Mental health outcomes, literacy and service provision in low- and middle-income settings: a systematic review of the Democratic Republic of the Congo

In the Democratic Republic of the Congo (DRC), the prevalence of mental health issues could be greater than in other low-income and middle-income countries because of major risk factors related to armed conflicts and poverty. Given that mental health is an essential component of health, it is surprising that no systematic evaluation of mental health in the DRC has yet been undertaken. This study aims to undertake the first systematic review of mental health literacy and service provision in the DRC, to bridge this gap and inform those who need to develop an evidence base. This could support policymakers in tackling the issues related to limited mental health systems and service provision in DRC. Following Cochrane and PRISMA guidelines, a systematic (Web of Science, Medline, Public Health, PsycINFO, and Google Scholar) search was conducted (January 2000 and August 2023). Combinations of key blocks of terms were used in the search such as DRC, war zone, mental health, post-traumatic stress disorder (PTSD), anxiety, depression, sexual violence, war trauma, resilience, mental health systems and service provision. We followed additional sources from reference lists of included studies. Screening was completed in two stages: title and abstract search, and full-text screening for relevance and quality. Overall, 50 studies were included in the review; the majority of studies (n = 31) were conducted in the Eastern region of the DRC, a region devastated by war and sexual violence. Different instruments were used to measure participants’ mental health such as the Hopkins Symptoms Checklist (HSCL-25), The Harvard Trauma Questionnaire, Patient Health Questionnaire (PHQ-9); General Anxiety Disorder (GAD-7), and Positive and Negative Symptoms Scale (PANSS). Our study found that wartime sexual violence and extreme poverty are highly traumatic, and cause multiple, long-term mental health difficulties. We found that depression, anxiety, and PTSD were the most common problems in the DRC. Psychosocial interventions such as group therapy, family support, and socio-economic support were effective in reducing anxiety, depression, and PTSD symptoms. This systematic review calls attention to the need to support sexual violence survivors and many other Congolese people affected by traumatic events. This review also highlights the need for validating culturally appropriate measures, and the need for well-designed controlled intervention studies in low-income settings such as the DRC. Better public mental health systems and service provision could help to improve community cohesion, human resilience, and mental wellbeing. There is also an urgent need to address wider social issues such as poverty, stigma, and gender inequality in the DRC.


INTRODUCTION
Poor mental health in low-and middle-income countries (LMICs) has become a real concern, due to its impact on human wellbeing, national disease burden, premature death, economic loss, and social cohesion 1,2 .Mental health is an integral component of health, defined as a state of physical, mental and social well-being and not merely the absence of disease or infirmity.According to the World Health Organization (WHO), mental health is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" 3 .Mental health conditions are problems involving changes in emotion, thinking or behaviour (or a combination of these), which are associated with distress and/or difficulties functioning in social, work or family activities 3 .Mental health is one of the most neglected areas of public health.Across the globe, close to one billion people are living with a diagnosis of mental disorder, and every 40 s one person dies by suicide 2 .Things have worsened in recent years as billions of people around the world have been affected by the COVID-19 pandemic 4,5 .
While many developed nations are making progress in supporting people with mental health conditions, in LMICs, more than 75% of people with mental, neurological and substance use problems receive no treatment or support at all.Unfortunately, stigma, discrimination, punitive legislation, lack of adequate health information, poor political will and human rights abuses are still widespread 1 .Additionally, a medical diagnostic model is the primary global mode of identifying mental health problems.The dominance of this approach and the limits of its biological treatments (such as drugs and hospital admission) are an additional threat to human rights.There is a real need to develop effective, especially psychosocial, mental health interventions in low-resource settings such as the DRC 1,2 .We therefore decided to undertake the first systematic review of the literature to examine the mental health literacy, symptoms, systems and service provision in DRC.
DRC is the largest country in sub-Saharan Africa, and because of its huge natural wealth and poor governance, DRC has suffered several wars including 1998 war involving nine African countries which was the deadliest conflict worldwide since World War II.Some authors describe DRC as in a chronic emergency, with endemic poverty, conflict, violence, forced dislocation of ethnic groups, and the use of torture and rape as weapons of war 6 , which have devastating effects on people's mental health 7,8 .Previous studies have reported that people living in 'humanitarian settings' in LMICs such as DRC are exposed to a constellation of physical and psychological stressors that make them vulnerable to developing what are often called 'mental disorders' 9 .On top of DRC's war, the COVID-19 pandemic has affected health infrastructure 10 and worsened the mental health problems of the population 11 .While many low-income countries have made some progress, the WHO 2019 report shows that DRC was not among 70 countries and territories that have so far prioritized coverage of mental health disorders 2 .This literature search aims to bridge this gap and inform those who need to develop an evidence base.We hope to help policymakers in tackling the issues related to limited mental health systems and service provision in DRC.

