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Mental health outcomes, literacy and service provision

in low- and middle-income settings: a systematic review
of the Democratic Republic of the Congo
Kayonda Hubert Ngamaba 1 ✉, Laddy Sedzo Lombo2, Israël Kenda Makopa3, Martin Webber 1
, Jack M. Liuta 4
,
Joule Ntwan Madinga 5, Samuel Ma Miezi Mampunza6 and Cheyann Heap1

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
1234567890():,;

(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.
npj Mental Health Research (2024)3:9 ; https://doi.org/10.1038/s44184-023-00051-w

INTRODUCTION one of the most neglected areas of public health. Across the
Poor mental health in low- and middle-income countries (LMICs) globe, close to one billion people are living with a diagnosis of
has become a real concern, due to its impact on human wellbeing, mental disorder, and every 40 s one person dies by suicide2.
national disease burden, premature death, economic loss, and Things have worsened in recent years as billions of people around
social cohesion1,2. Mental health is an integral component of the world have been affected by the COVID-19 pandemic4,5.
health, defined as a state of physical, mental and social well-being While many developed nations are making progress in
and not merely the absence of disease or infirmity. According to supporting people with mental health conditions, in LMICs, more
the World Health Organization (WHO), mental health is “a state of than 75% of people with mental, neurological and substance use
well-being in which the individual realizes his or her own abilities, problems receive no treatment or support at all. Unfortunately,
can cope with the normal stresses of life, can work productively stigma, discrimination, punitive legislation, lack of adequate
and fruitfully, and is able to make a contribution to his or her health information, poor political will and human rights abuses
community”3. Mental health conditions are problems involving are still widespread1. Additionally, a medical diagnostic model is
changes in emotion, thinking or behaviour (or a combination of the primary global mode of identifying mental health problems.
these), which are associated with distress and/or difficulties The dominance of this approach and the limits of its biological
functioning in social, work or family activities3. Mental health is treatments (such as drugs and hospital admission) are an

1
International Centre for Mental Health Social Research, Social Policy and Social Work, School for Business and Society, University of York, Heslington, York YO10 5DD, UK. 2Centre
Spécialisé dans la Prise en charge Psychosociale en Santé Mentale (CSPEMRDC), Université Chrétienne de Kinshasa, Kinshasa, Democratic Republic of Congo. 3Neuropsychiatre et
Addictologue Centre Spécialisé dans la Prise en charge Psychosociale en Santé Mentale (CSPEMRDC), Université Chrétienne de Kinshasa, Kinshasa, Democratic Republic of Congo.
4
Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK. 5WHO Country Office DRC & Medical Parasitology and Epidemiology, Faculty of Medicine,
University of Kikwit, Kikwit, Democratic Republic of Congo. 6Faculte de Medicine University of Kinshasa & Université Protestante au Congo (UPC), Kinshasa, Democratic Republic
of Congo. ✉email: [email protected]
 K.H. Ngamaba et al.
2
additional threat to human rights. There is a real need to develop Web of Science MEDLINE Public Health PsycINFO Google Scholar
effective, especially psychosocial, mental health interventions in
Citaons
low-resource settings such as the DRC1,2. We therefore decided to
undertake the first systematic review of the literature to examine
the mental health literacy, symptoms, systems and service
Create database
provision in DRC.
DRC is the largest country in sub-Saharan Africa, and because of Idenfy duplicates
its huge natural wealth and poor governance, DRC has suffered
several wars including 1998 war involving nine African countries Original arcles
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 SCREENING Review 10% for
groups, and the use of torture and rape as weapons of war6, which (tles/abstracts) homogeneity
have devastating effects on people’s mental health7,8. Previous
studies have reported that people living in ‘humanitarian settings’
in LMICs such as DRC are exposed to a constellation of physical Rejected by 2
Accepted by at
least 1 reviewer
and psychological stressors that make them vulnerable to reviewers
developing what are often called ‘mental disorders’9. On top of
DRC’s war, the COVID-19 pandemic has affected health infra- EXCLUDE SCREENING Review 25% for
structure10 and worsened the mental health problems of the (full text) homogeneity
population11. 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 disorders2. This literature search aims to bridge this
gap and inform those who need to develop an evidence base. We
1234567890():,;

Rejected by 2 Accepted by 2 Accepted by 1

hope to help policymakers in tackling the issues related to limited reviewers reviewers of 2 reviewers
mental health systems and service provision in DRC.
EXCLUDE
Aims of the study Discussion unl
INCLUDE
This study is the first systematic evaluation of mental health in consensus achieved
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 EXCLUDE
has been defined as knowledge and beliefs about mental health
disorders that aid their recognition, management, or prevention12. Fig. 1 Search strategy and databases. The search strategy used in
Mental health systems and service provision focused on DRC’s each of the databases.
institutions and services that provide support to people with
mental health conditions. The service provision included Study selection
community-based support, respite for families and caregivers, Screening was completed in two stages. Initially, the titles and
traditional healers, and basic necessities such as shelter and abstracts of the identified studies were screened for eligibility.
clothing for people with mental health disorders1,13. 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
METHODS Diagram (Fig. 2).
The systematic review was conducted and reported according to
Preferred Reporting Items for Systematic Reviews, Meta-Analyses Eligibility criteria
(PRISMA), Cochrane Handbook recommendations14,15 and the Studies were eligible for inclusion if they met the following
COSMIN Risk of Bias checklist for systematic reviews16. criteria: studies that have been conducted in DRC, and studies that
have evaluated mental health literacy. Also included were the
Search strategy and data sources studies that assessed mental health service provision. Papers
Systematic searches of the literature published between January published in English and French were included, regardless of
2000 and August 2023 were carried out using Web of Science, study design (e.g., qualitative, quantitative, randomized controlled
MEDLINE, Public Health, PsycINFO and Google Scholar. Combina- trials, nonrandomized, descriptive studies, mixed-methods, and
tions of two key blocks of terms were used: (1) Democratic cluster randomized controlled trials). This systematic review
Republic of Congo, DRC, Zaire, Low-income country, low-income therefore included studies that explored at least one of the main
settings, Poor nations, Sub-Saharan country, War zone and (2) components of mental health literacy and/or service provision,
mental health, symptoms, outcome measures, validity assessment, which are: assessment of mental health, receiving a diagnostic
PTSD, anxiety, depression, schizophrenia, psychosis, psychotic, label, understanding signs of poor mental health, training and
ICD-10, rape, sexual violence, war trauma, mental health integra- health professionals, treatments, community-based support, pre-
tion into general health care, and mental health systems and vention, stigma, abuses, and mental health institutions and
service provision. We also checked the reference lists of the management.
studies meeting our inclusion criteria. Our search strategy used
Jorm’s definition and conceptual framework to identify eligible Data extraction
studies12. The search strategy in each of the databases is An Excel file was devised for the purpose of data extraction. Two
presented in Supplementary Fig. 1. The search and screening people conducted the data extraction and screening. This
process was conducted by two reviewers (Fig. 1). extraction was piloted across five randomly selected studies and

