Table 2:

Adaptations made to the standard Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) to meet realities of the Greater Tunis area (Tunisia)

Required adaptation	Local realities	Implications	Suggested adaptation
Selecting training modules	Context's influence on choice of modules. The need to address:
	the rise in anxiety, depressive and substance use disorders, as well as suicide since the 2010-2011 Revolution. the association between schizophrenia and suicide/suicide attempts and reported increase in annual mortality rates associated with schizophrenia.	All needed modules were available, except the training material on conditions specifically related to stress.	General practitioners in charge of continuing medical education in the Greater Tunis area were assigned the role of “tutors” and given access to trainer-psychiatrists for support in filling this knowledge gap during and post-training. Anxiety disorders were covered indirectly in the depression module.
	field observations highlighting that general practitioners may share offices to provide care, were interrupted during consultations by waiting patients, and/or answered phone calls during consultations.	Discussions with trainees on confidentiality and good clinical practices for effective communication and interactions of healthcare professionals with people seeking mental health care were encouraged.	These local realities observed through field observation reinforced the need for the “General Principles of Care” module.
Developing a training format	Context's influence on training model and schedule. General practitioners have a restrained work schedule. Deficits in continuing mental health training programs in the Greater Tunis area. Psychiatrists in Tunisia have time constraints and a heavy workload. Letter written by general practitioners to refer patients to more specialized care. Consultations with patients in Tunisia are conducted in Tunisian Arabic.	General practitioners conduct clinical practice from 8 h-14 h, Monday to Saturday. These deficits create a high demand for training. Ongoing supervision post-training, as suggested by the standard programme, was not feasible. Challenges for trainees given short training programme, and often long referral procedure by letter. Role plays would thus be more realistic if conducted in Tunisian Arabic.	The training was designed to include only 1 session per week. The general lecture was conducted with all trainees, but small groups for role plays and more in-depth discussion were created. A 2-hour support session post-training was offered. In addition, the role of tutors was extended: they would provide guidance to trainees during and after training; if needed, they had access to trainer-psychiatrists during and after training for more in-depth questioning; and they would be able to organize support sessions with trainees post-training given their active role in continuing medical education. Trainer-psychiatrists provided their numbers to trainees, to facilitate referrals (if needed) during training. Tunisian trainers translated role plays into Tunisian Arabic, and simulation of consultations were conducted in this language by general practitioners during role plays.
Altering content based on context.	Context's impact on conditions’ specificities. Suicide Means of suicide are affected by availability and affordability of the means, and political context. Substance use disorders Substance use disorders are heavily stigmatized in the country. Rise of substance use and substance use disorders in Tunisia. Psychotherapies Psychotherapies are usually considered the responsibility of psychosocial care providers, not general practitioners.	Main means of suicide in Tunisia are hanging and immolation, not by use of firearms or ingestion of pesticides (ingestion of pesticides is a common way of attempted suicide). General practitioners do not always acknowledge substance use disorders as an ‘illness.’ No national prevalence of substance use disorders in Tunisia is available, only estimated statistics. Rise of substance use disorders caused by specific substances, which have local names. General practitioners usually engage in active listening and psychoeducation.	Training included local means of suicide/suicide attempts, but also highlighted the possibility of completed suicide by ingestion of pesticides given their availability and affordability. Information on the effect of drugs and alcohol on the brain and what may cause dependency was added to the training. Estimated statistics by the Ministry of Health were included in the training on substance use disorders to familiarize trainees with the realities associated with these disorders in Tunisia. General practitioners were informed of the local names of substances. Suggested therapies were removed from the standard training content but were mentioned orally to highlight other types of treatment than pharmacological. General practitioners do engage in psychoeducation. Therefore, appropriate information to be shared with people consulting for mental illness or suicidal ideation, as listed in the standard guide, was taught and reinforced.
	Context's impact on availability of medication. Listed medication in the standard training and World Health Organization Model List of Essential Medicines are available in Tunisia, but there are different internal procedures for the availability and prescription of these medications within healthcare clinics. Substance use disorders are heavily stigmatized in Tunisia. Context's impact on availability of community-based mental health services. While there is a budget for mental health prevention activities, most mental health funding is allocated to sustain institutionally-based resources. Substance use disorders are heavily stigmatized in Tunisia.	There is an uneven distribution of needed medication across healthcare clinics and the ability to prescribe it is sometimes challenging. Medications to treat these disorders, if available, are mainly available in emergency settings, hospital settings, or the private sector. There are deficits in community-based services that promote recovery and reintegration. For people living with substance use disorders, there are no standardized structures of care rooted in the community or formal support/self-help groups available. This encourages greater short-term follow-up.	To highlight health inequity, the uneven distribution of essential medicines and the conditions to prescribe them for people living with mental health problems in primary care settings was included in the training. The monopoly of these medicines in emergency, hospital, or private settings were highlighted, but general practitioners’ role in treatment, if resources and support were available, was emphasized. Missing community-based services were included in the training to highlight their importance and encourage general practitioners to advocate for them. Training included ways in which general practitioners can manage this population over the longer term, and the need for formal support/self-help groups and residential rehabilitation services.