Novel Strategy May Boost Access to Mental Health Care

Megan Brooks

December 29, 2016

Training laypeople in resource-poor settings to deliver mental health services may be an effective way of boosting access to psychological services for individuals in need, new research suggests.

Among individuals who screened positive for common mental disorders in Zimbabwe, a lay health worker–administered intervention led to improved symptoms at 6 months compared to enhanced usual care.

This study shows that "lay health workers can be trained to deliver psychological interventions normally reserved for professionals such as psychologists and psychiatrists and can contribute towards reducing the treatment gap for common mental disorders," Dixon Chibanda, MD, of the Department of Community Medicine Harare, Zimbabwe AIDS Prevention Project–University of Zimbabwe, told Medscape Medical News.

"There is now need to integrate [this] into existing programs, such as those for HIV, maternal, and child health, as part of a scaled-up strategy," he added.

The study was published online December 27 in JAMA.

Lack of Access

Few people with depression and anxiety and other common mental disorders in sub-Saharan Africa and other low-income settings have access to effective treatments, the investigators note.

"Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap," they write.

For the study, the investigators tested the effect of a primary care–based psychological intervention vs enhanced usual care in a cluster randomized trial involving 24 clinics in Harare.

Participants were 573 clinic attendees aged 18 years or older who screened positive for common mental disorders such as depression and generalized anxiety on the locally validated Shona Symptom Questionnaire (SSQ-14).

Most were women (86%). Half had completed primary education, and 42% were HIV positive. At study enrollment, three quarters of participants listed three or more problems that they were experiencing, with 74.1% reporting physical illness, 70.1% domestic violence/upheaval, and 66.2% loss of income.

The 286 individuals in the intervention group received six sessions of individual problem-solving therapy delivered by trained, supervised LHWs and could participate in an optional six-session peer support program. The 287 individuals in the control group received standard care plus information, psychological education, and support for common mental disorders.

The primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cut point of 9.

The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire (PHQ-9), with a range of 0 (best) to 27 and a cut point of 11. Outcomes were analyzed by modified intention to treat.

At 6 months, the average score on the SSQ-14 was significantly lower in the intervention group (3.81; 95% confidence interval [CI], 3.28 - 4.34) than in the control group (8.90; 95% CI, 8.33 - 9.47). The adjusted mean difference was -4.86 (95% CI, −5.63 to −4.10).

Likewise, in the secondary binary outcome, fewer intervention group participants screened positive on the PHQ-9 (13.7% vs 49.9% control; adjusted risk ratio, 0.28; 95% CI, 0.22 - 0.34).

There was little evidence that the beneficial effects were moderated by severity of symptoms, as assessed with the SSQ-14 or PHQ-9, the researchers note.

Attractive Option

"Our findings are consistent with evidence on problem-solving therapy from high-income countries. Problem-solving therapy is an attractive option in a low-resource context because, unlike cognitive behavior therapy, it does not require extensive training or complex skills," they point out.

The researchers also note that having a "contextually relevant cadre of health workers to deliver the psychological therapy who were perceived as mature and trustworthy by the community is likely to have been important in forming a strong therapeutic alliance."

In an accompanying editorial, Richard Neugebauer, PhD, of the New York State Psychiatric Institute in New York City, notes that randomized controlled trials (RCTs) conducted to date in many resource-poor settings have demonstrated the "feasibility, acceptability, and effectiveness of task shifting from highly qualified health personnel to lay health workers.

"However, this demonstration has been accomplished solely within the framework of an RCT. Implementation is a different matter and requires translation of research findings from the controlled environment of an RCT into actual clinical programs and settings," he writes.

This study, Dr Neugebauer adds, contributes to the "evidence base guiding the development and deployment of mental health services in resource-limited settings. However, to be sustained, large-scale social planning involves the active and full engagement of the numerous anticipated participants and beneficiaries. For this reason, studies on local attitudes and perspectives are essential in preparation for implementation."

The study was funded by Grand Challenges Canada. The authors have disclosed no relevant financial relationships.

JAMA. Published online December 27, 2016. Abstract, Editorial


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