npj Mental Health Research (2024) 9

 K.H. Ngamaba et al.
3
Identification of studies via databases

Records identified from Records removed before

Databases screening:
Identification (n =384) Duplicate records removed
Web of Science: 145 (n = 240)
MEDLINE: 156 Records removed for other
Public Health: 14; PsycINFO: 2 reasons (n = 56), e.g. not
Citations: 5; Google scholar: 48 investigate mental health
Additional records identified (MH)
through other sources (e.g.,
contacting authors: 14

Records excluded e.g. Study not

conducted in DRC; mental health
Records screened of DRC refugees abroad; sexual
(n = 89) diseases without MH; protocol
study
(n = 39)
Screening

Reports sought for retrieval Reports not retrieved

(n = 50) (n = 0)

Reports assessed for eligibility

(n = 50) Reports excluded:
Reason (n = 0)

Studies included in review

Included

(n = 50)
Reports of included studies
(n = 50)

Fig. 2 PRISMA flow diagram. The PRISMA flow diagram presents the screening process and selection of studies used in this systematic
review.

changes were made where necessary to ensure inter-author each of the criteria achieved (maximum 4). This appraisal process
consistency. Information about the following characteristics of the was done during the data extraction and verified after the
studies were extracted: first author’s name and year of publication, systematic review was written.
region/setting and sample, objective and research design, mental
health outcome measure(s), findings, quality rating score, and
comments/limitations. Another author confirmed the data RESULTS
extracted from each included study. Any discrepancy in the data We retrieved 384 studies. After removing duplicates (n = 240),
obtained was discussed until a consensus was obtained. studies were assessed and 56 articles were excluded after reading
the titles and the abstracts for not investigating mental health
Quality appraisal and assessment disorders. Eighty-nine full-text studies were assessed and 39
articles were excluded for several reasons such as not using
The quality appraisal was used to (a) find the most relevant
participants who were in the DRC; some studies looked at the
studies, (b) get rid of irrelevant and weak studies, (c) separate
mental health of refugees who were settling in other countries;
evidence from opinions, and (d) identify any risk of bias. Following
and protocol studies were also excluded. Overall, 50 studies were
PRISMA and COSMIN recommendations, studies were rated for
included in the final analysis. While the quality appraisal was
their quality by one researcher and verified by another researcher
carefully and systematically followed, 19 of 50 studies were cross-
using criteria adapted from guidance on the quality assessment
sectional and investigated the association between key variables
tools for quantitative studies14,16,17. Any disagreements were
as we have described below. The flowchart of the screening and
resolved by discussion. The quality review included assessment of
selection process15 is shown in Fig. 2.
(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 Descriptive characteristics of the studies
the (4) outcome variable was clearly identified and appropriate. Table 1 presents the main characteristics of the 50 studies
The quality rating score was calculated by awarding one point for included in the review. All studies were conducted in the DRC.