Aims of the study
This study is the first systematic evaluation of mental health in low-resource settings of the DRC.The systematic evaluation looks at mental health literacy, symptoms, outcome measures, mental health systems and service provision in DRC.Mental health literacy has been defined as knowledge and beliefs about mental health disorders that aid their recognition, management, or prevention 12 .Mental health systems and service provision focused on DRC's institutions and services that provide support to people with mental health conditions.The service provision included community-based support, respite for families and caregivers, traditional healers, and basic necessities such as shelter and clothing for people with mental health disorders 1,13 .

METHODS
The systematic review was conducted and reported according to Preferred Reporting Items for Systematic Reviews, Meta-Analyses (PRISMA), Cochrane Handbook recommendations 14,15 and the COSMIN Risk of Bias checklist for systematic reviews 16 .

Search strategy and data sources
Systematic searches of the literature published between January 2000 and August 2023 were carried out using Web of Science, MEDLINE, Public Health, PsycINFO and Google Scholar.Combinations of two key blocks of terms were used: (1) Democratic Republic of Congo, DRC, Zaire, Low-income country, low-income settings, Poor nations, Sub-Saharan country, War zone and (2) mental health, symptoms, outcome measures, validity assessment, PTSD, anxiety, depression, schizophrenia, psychosis, psychotic, ICD-10, rape, sexual violence, war trauma, mental health integration into general health care, and mental health systems and service provision.We also checked the reference lists of the studies meeting our inclusion criteria.Our search strategy used Jorm's definition and conceptual framework to identify eligible studies 12 .The search strategy in each of the databases is presented in Supplementary Fig. 1.The search and screening process was conducted by two reviewers (Fig. 1).

Study selection
Screening was completed in two stages.Initially, the titles and abstracts of the identified studies were screened for eligibility.Next, the full texts of studies initially assessed as "relevant" for the review were retrieved and checked against our inclusion/exclusion criteria.The screening process is presented in PRISMA Flow Diagram (Fig. 2).

Eligibility criteria
Studies were eligible for inclusion if they met the following criteria: studies that have been conducted in DRC, and studies that have evaluated mental health literacy.Also included were the studies that assessed mental health service provision.Papers published in English and French were included, regardless of study design (e.g., qualitative, quantitative, randomized controlled trials, nonrandomized, descriptive studies, mixed-methods, and cluster randomized controlled trials).This systematic review therefore included studies that explored at least one of the main components of mental health literacy and/or service provision, which are: assessment of mental health, receiving a diagnostic label, understanding signs of poor mental health, training and health professionals, treatments, community-based support, prevention, stigma, abuses, and mental health institutions and management.

Data extraction
An Excel file was devised for the purpose of data extraction.Two people conducted the data extraction and screening.This extraction was piloted across five randomly selected studies and

Quality appraisal and assessment
The quality appraisal was used to (a) find the most relevant studies, (b) get rid of irrelevant and weak studies, (c) separate evidence from opinions, and (d) identify any risk of bias.Following PRISMA and COSMIN recommendations, studies were rated for their quality by one researcher and verified by another researcher using criteria adapted from guidance on the quality assessment tools for quantitative studies 14,16,17 .Any disagreements were resolved by discussion.The quality review included assessment of (1) adequate information on population and recruitment methods, (2) robust research design, verified if (3) the mental health outcome measure used was valid and reliable, and determined if the (4) outcome variable was clearly identified and appropriate.The quality rating score was calculated by awarding one point for each of the criteria achieved (maximum 4).This appraisal process was done during the data extraction and verified after the systematic review was written.

