Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

Abstract

Background Community‐based primary‐level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low‐ and middle‐income countries. Objectives To evaluate the effectiveness of PW‐led treatments for persons with mental health symptoms in LMICs, compared to usual care. Search methods MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019). Selection criteria Randomised trials of PW‐led or collaborative‐care interventions treating people with mental health symptoms or their carers in LMICs. PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non‐health professionals (CPs). Data collection and analysis Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality‐of‐life (QOL), functioning, service use (SU), and adverse events (AEs). Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. Analysis timepoints: T1 (<1 month), T2 (1‐6 months), T3 ( >6 months) post‐intervention. Main results Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. Intervention effects *Unless indicated, comparisons were usual care at T2. “Probably”, “may”, or “uncertain” indicates "moderate", "low," or "very low" certainty evidence. Adults with common mental disorders (CMDs) LHW‐led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD ‐0.59, 95%CI ‐1.01 to ‐0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD ‐0.47, 95%CI ‐0.8 to ‐0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative‐care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little‐or‐no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly red...

Post-traumatic stress disorder psychological interventions in sub-Saharan Africa: protocol for a systematic review of the literature

“…An average of 1.4 mental health workers are available per 100 000 persons in Africa compared with the global average of 9 per 100 000 15 27 28. The provision of specialised community-based services, collaborative care interventions, task-shifting and task sharing approaches are some of the strategies implemented to strengthen mental healthcare provision in low resource settings 29 30. Specialised community-based services entail formal links between primary and specialist care, where professional mental healthcare providers run services that are located at community level 29.…”

“…Specialised community-based services entail formal links between primary and specialist care, where professional mental healthcare providers run services that are located at community level 29. In collaborative care interventions, mental healthcare provision is provided in a structured way between the various types of providers 29 30. Task shifting and task sharing is the provision of mental healthcare services by individuals who have had no professional health training 31.…”

Scaling up public mental health care in Sub-Saharan Africa: insights from infectious disease

“…How can we translate lessons from the success of the HIV care continuum into specific strategies for the SSA mental healthcare cascade? We draw on our above discussion to provide a template of needed research to drive the expansion of public sector mental health care, and an example of how specific targets and timelines might be implemented and assessed for depressed individuals in public sector primary care by adding a workforce of mental health non-specialists trained to screen and deliver evidence-based mental health care at the clinic (van Ginneken et al ., 2021 ) ( Table 1 ). We acknowledge that advancing the mental healthcare cascade among primary care patients (who are already linked to healthcare) may be faster and less complex than with the general population.…”

“…Similar to HIV, mental disorders are stigmatized in many SSA settings and addressing the burden of mental disorders requires community engagement and long-term treatment. However, in stark contrast to HIV , care and treatment cascades for mental health have not expanded across the SSA public sector care continuum, despite nearly 20 years of epidemiological, efficacy and effectiveness data demonstrating that local non-specialists are capable of successful mental health care delivery for common mental health disorders in SSA (Bolton et al ., 2003 ; Lancet Global Mental Health Group et al ., 2007 ; van Ginneken et al ., 2021 ). Despite progress toward integrated models of mental health treatment delivered within HIV care (Collins et al ., 2006 ; Chibanda et al ., 2015 ; Chuah et al ., 2017 ), the scale up of mental health services that are not linked to HIV care and/or embedded with other services still lags and has much to learn from HIV implementation methods.…”

Public mental health: An opportunity to address implementation failure

“…For instance, integration between primary care and secondary mental health care can be supported by collaborative care and task sharing (van Ginneken et al ., 2021). [ 40 ] India is trying to integrate mental health care into community and primary health-care settings as part of an integrated chronic disease management approach (Ved et al ., 2019). [ 41 ] An integrated, multilevel approach across sectors is required to prevent suicide (Vijayakumar et al ., 2021).…”