npj Mental Health Research (2024) 9

 K.H. Ngamaba et al.
4
Thirty-one studies (64%) were conducted in the Eastern region of Psychosocial interventions
the DRC, a region devastated by war and sexual violence6. Among Six studies looked at psychosocial interventions, where four
the remaining 19 studies, two were cross-national looking at the focussed on group therapy and family support, and the other two
association between key factors18,19, four looked at the service investigated socio-economic support.
provision at the national level20–22, eleven were conducted in the Amongst the studies that focussed on group and family
capital city Kinshasa, one was conducted in Vanga health zone in therapy, we noticed variation in the way participants were
Central-West region, and one study was conducted in Equateur in supported. For example, after 6-month follow-ups, group psy-
the North-West region, and one study conducted in the southeast. chotherapy reduced PTSD symptoms and combined depression
All studies were published between 2005 and 2022. Sample sizes and anxiety symptoms among Congolese women survivors of
varied from 12 to 3941, with an average M = 543.2 (SD = 688.1). sexual violence36. A cross-national study conducted in DRC, Mali
Participants were from different demographic categories including and Nigeria found that the involvement of family and other
children and adolescents affected by war, children with epilepsy, caregivers in psychosocial support reduced the symptoms of
female sexual violence survivors, survivors of Intimate Partner depression and anxiety among war-wounded men18. Similar
Violence (IPV), war-wounded men, people with psychosis, adults positive findings were found in another cross-national study,
affected by the Ebola outbreak, postpartum mothers, psychiatrists, where brief trauma-focused therapy and Medicine Sans Frontier
and members of organizations that support war-affected women (MSF) mental health therapeutic intervention were used among
and the general population. The majority of participants were young people. Brief trauma-focused therapy appears to be
people affected by war or women who had experienced sexual effective in reducing symptoms among young people exposed
to armed conflict in DRC, Iraq and the Occupied Palestinian
violence.
Territory19. Moreover, a 12-week music session and community
Most studies collected primary data using questionnaires,
engagement programme led by a psychologist and music
interviews, and observation. Six studies included longitudinal
producer were associated with significant improvement in
follow-ups23–25. Few studies used secondary data to investigate
women’s mental health, which was sustained up to 6 months
women who experienced sexual violence in Eastern DRC26, and post-completion of the programme, despite instability in the
service provision and psychiatric treatment in Kinshasa27. region and evidence of continued experience of conflict-related
Several designs were used including descriptive, correlational, trauma24.
causal-comparative/quasi-experimental, and experimental Regarding socio-economic support, two studies reported that
research. Randomized controlled trials and step-wedged design people living in war-affected zones of the DRC are often poor and
were used where participants were pre-tested and post-tested 3 have limited access to traditional financial institutions. However,
and 6 months later24, and 8 months later23. Eighteen studies microfinance programmes have the potential to help in improving
were cross-sectional and descriptive. Three studies used income, economic productivity and mental health37. Two studies
qualitative ethnographic and case study designs where partici- found that group-based economic interventions were effective to
pants were interviewed with semi-structured interviews and support female sexual violence survivors23,37. An innovative
focus groups28–30. productive asset transfer programme, Pigs for Peace (PFP),
increased economic stability, improved subjective health and
Mental health outcome measures and validity assessment mental health in 10 conflict-affected villages37.
Different instruments were used to measure participants’ mental
health (e.g. anxiety, depression, and PTSD), partner intimate Stigma and rejection
violence, stigma, experience of sexual violence, and exposure to Five studies highlighted the stigma and rejection. The stigma
adversity (e.g. Ebola virus outbreaks). Most studies assessed around mental health issues and social rejection were depicted in
depression (n = 19), anxiety (n = 15), and PTSD (n = 14) symptoms various ways across the reviewed studies. For example, a study on
of their participants. For anxiety and depression, the Hopkins sexual violence survivors revealed that rape survivors need a way
Symptoms Checklist (HSCL-25) was the most common mea- to regain their “worth” in the family and the village38. Many
sure24,31. One recent study used both Patient Health Question- women experienced significant physical and mental health
naire (PHQ-9) and General Anxiety Disorder (GAD-7) to assess the consequences of sexual violence and were rejected because of
prevalence of depression and anxiety during the pandemic the stigma around mental health and the violence itself39. The
COVID-1932. The Harvard Trauma Questionnaire was the most social rejection was closely linked with spousal rejection. The
common measure used to assess PTSD. Positive and negative perceived loss of dignity, the shame of living with a woman who
symptoms scale (PANSS), for example, was used to identify had experienced rape, and the influence of the family members
possible deficits in facial emotion recognition among patients with were contributing factors to spousal rejection39. However, gender-
schizophrenia33. Stressful life events were assessed using the based violence is not a mental health problem: contributors to
violence against women include social norms and attitudes,
Impact of Event Scale revised version (IES-R)29. To assess stigma, a
economic inequality, and women’s lack of socio-political power.
20-item scale that measures 20 possible forms of stigmatization
Mental health support should sit alongside social and structural
related to Ebola Virus Disease (EVD) was used34. Most instrument interventions such as economic help23 and addressing attitudes
measures used multiple items to assess participants’ mental health that enable violence against women31.
and other conditions. Of 50 studies, 21 studies used question- Our search suggested that mental health awareness may help
naires adapted from other standardized measures used in other to reduce some general stigma around mental health difficulties,
countries. One study validated two broadly used mental health because many people in the DRC region believe that mental
self-report measures: the Impact of Event Scale Revised (IES-R) and health problems are a curse of witchcraft, or caused by bad
the Hopkins Symptom Checklist 37 for Adolescents (HSCL-37A)29, spirits40. Social stigma and rejection can link to local beliefs about
and another study validated two standard depression measures: mental distress: a family may prefer to go to a traditional healer, or
the Edinburgh Post-partum Depression Scale and the Hopkins to an exorcist pastor/priest to pray rather than seek more
Symptom Checklist28. A small number of two studies used self- ‘professional’ interventions40. This study found that some people
designed surveys to measure the positive impact of socio- may believe that the consequences of the war are only physical,
economic projects on the mental health and well-being of sexual and ignore the consequences of the war from a psychological
violence survivors23, or young people in war zones35. point of view20.

npj Mental Health Research (2024) 9

 K.H. Ngamaba et al.
5
Table 1. Characteristics of included studies and quality ratings (MH = ‘mental health’).

No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

1. Andersen, I. DRC, Mali, Nigeria 2008 To identify patient The 21-item Depression Following MHPSS, 4 Pre-test & follow-
202218 war-wounded DRC: 791 characteristics and Anxiety Scale 92.28% of the patients up Intervention:
Mali: 538 Nigeria: 679 associated with high (DASS21), the Impact of showed an Psychosocial
distress prior to & after Events Scale Revised improvement on the support
pre- and post- (IES-R) and the ICRC DASS21, 93.00% (involvement of
intervention. Mental functionality scale showed an family and other
health and psychosocial before and after MHPSS improvement on the caregivers in the
support (MHPSS) intervention. IES-R and 83.04% MHPSS)
Logistic regression showed an
model, Cross-sectional improvement on the
ICRC Africa functioning
scale.
2. Bass, J. Eastern DRC 301 female Measures of economic Economic and social Economic programme 4 8-month follow-
201623 sexual violence and social functioning functioning and mental has a positive impact: up
survivors. and mental health health severity Female sexual violence
severity. Randomized survivors with elevated
controlled trial. mental health
difficulties were
successfully integrated
into a community-
based economic
programme.
3. Bass, J.K. South & North Kivu To assess the impact of PTSD symptoms and Group psychotherapy 4 Used robust
201336 province, DRC. 7 group therapy & combined depression reduced PTSD scores, assessment
villages (therapy to 157 individual support to and anxiety. reduced combined measures.
women) and 8 villages Congolese survivors of Psychosocial depression and anxiety Baseline and 6
(individual support to sexual violence. functioning. scores, and improved months Follow-
248 women) Controlled trial functioning. up.
4. Bass, J. Kinshasa, DRC. 133 To investigate post- Validating two standard Found a local syndrome 4.
200828 women with and partum depression depression measures: that closely
without the local syndrome among the Edinburgh Post- approximates the
depression syndrome. mothers in Kinshasa. partum Depression Western model of major
Qualitative interviews. Scale and the Hopkins depressive disorder.
Symptom Checklist. Useful for cross-cultural
applicability and
validation of the
adapted screening
instruments.
5. Cenat J. M. Equateur, DRC. 1614 Investigate the EVD exposure level, Adults in the two 4
202234 adults affected by the prevalence of, and risk stigmatization related higher score categories
ninth month of Ebola factors associated with, to EVD and Beck of exposure to EVD
outbreak depressive symptoms Depression Inventory- were at two times
among individuals Short Form (BDI-SF) higher risk of
affected by Ebola Virus developing severe
Disease (EVD) depressive symptoms.
Multivariable logistic
regression
6. Cherewick, Eastern DRC. 434 male Examine coping Measures of exposure Coping flexibility, or the 3
M. 201635 and female youth (aged strategies among to potentially traumatic use of multiple coping
10–15 years) conflict-affected youth events, an adapted strategies, may be
exposed to potentially coping strategies particularly useful in
traumatic events and checklist, and measures improving mental
the relationship to of psychosocial distress health and well-being.
psychological and well-being.
symptoms and well-
being. Hierarchical
regression.
7. Cikuru, J. South Kivu, DRC. 167 Impact of music Hopkins Symptoms Significant 4 Intervention:
202124 women aged 15–69 therapy group on Checklist (anxiety and improvement in Music therapy 3 &
years women’s mental health. depression). The women’s mental health: 6 months FU
Step-wedged design, Harvard Trauma anxiety, depression, and
two pre-tests, a post- Questionnaire (PTSD). PTSD 6 months after
test, 3 & 6 months FU the intervention
compared to baseline.

