Can General Practitioners manage mental disorders in primary care? A partially randomised, pragmatic, cluster trial

Abstract

BackgroundFor a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care.MethodsIn this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment.All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ‐5D-3L, and resource use and costs evaluated from a health services perspective, at six months.Results153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY.ConclusionGeneral Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap.Trial registrationClinicalTrials.gov NCT02700490

Using the GHQ-12 to screen for mental health problems among primary care patients: psychometrics and practical considerations

“…Primary care patients who screened positive based on this threshold have 7.52-fold higher odds of receiving a CIS-R diagnosis (95% CI 3.72–15.20, p < 0.001). Applying this threshold score of ≥ 2 for a further 2 weeks of screening (as part of the recruitment of a trial [ 9 ] resulted in the identification of 574 patients who met the screening criteria from 2320 primary care patients screened (24.7%).

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“…Those who screened positive should be provided additional information regarding common mental health problems [55]. It could be argued that screening played a key role in identifying patients with indication of mental health problems in the trial we conducted in Indonesia, at very little additional costs to the health systems as screening was embedded into routine procedure [9]. With service expansion planned to reach all 10,000 primary care clinics, policy makers should consider encouraging screening for mental health problems to help clinicians quickly identify patients at risk.…”

“…This is a cross sectional study conducted to test the validity and screening accuracy of the GHQ-12 and determine the point at which the balance between sensitivity and specificity is optimised. This study piloted the recruitment procedures for a trial examining the clinical and cost-effectiveness of two mental health care frameworks for primary care [ 9 ]. A pilot study was conducted in June 2016 to test the screening procedure.…”

“…These clinics, called Puskesmas, also provide care at a nominal fee for non-residents. This study recruited participants from 28 Puskesmas in Yogyakarta, Indonesia, as part of a pre-study of a cluster randomised controlled trial [9]. These 28 Puskesmas provide mental health services.…”

“…Screening alone cannot and will not improve the outcomes for common mental disorders such as depression, if resources for effective intervention must also be in place [8]. In Indonesia, mental health services are increasingly provided at zero or very low costs in primary care following the systematic introduction of the World Health Organization (WHO) Mental Health Gap Action Programme to 10,000 primary care clinics [9].…”