 = 0.1; p =.9, F2, 126, 0.05 = 0.03; p = 1.0 and F2, 126, 0.05 = 0.04; p = 1.0, respectively. In the months January to May 2014 (before training), median number of cases per month was 77 (inter quartile range [IQR]: 65-87) whereas after training (months June to December) median number of cases was 186 (IQR: 175-197) showing a significant increase in median number of cases before and after the training; p =0.001. Conclusion: The results show clear improvements in the knowledge, confidence and detection of severe mental illness in primary care in Mulanje and demonstrate the potential for narrowing the treatment gap by rolling out mhGAP training nationally in Malawi. The findings of this study add to the growing evidence for policy makers of the effectiveness of mental health training and supervision of primary care workers in a resource-constrained country. Further research is needed to evaluate factors that may lead to change in health worker attitudes, to evaluate training and supervision programmes using more robust evaluation designs, such as randomised controlled trials, and to assess the scale up of mhGAP programmes at larger population levels.

Background: Common mental disorders, which account for a major proportion of disease burden globally, can have an onset in childhood and adolescence. The Friendship Bench is a psychosocial intervention aimed at reducing and treating common mental disorders and is provided at 42 City health department clinics in Harare, Zimbabwe. Yet research and anecdotal evidence suggests that adolescents do not remain engaged in this intervention. Reasons for lack of engagement often include demographic, psychosocial, logistical and cultural factors. Understanding the barriers and facilitators to retention amongst adolescents would help to improve retention and mental health outcomes among this vulnerable population. The aim of this study is to explore the barriers and facilitators that adolescents with common mental disorders experience in retention to the Friendship Bench. Methods: A qualitative study was conducted among adolescents who were aged 15-17 years at the time of accessing the Friendship Bench service. Twelve adolescents who visited the Friendship Bench between June 2016 and December 2017 were recruited using purposive sampling. Theoretical saturation was not reached due to recruitment barriers. The adolescents were recruited from five primary care clinics which were selected based on ease of access to the researcher. Semi-structured interviews with open-ended questions were employed to explore the barriers and facilitators adolescents faced in accessing the service, guided by Andersen’s Behavioural Model of Health services use. The interviews were conducted in a space convenient to the participant or at the participant’s local clinic grounds, and they lasted approximately 30 minutes. The adolescents were interviewed by two qualitative researchers and given the option on whether to be interviewed in Shona or English. Data was analysed using thematic analysis with NVivo 12. Results: Barriers to returning to the service included lack of privacy, school or work commitments, poor social support systems, and lack of a nearby clinic, resulting in having to travel far to access clinic services. Some participants who felt better saw no need to continue coming for sessions. Other emerging barriers found included lay health workers’ (LHWs’) attributes and forgetfulness. Important facilitators to retention included knowledge of what depression is, family support, experience with depressive symptoms, a nearby clinic, having other reasons to visit the clinic, and LHW attributes. Discussion: Given the study’s findings, it is recommended that mobile Friendship Benches and phonebased counselling applications be introduced, in addition to recruiting younger LHWs and male LHWs in order to improve retention. Provision should be made to locate Friendship Benches in more private or youth friendly spaces, to raise awareness on mental health issues in schools and communities and to involve parents and caregivers in the intervention development process. Further investigation into barriers and facilitators into psychosocial interventions is required, particularly with LHWs in order to get their perspective. Conclusion: By identifying barriers and facilitators that adolescents experience, this study contributes towards improving access and retention of adolescents to the Friendship Bench, as well as other psychosocial interventions aimed at adolescents in Zimbabwe.

Background Major Depressive Disorder is a leading cause of disease burden for women of childbearing age. The prevalence of perinatal depression is significantly higher in women from low and middle income countries than from high income countries. Antenatal depression is associated with low birth weight and preterm delivery. There is also evidence that depression during pregnancy can alter the development of a woman's fetus and her child, with an increased risk for child emotional and behavioral problems. Detection of perinatal depression in primary health care (PHC) is very low. This research gathered evidence on the current practice of detection of pregnant women with moderate-severe depression in the Sodo district and explored potential solutions to the identified challenges. Methods A qualitative study was conducted in four health centres and a primary hospital, located in the Sodo district, Ethiopia. In-depth interviews were carried out with pregnant women diagnosed to have depression. Focus group discussions (FGDs) were conducted with antenatal care (ANC) PHC workers. A framework approach to qualitative data analysis was used. OpenCode computer software was used for data handling during the analysis. Results Nine pregnant women were interviewed in-depth and twelve ANC PHC workers participated in two FGDs. Identified themes were categorized under client, provider and system level barriers, and illness related influences. Women's reluctance to disclose symptoms and seek help and not thinking what they had was an illness and/or not thinking they would get help from ANC clinic were client-side barriers to identifying depression. ANC PHC workers not asking about depressive symptoms, their reluctance to disclose a diagnosis of depression to the affected women and not thinking women with mental health problems are in their clinics were the main provider level barriers. The setting not being conducive for depression assessment, inadequate mental health training and ANC assessment format not having a place for recording mental health assessment were system level barriers raised. Difficulty in differentiating clinical depression from normal emotional reaction emerged as the main illness related influence. ANC PHC workers proposed community awareness-raising, improving communication between women and PHC workers and making mental health assessment part of the routine ANC service, among others, as possible solutions to improve detection of antenatal depression in ANC clinics. Conclusion Multiple client, provider and system level barriers to detection of depression in pregnant women in ANC clinics were identified in the current study. The identified barriers call for interventions at different levels; awareness raising at a community level, training on communicating about emotional concerns and mental health care at a provider level and enabling the health care system to support integration of mental health care into maternal health services at a higher level. Follow-up studies are required to better understand the experiences of women and providers, to quantify the magnitude of the problem and to develop and evaluate contextually appropriate interventions to improve detection of depression in pregnant women.