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 K.H. Ngamaba et al.
6
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

8. Corley, A. South Kivu, DRC. 784 Investigate the Attitudes towards Individuals in the 4 Cross-sectional
202131 participants from 10 association between gender equality; IPV moderately gender-
rural villages in South attitudes towards experiences; Hopkins equitable and fully
Kivu. gender equality, Symptom Checklist-25 gender-equitable
intimate partner (HSCL-25) for anxiety classes had significantly
violence (IPV) and and depression; lower mean scores on
mental health. Pearson’s Harvard Trauma symptoms associated
chi-square test and Questionnaire (HTQ) for with PTSD than
logistic PTSD individuals in the least
regression.Cross- gender-equitable class.
sectional design.
9. Dossa, N. I. Goma, DRC. 320 To investigate the Post-traumatic stress Experience of any SV 3 Cross-sectional
201561 women mental health disorders disorder (PTSD) was associated with study
among women victims symptoms severity and more severe PDS. Only
of sexual violence (SV). psychological distress conflict-related sexual
A cross-sectional symptoms (PDS) violence (CRSV) was
design. Multivariate severity associated with more
analyses severe PTSD symptoms.
10. Emerson, J.A. South Kivu, DRC. 828 To investigate the HSCL-25 and PTSD with Mental health measures 3 Cross-sectional
202062 mothers of young association between the HTQ. for women of young
children. mental health children were
symptoms, and diet associated with higher
and nutritional status of dietary diversity scores.
mothers of young Mental health
children. Cross- symptoms were not
sectional design. associated with body
Bivariate and mass index.
multivariate regression
analyses.
11. Espinoza, S. DRC Evaluating the Barriers Risk factors to poor
Barriers to MH: Different 3 Service provision
201621 to Mental Health mental health include
Perceptions of Mental
Treatment within the exposure to war, Illness, Dependence on
Congolese Population. torture, and refugee
Treatment within their
Descriptive case study camps. 39.7% of own Community, Lack
women and 23.6% ofof Mental Health
men have been Screening. Possible
exposed to sexual Interventions: Provide
violence during their
Service within the
lifetime. 40.5% meet
Community, CBT
the criteria for major
individual therapy and
depressive disorder and
group therapy, and
50.1% for PTSD after a
Education. Prevalence
1-year recall period.
of sexual violence is
higher.
12. Glass, N. Eastern DRC. 833 Test the effectiveness of Harvard Trauma The intervention 4 18 months FU
201737 household participants livestock asset transfer Questionnaire (HTQ) for increased economic
in 10 villages. intervention (Pigs for PTSD; Hopkins stability, improved
Peace) on mental Symptom Checklist subjective health and
health. Randomized (HSCL) for anxiety and mental health
controlled trial. From depression; and
baseline to 18 months Intimate partner
between the violence (IPV).
intervention and
delayed control groups.
13. Glass, N. Eastern DRC 188 Parental and adolescent Parent PTSD and Parent mental health 4 8-month follow-
20187 adolescents and mental health and depression, subjected and IPV can have a up assessment
parents. experience of intimate to IPV, Adolescent negative impact on
partner violence (IPV). behaviours, stigma, and children’s well-being
Secondary analysis. school attendance.

npj Mental Health Research (2024) 9

 K.H. Ngamaba et al.
7
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

14. Glass, N. Eastern DRC. 50 Case study of Poverty and traumatic Survivors and family 4
201238 women. Congolese-US stress for survivors. members experience
community-academic physical and mental significant health
research partnership, to health impact, stigma, consequences of sexual
make an intervention to exile; food security, violence. The survivor
rebuild the lives of rape employment; local needs a way to regain
survivors and their availability of health her ‘worth’ in the family
families. Qualitative care services and and the village. This
interviews schools. study supports the
feasibility of the
international
partnership.
15. Gerstl, S. Eastern DRC. 552 To determine the socio- Evaluating the Living conditions were 4 Service provision
201146 randomly selected economic conditions of affordability of health very basic. Major source and affordability
households the population and to services; fees and drug of income was
assess their ability to prices and whether free agriculture (57%); 47%
contribute to health health care is possible. of the households
care. Service provision. earned less than US
Questionnaire cross- $5.5/week. 92% able to
sectional contribute to
consultation fees (max
$0.27) and 79% to the
drug prices (max $1.10).
6% opted for free
consultations and 19%
for free drugs.
16. Ikanga, J. DRC. General Psychology in the DRC; Evaluating the Mental health facilities 3 Service provision
201453 population Service provision contribution of lacking psychological
psychological departments in the DRC
departments to need to be known.
improve MH conditions. Partnership is needed
Evaluating access to between Western
Mental health facilities psychology and
Congolese culture.
17. Johnson, K. Eastern DRC 998 Explore the link Measures sexual Self-reported sexual 3
20108 households. between sexual violence prevalence, violence and other
violence and human symptoms of major human rights violations
rights violations, and depressive disorder were prevalent and
physical and mental (MDD) and PTSD, were associated with
health. Cross-sectional human rights abuses, poorer physical and
study Structured and physical and mental health
interviews and mental health needs. outcomes. 41%
questionnaires. (n = 374/991) met the
criteria for MDD and
50.1% met the criteria
for PTSD.
18. Kangoy. A. K. Eastern DRC. 69 adults. To investigate the Post Traumatic Social rejection, the 3
201639 mental health Syndrome Disorder characteristic of the
consequences of rape (PTSD), Major rape event and the
for the survivor. Depressive Disorder residential area were
Questionnaires Cross- (MDD), comorbid PTSD/ significantly related to
sectional depression the severity of mental
health consequences
for the survivor.
19. Kashala, E. Kinshasa 1187 children, To investigate mental Mental health problems Poor nutrition, low 3
200563 7–9 years old health problems, and were assessed with the socioeconomic status
the association Strengths and and illness increased
between these Difficulties the risk for mental
problems and school Questionnaire (SDQ), a health problems and
performance, questionnaire on child low school
demographic factors, behaviours performance.
illness and nutrition. administered to
Questionnaire cross- teachers.
sectional

