Treatment Preferences for Pharmacological versus Psychological Interventions among Primary Care Providers in Nepal: Mixed Methods Analysis of a Pilot Cluster Randomized Controlled Trial

Bhardwaj, Anvita; Gurung, Dristy; Rai, Sauharda; Kaiser, Bonnie N.; Cafaro, Cori L.; Sikkema, Kathleen J.; Lund, Crick; Luitel, Nagendra P.; Kohrt, Brandon A.

doi:10.3390/ijerph19042149

Cited by 7 publications

(3 citation statements)

References 49 publications

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“…The visual recovery narratives presented by the persons with lived experience as well as other forms of structured social interaction of persons with lived experience are incorporated into mental health trainings for PHC staff. A pilot study showed that incorporating these social contact components into PHC trainings reduced stigma, increased MHC diagnostic accuracy of HCPs, and increased willingness to endorse and deliver psychological and psychosocial treatments (i.e., not solely rely upon medication) [ 42 , 43 ]. The RESHAPE intervention is now being piloted in Tunisia, Ethiopia, India, and China.…”

Section: Discussionmentioning

confidence: 99%

Mental health stigma at primary health care centres in Lebanon: qualitative study

Hana

Arnous

Heim

et al. 2022

Int J Ment Health Syst

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Background Mental health-related stigma is a global public health concern and a major barrier to seeking care. In this study, we explored the role of stigma as a barrier to scaling up mental health services in primary health care (PHC) centres in Lebanon. We focused on the experiences of Healthcare Providers (HCPs) providing services to patients with mental health conditions (MHCs), the views of policy makers, and the perceptions of stigma or discrimination among individuals with MHCs. This study was conducted as part of INDIGO-PRIMARY, a larger multinational stigma reduction programme. Methods Semi-structured qualitative interviews (n = 45) were carried out with policy makers (n = 3), PHC management (n = 4), PHC staff (n = 24), and service users (SUs) (n = 14) between August 2018 and September 2019. These interviews explored mental health knowledge, attitudes and behaviour of staff, challenges of providing treatment, and patient outcomes. All interviews were coded using NVivo and a thematic coding framework. Results The results of this study are presented under three themes: (1) stigma at PHC level, (2) stigma outside PHC centres, and (3) structural stigma. SUs did not testify to discrimination from HCPs but did describe stigmatising behaviour from their families. Interestingly, at the PHC level, stigma reporting differed among staff according to a power gradient. Nurses and social workers did not explicitly report incidents of stigma but described patients with MHCs as uncooperative, underscoring their internalized negative views on mental health. General practitioners and directors were more outspoken than nurses regarding the challenges faced with mental health patients. Mental health professionals revealed that HCPs still hold implicitly negative views towards patients with MHCs however their attitude has improved recently. Our analysis highlights five layers of stigma affecting SUs. Conclusion This qualitative study reveals that stigma was still a key concern that affects patients with MHC. SUs reported experiencing overt stigmatising behaviour in the community but less explicit discrimination in a PHC setting. Our findings emphasise the importance of (1) combatting structural stigma through legal reform, (2) addressing interpersonal stigma, (3) committing PHC management to deliver high quality mental health integrated services, and (4) reducing intrapersonal stigma by building public empathy.

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Section: Discussionmentioning

confidence: 99%

Mental health stigma at primary health care centres in Lebanon: qualitative study

Hana

Arnous

Heim

et al. 2022

Int J Ment Health Syst

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“…Mixed methods evaluation of the pilot cRCT demonstrated feasibility and acceptability of the RESHAPE implementation strategy. Qualitative narratives demonstrated that the PCPs felt they better understood the experience of patients and felt more confident that they could diagnose and treat such patients after hearing the recovery narratives [32,[38][39][40][41]. They also had more willingness to initiate psychological services [41].…”

Section: Preliminary Studies Of the Reshape Implementation Strategymentioning

confidence: 99%

Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial

Kohrt

Turner

Gurung³

et al. 2022

Implementation Sci

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Background There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services. Design In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists. Discussion This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness. Trial registration ClinicalTrials.gov, NCT04282915. Date of registration: February 25, 2020.

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“…These findings align with evidence indicating psychological interventions are effective in LMIC (Cuijpers et al ., 2018 ; Karyotaki et al ., 2022 ) and may have more enduring effects than antidepressants alone for people with depression (Cuijpers et al ., 2013 ). Despite this, there is evidence primary care providers in Nepal prefer pharmacotherapy to psychological or psychosocial interventions when treating depression (Bhardwaj et al ., 2022 ).…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of psychological intervention within services for depression delivered by primary care workers in Nepal: economic evaluation of a randomized control trial

Aldridge

Luitel²,

Jordans

et al. 2022

Glob. Ment. Health

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Background Integrating services for depression into primary care is key to reducing the treatment gap in low- and middle-income countries. We examined the value of providing the Healthy Activity Programme (HAP), a behavioral activation psychological intervention, within services for depression delivered by primary care workers in Chitwan, Nepal using data from the Programme for Improving Mental Health Care. Methods People diagnosed with depression were randomized to receive either standard treatment (ST), comprised of psychoeducation, antidepressant medication, and home-based follow up, or standard treatment plus psychological intervention (T + P). We estimated incremental costs and health effects of T + P compared to ST, with quality adjusted life years (QALYs) and depression symptom scores over 12 months as health effects. Nonparametric uncertainty analysis provided confidence intervals around each incremental effectiveness ratio (ICER); results are presented in 2020 international dollars. Results Sixty participants received ST and 60 received T + P. Implementation costs (ST = $329, T + P = $617) were substantially higher than service delivery costs (ST = $18.7, T + P = $22.4) per participant. ST and T + P participants accrued 46.5 and 49.4 QALYs, respectively. The ICERs for T + P relative to ST were $4422 per QALY gained (95% confidence interval: $2484 to $9550) – slightly above the highly cost-effective threshold – and −$53.21 (95% confidence interval: −$105.8 to −$30.2) per unit change on the Patient Health Questionnaire. Conclusion Providing HAP within integrated depression services in Chitwan was cost-effective, if not highly cost-effective. Efforts to scale up integrated services in Nepal and similar contexts should consider including evidence-based psychological interventions as a part of cost-effective mental healthcare for depression.

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Treatment Preferences for Pharmacological versus Psychological Interventions among Primary Care Providers in Nepal: Mixed Methods Analysis of a Pilot Cluster Randomized Controlled Trial

Cited by 7 publications

References 49 publications

Mental health stigma at primary health care centres in Lebanon: qualitative study

Mental health stigma at primary health care centres in Lebanon: qualitative study

Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial

Cost-effectiveness of psychological intervention within services for depression delivered by primary care workers in Nepal: economic evaluation of a randomized control trial

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