RESULTS
We retrieved 384 studies.After removing duplicates (n = 240), studies were assessed and 56 articles were excluded after reading the titles and the abstracts for not investigating mental health disorders.Eighty-nine full-text studies were assessed and 39 articles were excluded for several reasons such as not using participants who were in the DRC; some studies looked at the mental health of refugees who were settling in other countries; and protocol studies were also excluded.Overall, 50 studies were included in the final analysis.While the quality appraisal was carefully and systematically followed, 19 of 50 studies were crosssectional and investigated the association between key variables as we have described below.The flowchart of the screening and selection process 15 is shown in Fig. 2. Thirty-one studies (64%) were conducted in the Eastern region of the DRC, a region devastated by war and sexual violence 6 .Among the remaining 19 studies, two were cross-national looking at the association between key factors 18,19 , four looked at the service provision at the national level [20][21][22]  Most studies collected primary data using questionnaires, interviews, and observation.Six studies included longitudinal follow-ups [23][24][25] .Few studies used secondary data to investigate women who experienced sexual violence in Eastern DRC 26 , and service provision and psychiatric treatment in Kinshasa 27 .Several designs were used including descriptive, correlational, causal-comparative/quasi-experimental, and experimental research.Randomized controlled trials and step-wedged design were used where participants were pre-tested and post-tested 3 and 6 months later 24 , and 8 months later 23 .Eighteen studies were cross-sectional and descriptive.Three studies used qualitative ethnographic and case study designs where participants were interviewed with semi-structured interviews and focus groups [28][29][30] .

Mental health outcome measures and validity assessment
Different instruments were used to measure participants' mental health (e.g.anxiety, depression, and PTSD), partner intimate violence, stigma, experience of sexual violence, and exposure to adversity (e.g.Ebola virus outbreaks).Most studies assessed depression (n = 19), anxiety (n = 15), and PTSD (n = 14) symptoms of their participants.For anxiety and depression, the Hopkins Symptoms Checklist (HSCL-25) was the most common measure 24,31 .One recent study used both Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) to assess the prevalence of depression and anxiety during the pandemic COVID-19 32 .The Harvard Trauma Questionnaire was the most common measure used to assess PTSD.Positive and negative symptoms scale (PANSS), for example, was used to identify possible deficits in facial emotion recognition among patients with schizophrenia 33 .Stressful life events were assessed using the Impact of Event Scale revised version (IES-R) 29 .To assess stigma, a 20-item scale that measures 20 possible forms of stigmatization related to Ebola Virus Disease (EVD) was used 34 .Most instrument measures used multiple items to assess participants' mental health and other conditions.Of 50 studies, 21 studies used questionnaires adapted from other standardized measures used in other countries.One study validated two broadly used mental health self-report measures: the Impact of Event Scale Revised (IES-R) and the Hopkins Symptom Checklist 37 for Adolescents (HSCL-37A) 29 , and another study validated two standard depression measures: the Edinburgh Post-partum Depression Scale and the Hopkins Symptom Checklist 28 .A small number of two studies used selfdesigned surveys to measure the positive impact of socioeconomic projects on the mental health and well-being of sexual violence survivors 23 , or young people in war zones 35 .

Psychosocial interventions
Six studies looked at psychosocial interventions, where four focussed on group therapy and family support, and the other two investigated socio-economic support.
Amongst the studies that focussed on group and family therapy, we noticed variation in the way participants were supported.For example, after 6-month follow-ups, group psychotherapy reduced PTSD symptoms and combined depression and anxiety symptoms among Congolese women survivors of sexual violence 36 .A cross-national study conducted in DRC, Mali and Nigeria found that the involvement of family and other caregivers in psychosocial support reduced the symptoms of depression and anxiety among war-wounded men 18 .Similar positive findings were found in another cross-national study, where brief trauma-focused therapy and Medicine Sans Frontier (MSF) mental health therapeutic intervention were used among young people.Brief trauma-focused therapy appears to be effective in reducing symptoms among young people exposed to armed conflict in DRC, Iraq and the Occupied Palestinian Territory 19 .Moreover, a 12-week music session and community engagement programme led by a psychologist and music producer were associated with significant improvement in women's mental health, which was sustained up to 6 months post-completion of the programme, despite instability in the region and evidence of continued experience of conflict-related trauma 24 .
Regarding socio-economic support, two studies reported that people living in war-affected zones of the DRC are often poor and have limited access to traditional financial institutions.However, microfinance programmes have the potential to help in improving income, economic productivity and mental health 37 .Two studies found that group-based economic interventions were effective to support female sexual violence survivors 23,37 .An innovative productive asset transfer programme, Pigs for Peace (PFP), increased economic stability, improved subjective health and mental health in 10 conflict-affected villages 37 .