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 K.H. Ngamaba et al.
8
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

20. Kitoko, G. M. Kinshasa 60: 30 patients Identify possible Diagnosed with Patients with 3 Cross-sectional
B. 201933 with schizophrenia & 30 deficits in facial schizophrenia schizophrenia had
healthy participants emotion recognition according to DSM-5 emotion recognition
among patients with criteria Beck depression deficits, particularly for
schizophrenia. inventory; positive and negative emotions
Descriptive and negative symptoms
correlations scale (PANSS)
21. Kohli, A. Eastern DRC. 315 Relationship among Exposure to trauma, Exposure to conflict- 4
201464 women in 10 villages. conflict-related trauma, sexual assault, family related trauma,
family rejection, and rejection, and mental including sexual
mental health in adult health (PTSD and assault, was associated
women living in rural depression). with an increased
eastern DRC. likelihood of family
Questionnaires and rejection, and poorer
interviews. mental health
outcomes.
22. Koegler, E. Eastern DRC 12 Exploring the impact of Physiological, All women identified 3 Qualitative data
201965 members of solidarity joining the solidarity psychological, some improvement
groups for female group and factors that economic, or social (physiological,
survivors of sexual contributed to the measures psychological,
violence. mental health of female economic, or social)
survivors of conflict- since joining the
related sexual violence. solidarity group, but
Interviews. none of the women
were free from personal
distress.
23. Koegler, E. Eastern DRC. 753 adults Association between Depression, anxiety, People with higher 4
201866 mental health and PTSD and STIs scores on mental health
sexually transmitted measures were more
infections (STIs) in likely to be treated for
conflict-affected an STI than those with
settings Regression lower scores.
analysis
24. Kohli, A. Eastern DRC. 701 Association between Trauma experiences, Increased trauma was 4
201567 women trauma experiences, PTSD, depression and associated with fewer
PTSD, depression and the amount of social visitors to women’s
amount of social interaction homes, and fewer visits
interaction. Regression to the homes of family/
analysis community members.
25. Kohli, A. Eastern DRC. 772 Case study focused on: Anxiety, depression, 85% of participants 3 Case study
201268 women survivors of 1. expansion of mobile PTSD, social reported being descriptive
sexual violence in 6 clinic services; 2. dysfunction, suicide survivors of sexual
rural villages evaluation system; and ideation. violence; 45% never
3. brief psychosocial received health services
support Case study: after the last sexual
descriptive assault. Participants
experienced anxiety
(29.8%), sadness
(43.8%), and shame
(34.4%).
26. Lieberman Beni, Butembo and To understand the Post-traumatic stress Survivors met symptom 3 Cross-sectional
Lawry, L. Katwa health zones in prevalence of mental disorder (PTSD), criteria for depression
202269 DRC. 223 adult Ebola health problems in depression, anxiety, at higher rates than
survivors, 102 sexual Ebola-affected substance use, suicidal partners. PTSD
partners & 74 communities, and their ideation and attempts, symptom criteria for
comparison association with stigma, and sexual survivors were four
respondents. condom use. Case behaviour. times greater than the
study comparison
participants.

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 K.H. Ngamaba et al.
9
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

27. Lokuge, K. DRC, Iraq and the Evaluating Mental Anxiety-related,mood- Brief trauma-focused 4
201419 occupied Palestinian health services for related, behaviour- therapy, the current
Territory (oPt). 3025 children exposed to related and MSF mental health
individuals, 20 years of armed conflict. somatisation problems. therapeutic
age. DRC (14%), Iraq Consultation Brief intervention, appears to
(17,5%) and oPt (51%). trauma-focused be effective in reducing
therapy, the current symptoms. 45.7% left
MSF mental health programmes early.
therapeutic
intervention.
Descriptive cross-
sectional
28. Ngamaba, H. Kinshasa, DRC 100 Quality of life (MANSA), MANSA, EQ-5D-3L, Depression and anxiety 4
K. 202232 individuals, general prevalence of UCLA, PHQ-9, GAD-7. are more prevalent.
population depression & anxiety Negative link between
during COVID-19. MANSA and living
alone.
29. Ngoma, M. Kinshasa, DRC 341: 153 Cognitive deficits in Cognitive assessment, Patients perform 4
201070 healthy control subjects nonaffective functional PANSS, Antipsychotic significantly worse than
vs 188 patients psychoses drug healthy controls on all
cognitive domains with
cognitive deficits being
most pronounced in
verbal and working
memory, attention,
motor speed, and
executive function
30. Mankuta, D. Eastern DRC 441 To test an intervention PTSD and the Training local staff 4 Intervention:
201243 women- sexual trauma programme: training psychological showed improved Training staff
victims local staff; medical treatment based on knowledge, enhance
evaluation and EMDR (eye movement awareness and
treatment of patients; desensitization and providing them with
psychological reprocessing) tools to diagnose and
treatment of trauma principles. treat sexual assault and
victims. Intervention mutilation.
case study
31. Masika, Y. D. Eastern DRC 302 Influences of trauma Posttraumatic Checklist Trauma awareness and 4
201971 participants awareness and Scale, General Self- preparedness play an
preparedness on the Efficacy Scale, and important role among
development of PTSD. Traumatic Events List military personnel in
ANOVA, Relationships, moderating the risk of
Mediation developing PTSD, more
so than among the
civilian population
32. Masika, Y. D. Eastern DRC 120 Association between Traumatic Events List, The group of 3 Cross-sectional
201972 individuals peritraumatic the Peritraumatic participants with high
dissociation (PD) and Dissociative scores for PD had
PTSD in individuals Experiences significantly more PTSD.
exposed to recurrent Questionnaire, and the The primary target
armed conflict. French version of the population for
Descriptive cross- PTSD Checklist Scale prevention and early
sectional management should
comprise individuals
with high levels of PD,
low levels of education,
and women.
33. Matonda- Kinshasa DRC 104 Factors associated with The Child Behaviour Behavioural problems 3
Ma-Nzuzi, children with epilepsy behavioural problems Checklist (CBCL); the and cognitive
201873 (CWE) and cognitive Wechsler Nonverbal impairment are
impairment in CWE (WNV) scale of ability common in CWE.
Descriptive and Behavioural problems
Multivariate analysis were associated with
socioeconomic features
only