Background: Methamphetamine dependence is associated with impairment in executive function, as well as brain functional and structural alterations, findings on the relationship between executive function impairment and brain alterations seem inconsistent. Methamphetamine dependence may respond to contingency management, yet it is unclear if the treatment response is predicted by these neuropsychological, and brain functional and structural changes, and whether treatment alters neuropsychological impairment. I first conducted a systematic review to rigorously assess available findings on the relationship between executive function impairment and brain functional changes. I then explored data from a study of contingency management in methamphetamine dependence with the aims of determining 1) whether treatment response was predicted by executive function impairment and brain functional and structural alterations, and 2) whether treatment led to changes in executive function and brain functional and structural impairment in treatment responders and non-responders. Methods: The systematic review involved a rigorous search and assessment of articles on the association of stimulant use and resting state functional connectivity. In the empirical study, 33 subjects underwent executive function testing, resting state-fMRI, and structural neuroimaging prior to contingency management treatment. Executive function was assessed with the trail making task, the Stroop-word task, and the Connors continuous performance task. Seed-based analysis was used for functional MRI, with a focus on brain regions associated with executive function, and brain structural alterations were assessed using measures of cortical thickness and surface area. In the statistical analysis, first associations of baseline executive function, rs-fMRI, and brain structural alterations with treatment outcome were assessed using linear regression, and second, comparison of executive function, rsfMRI, and brain structural parameters at baseline versus at treatment end in treatment responders and non-responders was undertaken using linear regression, Cohen's d and a change score. Results: The systematic review noted specific associations between executive function impairment and resting state-fMRI. While in the study, treatment responders had improved executive function at baseline as assessed by two measures (faster completion times on the trail making, and greater accuracy on the Connors continuous performance task), but worse executive function on a third measure (lower accuracy on the Stroop word task) when compared with non-responders. No statistically significant differences between groups was found with regards to rsFC, however greater cortical thickness was found in responders brain regions associated with executive function, in comparison to non-responders. Analysis of pre vs post treatment findings showed that in treatment responders there was better executive function after treatment, in comparison to non-responders (as assessed by greater accuracy on the Connors continuous performance task). Furthermore, in treatment responders there was greater increase in cortical volume in regions associated with executive function, than in non-responders. Conclusion: These findings support the hypothesis that better executive function at baseline (task switching and selective attention) is associated with better outcomes in a contingency management trial of 8-weeks. There is also evidence of improved executive function post trial (in selective attention and cortical thickness findings support improved executive function) implying that abstinence as a consequence of a contingency management trial of 8-weeks may improve executive function, a larger sample size would be needed to determine if improvements extend to other regions of executive function