Stigma and rejection
Five studies highlighted the stigma and rejection.The stigma around mental health issues and social rejection were depicted in various ways across the reviewed studies.For example, a study on sexual violence survivors revealed that rape survivors need a way to regain their "worth" in the family and the village 38 .Many women experienced significant physical and mental health consequences of sexual violence and were rejected because of the stigma around mental health and the violence itself 39 .The social rejection was closely linked with spousal rejection.The perceived loss of dignity, the shame of living with a woman who had experienced rape, and the influence of the family members were contributing factors to spousal rejection 39 .However, genderbased violence is not a mental health problem: contributors to violence against women include social norms and attitudes, economic inequality, and women's lack of socio-political power.Mental health support should sit alongside social and structural interventions such as economic help 23 and addressing attitudes that enable violence against women 31 .
Our search suggested that mental health awareness may help to reduce some general stigma around mental health difficulties, because many people in the DRC region believe that mental health problems are a curse of witchcraft, or caused by bad spirits 40 .Social stigma and rejection can link to local beliefs about mental distress: a family may prefer to go to a traditional healer, or to an exorcist pastor/priest to pray rather than seek more 'professional' interventions 40 .This study found that some people may believe that the consequences of the war are only physical, and ignore the consequences of the war from a psychological point of view 20 .