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 K.H. Ngamaba et al.
10
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

34. Mukala, Lubumbashi, DRC 591 Integrating mental Evaluating the The burden of mental Service provision
Mayolo E. residents responded health care into the integration of mental health problems is a Cross-sectional
202341 and conducted 5 focus primary care system. health care into the major public problem
groups with 50 key Survey and Focus primary care system in in Lubumbashi. The
stakeholders (doctors, groups one region outpatient curative
nurses, managers, consultations are low at
community health 5.3%. There are no
workers. and leaders, dedicated psychiatric
health care users) beds, nor is there a
psychiatrist or
psychologist available
35. Mukala, Lubero District Eastern To investigate the Evaluating the 3941 patients with 4 Integration of
Mayoyo E. DRC 3941 used the integration of a mental Integration of mental mental health problems mental health
202142 services offered health care package health care package used the care offered at
into the general health into the general health the health centers and
care system. Case study care System. 7 new the district hospital
design cases/1000 inhabitants/ between 2012 and
year 2015. It is possible to
integrate mental health
into existing general
health services in the
DRC.
36. Mels, C. Ituri district in Eastern Validating two broadly Self-report measures— Community-based 3 Validating
201029 DRC 1046 adolescents used mental health self- Impact of Event Scale- adaptation can extend measures
(13–21 years) in 13 report measures-- Revised (IES-R) and the validity of the
secondary schools. Impact of Event Scale- Hopkins Symptom measures. The
Revised (IES-R) and Checklist 37 for availability of adequate
Hopkins Symptom Adolescents (HSCL- Swahili and Congolese
Checklist 37 for 37A). French adaptations of
Adolescents (HSCL- the IES-R and HSCL-37A
37A). Focus groups and could stimulate the
interviews assessment of
psychosocial needs in
DRC
37. Mudji, J. Vanga health zone in Investigate mental Hospital Anxiety and The presence of 4 Structured
202274 Kwilu in Bandundu. 93 distress and health- Depression Scale, Becks neurological sequelae interviews
patients related quality of life in Depression Inventory leads to mental distress
people with gambiense and the 36-item Short and a diminished QoL.
human African Form Health. Depression and anxiety
trypanosomiasis. T-test were higher in former
and chi2 or Fisher’s patients with
exact tests. Structured neurologic sequelae.
interviews The QoL scores were
lower.
38. Mukongo K. Kinshasa 136 caregivers The contribution of Outpatient support Caregivers are needed 3 Outpatient
J. 201947 working at the CNPP caregivers and holistic Evaluating the work of to support people with support for 6
support of people with caregivers giving MH conditions. They months plus
MH problems. Holistic support to need transport to visit
Descriptive and persons with mental patients. 53.8% of
correlation. disorders. careers were between
Observation, interview the ages of 41–60;
and questionnaires. 69.8% were males.
69.8% were nurses (2nd
level) and 34.6% had
31–40 years experience.
39. Ndjukendi, Kinshasa Zone de santé Adolescents Temperament Support for adolescents 3 Coping strategies
A, 201730 de Masina II 66 experiencing difficulties according to Eysenck, experiencing difficulties
adolescents in Kinshasa: what parenting style should focus on
coping strategies are according to Baumrind, strengthening
used? semi-structured maternal attachment socialization functions
two-phase evaluation interview adapted for and adaptive resources.
Cross-sectional study adolescents, and
coping strategies
according to Spirito’s
Kidcope.

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 K.H. Ngamaba et al.
11
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

40. O’Callaghan, North-eastern DRC 159 Investigate the Symptoms of post- At post-test, 4 Intervention:
P. 201425 war-affected children outcome of support for traumatic stress participants reported group-based
and young people war-exposed youth at reactions, internalizing significantly fewer psychosocial Pre-
risk of attack and problems, conduct symptoms of post- and post-
abduction. 8 sessions of problems and pro- traumatic stress intervention and
a group-based, social behaviour. reactions compared to at 3-month follow-
community- controls. At 3-month up
participative, follow-up, moderate to
psychosocial large improvements.
intervention. Pre- and
post-intervention.
41. On’okoko, M. DRC National level Map existing service Map existing service Mental health policy 4 Service provision
O. 201020 provision and evaluate provision and evaluate and legislation exist but
the delivery of mental the outcomes of no government budget.
healthcare. Service services: Mental health Popular beliefs persist
provision Descriptive policy and legislation. about supernatural
case study Mental disorders. causes. Mental
Psychiatric services. disorders are as
Mental health common as they are
workforce. elsewhere, but there is
no national
epidemiological data.
6–15% of
schizophrenia; 22% of
anxiety disorders;
13–23% of mood
disorders.
42. OSAR, 202240 DRC [Access to psychiatric Availability and limited Fewer than 60 4 Service provision
health care] accès à des capacity of mental neuropsychiatrists in
soins psychiatriques health care; High costs the whole country; Six
service provision of mental health care; MH hospitals; people
Drug availability and with mental disorders
costs can receive care in
secondary and tertiary
institutions; Lack of
qualified personnel;
High costs Psychiatric
daily rates, clinical
admission: $10–20,
Inpatient treatment
Public $20–25, Private
$50, Specialist
consultation
Psychiatrist $15–25,
Psychiatrist nurse $10;
Psychologist $10, CBT
$10, EMDR $25. Stigma:
often considered
“cursed”, no possibility
of recovery.
43. Schalinski, I. Eastern RDC 53 female Examine relationships PTSD, and depression. Cumulative exposure 4
201175 survivors of war between the number of and dissociation were
traumatizing events, associated with
degree of shutdown increased PTSD severity.
dissociation, PTSD, and PTSD and witnessing
depression. Cross- predicted depression.
sectional study, A path- PTSD mediated the link
analytic model between dissociation
and depression.
44. Schuster, A. Kinshasa (the capital) Map existing service Psychiatric treatment, Lack of Psychiatric 3
201327 provision Secondary Stigma, Informal treatment, Stigma
analysis support, Training need affecting informal
support, Lack of MH
professional training
Lack of MH services.