Background HIV-associated neurocognitive disorder (HAND) is the consequence of the effects of HIV-1 within the central nervous system (CNS). HIV-associated neurocognitive impairment differs in severity with milder forms presenting in 50% of people living with HIV (PLWH), regardless of treatment status. Chronic immune dysregulation has been associated with HAND; in particular, it has been noted that inflammation persists despite the successful treatment with antiretroviral therapy (ART). However, the nature to which (neuro)inflammation influences cognitive performance and brain integrity remain unclear. Further, it is not clear how sequence variation in neurotoxic viral proteins, including Tat, affects inflammation in PLWH. This study aimed to 1) perform a systematic review of the existing literature to identify changes in peripheral immune markers that are associated with HAND in ART-experienced PLWH, 2) determine the association of blood peripheral immune markers with domain-based neurocognitive performance and structural brain changes in South African PLWH, and 3) lastly, to evaluate the possible influence of Tat sequence variation on a dysregulated immune profile in HIV-1C infection (i.e. Tat-C). Methods A systematic review of the published literature was performed to identify the most common markers associated with HAND in the ART-era. A panel of markers was measured in a treatment naïve South African cohort by enzyme-linked immunosorbent assays (ELISA). Cognitive performance was established using a battery of tests sensitive to HIV-associated neurocognitive impairment, with domain based scores utilized in analysis. Thickness and surface area of all cortical regions were derived using automated parcellation of T1-weighted images acquired at 3T. Markers were correlated with neurocognitive performance and cortical thickness and surface area. Further, a prospective review of the literature was performed to determine the association between Tat sequence variation and underlying mechanisms (and inflammation) of HAND. The HIV-1 was genotyped and the influence of Tat sequence variation on immune marker levels was evaluated in a subset of South African participants. Results A systematic review of the existing literature suggested that peripheral immune markers of monocyte activation (sCD14 and sCD163) and inflammation (IL-18 and IP10) were associated with HAND in the majority of studies. Evaluation of blood immune markers in a treatment naïve South African cohort showed that thymidine phosphorylase (TYMP) and neutrophil gelatinase-associated lipocalin (NGAL) levels were significantly higher, while matrix metalloproteinase (MMP)9 levels were significantly lower in PLWH. The results further showed that in PLWH, worse psychomotor processing speed was associated with higher TYMP and NGAL levels and worse motor function was associated with higher NGAL levels. Further, in imaging analysis, it was reported that higher NGAL levels were associated with the reduced thickness of the bilateral orbitofrontal cortex. The association of NGAL withworse motor function was mediated by the cortical thickness of the bilateral orbitofrontal cortex. The associations between higher NGAL and TYMP levels with cortical thickness were largely found in the regions of the frontal cortex. A review of the literature suggests that key protein signatures (C31S and R57S) present in the Tat protein from HIV-1 subtype C (Tat-C) infection may contribute to the lowered inflammation. Supporting this hypothesis, the results from this thesis showed that HIV-1C participants with the R57S mutation had lower peripheral TYMP levels. Conclusions Current literature supports the premise that chronic inflammation may be an important contributor to the development of the milder forms of HAND. For patients on ART, other strategies are required to address the ongoing peripheral inflammation, in addition to simply suppressing the viral load. In a South African context, TYMP and NGAL may be promising markers for their involvement in HAND. Patients were largely treatment-naïve; therefore, these markers may represent HIV related effects without the potential confounding effects of ART. Therefore, these findings may represent long-standing effects which might persist in treatment experienced participants. In HIV-1C infection, the level of certain inflammatory markers may be influenced by the R57S Tat protein signature. To our best knowledge, this is the first thesis to report the association of these markers with HAND. These immune markers need to be investigated for their potential role in the underlying mechanisms of HAND.

Colleges in the United States today are facing a mental health crisis. Nearly one-third of students are diagnosed with a mental health condition, which is only aggravated by the stress of college environments. The alarming rate of student suicides indicates a need for increased support from institutions. Despite recent efforts across the nation to improve the accessibility and outreach of existing services, on-campus resources cannot sufficiently meet student needs. As a result, the majority of students suffering from mental and emotional distress are not receiving any form of counseling or treatment. Individuals who live with a serious mental illness are at higher risk for chronic medical conditions and typically have a shorter life expectancy, making treatment for these mental disorders essential to their well-being. Architecture offers an opportunity to influence human behavior and cognition by exposing people to different worlds from their own. This thesis investigates the power of manipulating architectural atmospheres in affecting human perception. Experiencing a space is more than the visual perception of aesthetics and form; it involves the sensory experience of the body to evoke an emotional and physical response (Goodwin). Spatial qualities, like materiality, lighting, color, degree of enclosure and proportioning, contribute to the sensory experience of a space, informing how people feel in it. Manipulating these qualities to produce a sequence of spatial experiences, representative of a range of mental states, can help everyday people empathize with those suffering from mental illnesses, while offering an outlet for those with a mental health condition. / 0 / SPK / specialcollections@tulane.edu

This study examined whether faculty members’ mental health literacy and perceptions of their role in communicating with college students influenced willingness to intervene and refer students impacted by mental health concerns to available services and support. Study participants (N=246) included faculty members from a four-year research university and a two-year community and technical college. Participants completed an online survey assessing their mental health literacy, perception of their role in communicating with students about mental health concerns, and willingness to intervene and refer students. Results indicated an overall willingness to assist students with mental health concerns, but also showed the continued existence of mental health-related stigma and a lack of training and direction for faculty. Results further revealed that faculty members’ view of their role directly impacts their confidence and willingness to intervene and refer students to help. Practical implications for institutions, as well as recommendations for future research, are discussed.