Mental health systems, service provision and training
There are very few hospitals for the treatment of mental health disorders in DRC.The country has only six public psychiatric hospitals, and a dozen private mental health centres with 500 beds for nearly 90 million inhabitants, almost all of which are in big cities 41,42 .Among the few well-known specialized mental health facilities, Kinshasa, the capital city, has two mental health hospitals, the Centre Neuro-Psycho Psychiatrique de Kinshasa (CNPP) run by the University of Kinshasa, and the Telema Mental Health Centre which is managed by the Roman Catholic Church.In provinces, DRC has: the CNPP at the Katwambi Centre (Centre de Katwambi) in the province of Western Kasai; the Doctor Joseph Guillain of Lubumbashi Neuropsychiatric Centre (Centre Neuropsychiatrique Docteur Joseph Guillain de Lubumbashi); the Department of Neuropsychiatry of Sendwe Hospital in Lubumbashi in Katanga province; and the psychiatric facilities in the South-Kivu province called Centre Psychiatrique de Soins de Santé Mentale (SOSAME) in Bukavu 20,41 .We also note how this lack of hospital provision links to the need for a change of focus towards the social causes of poor mental health.It's unlikely that existing mental health training has yet caught up with this mandate for communitycentred and social (rather than biological) treatments, even in those few existing hospitals.
Three studies in this review highlighted the need for training local staff 20,43,44 .An intervention programme for 441 women sexual trauma victims found that training local staff showed improved knowledge, enhanced awareness and provided them with tools to recognize sexual assault and to provide psychological support 43 .Another study, implementing mental health services in an area affected by prolonged war and Ebola disease outbreak, found deficiencies in mental health services, and no functional work plan was in place.However, integrative training programmes, advocacy and social mobilization, provision of emergency mental health services, and community outreaches were needed in the region 44 .
DRC's mental health policy was formulated in 1999 but so far, there are no budgetary allocations for mental health.The DRC mental health policy promotes a recovery approach to mental health care, which emphasizes support for individuals to achieve their aspirations and goals.Unfortunately, not much has been done due to the lack of a budget allocated to mental health 20,40,41 .
Integration of mental health care into the general health care and who can afford health cost A study conducted in the eastern DRC, looking at the experience of integrating mental health care into the general health care system, found that it is possible.3941 patients used care offered at health centres and the district hospital between 2012 and 2015, and an average of 7 new cases/1000 inhabitants per year was recorded 42 .Moreover, a study that interviewed 16 psychiatrists in Kinshasa supported the idea that mental health care can be integrated into general health care if new ways of approaching global mental health are applied.For example, using more responsive forms of support which acknowledge the value of patient experiences 45 , and are not limited to the reductive rationalism typical of the biological paradigm 45 .A household survey to which 591 residents responded and five focus group discussions (FGDs) were held with 50 key stakeholders (doctors, nurses, managers, community health workers and leaders, health care users) found that the integration of mental health care into the primary care system is difficult in Lubumbashi due to the lack of service provision 41 .For example, the study found that there are no dedicated psychiatric beds, nor is there a psychiatrist or psychologist available.Participants in the FGDs stated that in this context, the main source of care for people remains traditional medicine 41 .
Another study looking at who can afford health care found that most of the Congolese population struggles to afford health care costs because 47% of households earn <US $5.50/week 46 .Figures suggest that diagnosable mental health disorders are as common in the DRC as elsewhere: 6-15% of people meet the criteria for schizophrenia; 22% for anxiety disorders; and 13-23% for mood disorders 20 .Yet, individuals and their families absorb costs related to drugs, treatment, food, bedding, and hospitalization in a country where most people live on less than US$2 per day 46,47 .The impact of this financial burden is greater for women, as they have less income 48 .Interviews with 552 households found that to afford health care people may sacrifice other basic needs such as food and education, with serious consequences for the household or individuals within it.However, 92% said that they were able to contribute to treatment consultation fees (max.$0.27) and 79% were able to pay for any drug prices (max.$1.10); 6% opted for free consultations and 19% for free drugs 46 .This demonstrates again the need for community-based treatments that use and bolster existing community resources, rather than relying on hospital stays that families can ill afford.
Mental health care as it stands is expensive, and costs for professional support vary from public to private.The daily rates for public psychiatric treatment are US$10-20 for outpatients, or US $20-25 for inpatients; private inpatient treatment costs double (US$50).A specialist consultation with a psychiatrist costs $15-25; Eye Movement Desensitization and Reprocessing (EMDR) is US$25; and other professionals cost US$10 (psychiatric nurse, psychologist, or a session of Cognitive Behavioural Therapy (CBT)) 40 .It is worth noting that in a country with a significant number of people traumatized by war and sexual violence, trauma-based therapy (EMDR) is the most expensive treatment.