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 K.H. Ngamaba et al.
12
Table 1 continued
No 1st Author & Region/setting Sample Objective and research Mental health outcome Findings Quality Comments
Year of design measure(s) rating
publication score

45. Scott, J. Bukavu, DRC 757 adult Assess mental health Patient Health 48.6% met symptom 4
201576 women raising children outcomes among Questionnaire PHQ-9, criteria for major
from sexual violence- women raising children GAD-7, the PTSD depressive disorder,
related pregnancies from SVRPs, and stigma Checklist-Civilian 57.9% for post-
(SVRPs). Cross-sectional toward and acceptance Version (PCL-C), and traumatic stress
Descriptive analysis. of women and their Suicidal ideation and disorder, 43.3% for
children. Cross- attempt, and Perceived anxiety and 34.2%
sectional stigma. reported suicidality.
Women who reported
stigma were more likely
to meet symptom
criteria.
46. Taylor, S. Kinshasa, DRC Develop a greater Mental health There is a need to 3 Service delivery
201745 interviews with 16 understanding of interventions an increase the global
psychiatrists mental health alternative availability of mental
interventions to epistemological health services. Critical
diminish the treatment framework is needed. treatment practices:
gap in Kinshasa thinking with and
Interviews beyond biomedicine.
47. Vaillant, J. Eastern DRC 1053 Link between mental PTSD, depression and/ A positive relationship 4 RCT baseline & FU
202377 women health disorders (PTSD, or anxiety. between work or
depression and/or working hours and
anxiety) and increased symptoms of
employment for PTSD and depression
women in conflict zone. and/or anxiety. Working
RCT of Narrative women with worse
Exposure Therapy (NET) PTSD and depression
and/or anxiety
symptoms are also less
likely to be self-
employed.
48. Verelst, A. Bunia, eastern Congo Investigate the link Self-report measures of Daily stressors, 3 Cross-sectional
201478 1305 school-going between sexual mental health stigmatization, and war-
adolescent girls aged violence and mental symptoms, war-related related events showed
11–23 health of eastern traumatic events, a large impact on girls’
Congolese adolescents experiences of sexual mental health. Link
and its differing violence, daily stressors, between sexual
associations with daily and stigmatization violence (rape or non-
stressors, stigma, and were administered consensual sexual
the labelling of sexual experiences) and
violence Questionnaire poorer mental health.
Cross-sectional
49. Vivalya, B. M. North-Kivu Province, Implementing of Mental health services There are deficiencies 3 Service Provision
202044 DRC mental health services The deficiencies of of mental health
in an area affected by mental health services services and no
prolonged war and in North-Kivu and functional work plan is
Ebola disease outbreak. solutions on how to in place. The need for
Case study service provide holistic mental integrative training
provision health services in the programmes, Advocacy
presence of an ongoing and social mobilization,
war and highly Provision of emergency
contagious epidemic. MH services, and Com.
outreach.
50. Wachter, K. Eastern DRC 744 Investigate the Social support Emotional support 4
201826 women who relationship between variables, felt stigma, seeking and felt stigma
experienced sexual social support, and depression, anxiety were positively
violence. internalized and and PTSD. associated with
perceived stigma, and increased symptom
mental health. severity of depression,
Secondary cross- anxiety and PTSD.
sectional regression
analysis
HSCL-25: The Hopkins Symptom Checklist-25; HTQ: Harvard Trauma Questionnaire; PTSD: Post-Traumatic Stress Disorder; PHQ-9: Patient Health Questionnaire;
GAD-7: 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.

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Mental health systems, service provision and training Another study looking at who can afford health care found that
There are very few hospitals for the treatment of mental health most of the Congolese population struggles to afford health care
disorders in DRC. The country has only six public psychiatric costs because 47% of households earn <US $5.50/week46. Figures
hospitals, and a dozen private mental health centres with 500 suggest that diagnosable mental health disorders are as common
beds for nearly 90 million inhabitants, almost all of which are in in the DRC as elsewhere: 6–15% of people meet the criteria for
big cities41,42. schizophrenia; 22% for anxiety disorders; and 13–23% for mood
Among the few well-known specialized mental health facilities, disorders20. Yet, individuals and their families absorb costs related
Kinshasa, the capital city, has two mental health hospitals, the to drugs, treatment, food, bedding, and hospitalization in a
Centre Neuro-Psycho Psychiatrique de Kinshasa (CNPP) run by the country where most people live on less than US$2 per day46,47.
University of Kinshasa, and the Telema Mental Health Centre The impact of this financial burden is greater for women, as they
which is managed by the Roman Catholic Church. In provinces, have less income48. Interviews with 552 households found that to
DRC has: the CNPP at the Katwambi Centre (Centre de Katwambi) afford health care people may sacrifice other basic needs such as
in the province of Western Kasai; the Doctor Joseph Guillain of food and education, with serious consequences for the household
Lubumbashi Neuropsychiatric Centre (Centre Neuropsychiatrique or individuals within it. However, 92% said that they were able to
Docteur Joseph Guillain de Lubumbashi); the Department of contribute to treatment consultation fees (max. $0.27) and 79%
Neuropsychiatry of Sendwe Hospital in Lubumbashi in Katanga were able to pay for any drug prices (max. $1.10); 6% opted for
province; and the psychiatric facilities in the South-Kivu province free consultations and 19% for free drugs46. This demonstrates
called Centre Psychiatrique de Soins de Santé Mentale (SOSAME) again the need for community-based treatments that use and
in Bukavu20,41. We also note how this lack of hospital provision bolster existing community resources, rather than relying on
links to the need for a change of focus towards the social causes hospital stays that families can ill afford.
of poor mental health. It’s unlikely that existing mental health Mental health care as it stands is expensive, and costs for
training has yet caught up with this mandate for community- professional support vary from public to private. The daily rates for
centred and social (rather than biological) treatments, even in public psychiatric treatment are US$10–20 for outpatients, or US
those few existing hospitals. $20–25 for inpatients; private inpatient treatment costs double
Three studies in this review highlighted the need for training (US$50). A specialist consultation with a psychiatrist costs $15–25;
local staff20,43,44. An intervention programme for 441 women Eye Movement Desensitization and Reprocessing (EMDR) is US$25;
sexual trauma victims found that training local staff showed and other professionals cost US$10 (psychiatric nurse, psycholo-
improved knowledge, enhanced awareness and provided them gist, or a session of Cognitive Behavioural Therapy (CBT))40. It is
with tools to recognize sexual assault and to provide psycholo- worth noting that in a country with a significant number of people
gical support43. Another study, implementing mental health traumatized by war and sexual violence, trauma-based therapy
services in an area affected by prolonged war and Ebola disease (EMDR) is the most expensive treatment.
outbreak, found deficiencies in mental health services, and no
functional work plan was in place. However, integrative training DISCUSSION
programmes, advocacy and social mobilization, provision of
emergency mental health services, and community outreaches This systematic review highlighted a clear demand for mental
were needed in the region44. health care. The prevalence of mental health issues is greatly
DRC’s mental health policy was formulated in 1999 but so far, increased by major risk factors related to armed conflicts and
there are no budgetary allocations for mental health. The DRC poverty. The review covered the whole DRC with a particular focus
mental health policy promotes a recovery approach to mental on the eastern part of the country. Mental health problems are
health care, which emphasizes support for individuals to achieve under investigated in the DRC. The number of studies found is
their aspirations and goals. Unfortunately, not much has been small and not consistent with the extent and significance of
done due to the lack of a budget allocated to mental health20,40,41. 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
Integration of mental health care into the general health care raised to condemn the atrocities, including Nobel Peace Prize
and who can afford health cost winner Dr Denis Mukwege, who has called for an end to the use of
A study conducted in the eastern DRC, looking at the experience rape as a weapon of war49. In line with previous work, our study
of integrating mental health care into the general health care found that wartime sexual violence and extreme poverty are
system, found that it is possible. 3941 patients used care offered at highly traumatic, and cause multiple, long-term mental health
health centres and the district hospital between 2012 and 2015, difficulties6,50. We found that depression, anxiety, and PTSD were
and an average of 7 new cases/1000 inhabitants per year was the most common problems in the DRC. Similarly, other
recorded42. Moreover, a study that interviewed 16 psychiatrists in systematic reviews in conflict-affected populations find high
Kinshasa supported the idea that mental health care can be frequencies of mental health illnesses such as depression, anxiety,
integrated into general health care if new ways of approaching post‐traumatic stress disorder, bipolar disorder, and schizophre-
global mental health are applied. For example, using more nia51, and PTSD among civilians who have experienced sexual
responsive forms of support which acknowledge the value of violence50.
patient experiences45, and are not limited to the reductive This review found that existing mental health services in the
rationalism typical of the biological paradigm45. A household DRC are limited. ‘Mental health’ diagnosis may sit in opposition to
survey to which 591 residents responded and five focus group local beliefs, leading to a lack of uptake in existing services. People
discussions (FGDs) were held with 50 key stakeholders (doctors, with mental health illnesses in DRC and many other sub-Saharan
nurses, managers, community health workers and leaders, health African countries are more likely to seek help from traditional
care users) found that the integration of mental health care into healers and religious leaders52–54. Hence, there needs to be
the primary care system is difficult in Lubumbashi due to the lack collaboration with local communities and a pluralistic framework
of service provision41. For example, the study found that there are of understanding45. Some problems identified in this review, such
no dedicated psychiatric beds, nor is there a psychiatrist or as stigma and rejection, sit within the social realm. Positive social
psychologist available. Participants in the FGDs stated that in this connections are important for physical and mental wellbeing.
context, the main source of care for people remains traditional They can provide emotional support, practical assistance, informa-
medicine41. tion and a sense of belonging55. However, ‘social support’ is not

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 K.H. Ngamaba et al.
14
always positive26, hence it’s crucial to understand a person’s needs pervasive sexual violence, and generally poorer mental health60.
within their local context. Additionally, more non-medical mental Third, this systematic review did not conduct a meta-analysis
health interventions are required—for example in the current because of the lack of appropriate data. Hence, the findings are
review, help with livestock had a positive impact on mental presented narratively.
health37.
To address the mental health treatment gap in LMICs, then,
there is a need to develop psychosocial interventions that are CONCLUSION
culturally appropriate and embedded in local knowledge, values This systematic review calls attention to the need to support
and practices56. Although most medical and psychological sexual violence survivors and many other Congolese people
interventions have been developed and evaluated in high- affected by traumatic events. This review also highlights the need
income countries, this review found positive effects for psycho- for validating culturally appropriate measures and the need for
social interventions such as group therapy, music therapy, family well-designed controlled intervention studies in the DRC. Better
support, and socio-economic projects18,36,37. This matches previous public mental health systems and service provision could help to
research in humanitarian settings, which supports the efficacy of improve community cohesion, resilience, mental well-being, and
psychosocial interventions for adults with common mental even economic productivity. There is also an urgent need to
disorders57, and therapy for reducing suicidal ideation58. Still, address wider social issues such as poverty, stigma, and gender
applying these findings to poor-resource settings might be a inequality in the DRC. More evidence is needed on reducing
challenge57, and in the DRC there is a lack of related health mental health stigma in the DRC. Further collaboration with
professionals from social work, psychology, and occupational communities is required to ensure people are willing and able to
therapy40. Effectively measuring the outcomes of such interven- access available services.
tions 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 DATA AVAILABILITY
these Western measures in the DRC context. This included the The authors confirm that the data supporting the findings of this study are available
within the article [and/or] its supplementary materials.
Impact of Event Scale-Revised (IES-R), two variations of the Hopkins
Symptom Checklist, and the Edinburgh Post-partum Depression
Scale28,29. As such, further studies are required to ensure that Received: 29 May 2023; Accepted: 20 December 2023;
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 profes-
sionals to tackle stigma, reduce social rejection and provide
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K.H.N. designed the study and K.H.N. and C.H. drafted the manuscript. K.H.N. creativecommons.org/licenses/by/4.0/.
prepared the data for the analysis. K.H.N. did the data analysis with advice from CH
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