DISCUSSION
This systematic review highlighted a clear demand for mental health care.The prevalence of mental health issues is greatly increased by major risk factors related to armed conflicts and poverty.The review covered the whole DRC with a particular focus on the eastern part of the country.Mental health problems are under investigated in the DRC.The number of studies found is small and not consistent with the extent and significance of mental health problems caused by war-related sexual violence.DRC in general, and the eastern region in particular, has been devastated by war and sexual violence.Many voices have been raised to condemn the atrocities, including Nobel Peace Prize winner Dr Denis Mukwege, who has called for an end to the use of rape as a weapon of war 49 .In line with previous work, our study found that wartime sexual violence and extreme poverty are highly traumatic, and cause multiple, long-term mental health difficulties 6,50 .We found that depression, anxiety, and PTSD were the most common problems in the DRC.Similarly, other systematic reviews in conflict-affected populations find high frequencies of mental health illnesses such as depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia 51 , and PTSD among civilians who have experienced sexual violence 50 .
This review found that existing mental health services in the DRC are limited.'Mental health' diagnosis may sit in opposition to local beliefs, leading to a lack of uptake in existing services.People with mental health illnesses in DRC and many other sub-Saharan African countries are more likely to seek help from traditional healers and religious leaders [52][53][54] .Hence, there needs to be collaboration with local communities and a pluralistic framework of understanding 45 .Some problems identified in this review, such as stigma and rejection, sit within the social realm.Positive social connections are important for physical and mental wellbeing.They can provide emotional support, practical assistance, information and a sense of belonging 55 .However, 'social support' is not always positive 26 , hence it's crucial to understand a person's needs within their local context.Additionally, more non-medical mental health interventions are required-for example in the current review, help with livestock had a positive impact on mental health 37 .
To address the mental health treatment gap in LMICs, then, there is a need to develop psychosocial interventions that are culturally appropriate and embedded in local knowledge, values and practices 56 .Although most medical and psychological interventions have been developed and evaluated in highincome countries, this review found positive effects for psychosocial interventions such as group therapy, music therapy, family support, and socio-economic projects 18,36,37 .This matches previous research in humanitarian settings, which supports the efficacy of psychosocial interventions for adults with common mental disorders 57 , and therapy for reducing suicidal ideation 58 .Still, applying these findings to poor-resource settings might be a challenge 57 , and in the DRC there is a lack of related health professionals from social work, psychology, and occupational therapy 40 .Effectively measuring the outcomes of such interventions will also be crucial in building the evidence base.Yet, whilst this review found common standardized measures in the literature (e.g.Hopkins Symptom Checklist), only two studies tried to validate these Western measures in the DRC context.This included the Impact of Event Scale-Revised (IES-R), two variations of the Hopkins Symptom Checklist, and the Edinburgh Post-partum Depression Scale 28,29 .As such, further studies are required to ensure that measurements are both valid and reliable for the DRC context.
Finally, this review highlighted a lack of mental health institutions, and the need to train more mental health professionals to tackle stigma, reduce social rejection and provide support 20,38,39,59 .We highlight the need for a greater breadth of professionals (including social work, psychology, and occupational therapy), and acknowledge that institutions are not the best or only way to support mental health.As such, more research is needed into social and community mental health interventions in the DRC.Moreover, this review highlights the need to integrate mental health care into general health care.Existing mental health care is unaffordable for many Congolese people 46 .Unfortunately, there are no governmental budget allocations for mental health, and there is no national epidemiological data on mental health 20,59 .
As such, despite the global impact of mental health disorders, mental health service provision in LMICs (and the DRC specifically) is inadequate.Previous studies have urged for the prioritization of mental health services in budgets and service planning, with an emphasis on incorporating local population and cultural needs.One study in this review found that training local staff improved their ability to support survivors of sexual violence 43 .Another study highlights that mental health provision in LMICs can be achieved only from a foundation of political will and strengthened legislation, including resource allocation, strategic organization, integrated care provided by sufficiently trained staff, and the meaningful involvement of patients, informal carers, and the wider community 1 .In the DRC, political will is still required to back up policy and legislation with funding.Addressing the research gaps noted above will strengthen the argument for improved mental health services, and provide evidence-based solutions to mental health needs in the DRC.

Limitations
First, the methodological weakness is that many studies (e.g.19 of 50) were cross-sectional and descriptive.Second, the current search identified studies from predominantly eastern DRC (64% of included studies) which, limits the generalizability of findings to other regions of the DRC.The large number of studies in the eastern region of the DRC is however justified because of war, pervasive sexual violence, and generally poorer mental health 60 .Third, this systematic review did not conduct a meta-analysis because of the lack of appropriate data.Hence, the findings are presented narratively.

CONCLUSION
This systematic review calls attention to the need to support sexual violence survivors and many other Congolese people affected by traumatic events.This review also highlights the need for validating culturally appropriate measures and the need for well-designed controlled intervention studies in the DRC.Better public mental health systems and service provision could help to improve community cohesion, resilience, mental well-being, and even economic productivity.There is also an urgent need to address wider social issues such as poverty, stigma, and gender inequality in the DRC.More evidence is needed on reducing mental health stigma in the DRC.Further collaboration with communities is required to ensure people are willing and able to access available services.

Table 1
presents the main characteristics of the 50 studies included in the review.All studies were conducted in the DRC.

Table 1 .
Characteristics of included studies and quality ratings (MH = 'mental health').

Table 1 continued
General Anxiety Disorder.We follow PRISMA and COSMIN recommendations and the quality rating score was calculated by awarding 1 point for each of the criteria: (1) population and recruitment methods, (2) research design, (3) if mental health outcome measure was valid and reliable and (4) if outcome variable was clearly identified.