Can we deliver effective health care for depression in the absence of psychiatrists?

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1 Can we deliver effective health care for depression in the absence of psychiatrists? Professor Ricardo Araya London School of Hygiene & Tropical Medicine Centre for Global Mental Health

2 OUTLINE Human Resources: the magnitude of the problem in lowand-middle income countries Potential solutions: Task shifting Does task shifting works? Some case studies using task shifting Problems with task shifting

3

4 DOCTORS PER 10,000 POPULATION

5 TRAIN MORE DOCTORS? Training = 5-7 years Retaining? It would take a long time Expensive, and high-risk investment

6

7 Psychiatrists per 100,000 population Conutry Ratio per 100,000 Brazil 3.07 Chile 0.99 Guatemala 0.59 India 0.30 Nigeria 0.06 Zimbabwe 0.06 Australia 12.8 UK 19.4 Switzerland 42.0 WHO Atlas, 2011

8 8 The situation in India India produces about 100 new psychiatrists per year, but half of them immediately leave to work overseas For India to achieve equivalent rates of psychiatrists as the UK, at current training and retention rates, it would need 2000 years If all psychiatrists in India did only face to face patient contact, for 8 hours a day, five days a week, with onehour consultations over a 12 month period, they would altogether provide care to less than 5% of people with child mental disorders, depression, and schizophrenia

9 9 The reality in most LMIC o 90% of the world s population live in LMIC o The vast majority of patients with mood, anxiety and substance use disorders go untreated(80-90%) o Those who are treated most of the time do not receive an evidence based treatment o Amongst those who do see psychiatrists, the vast majority only receive pharmacological treatments and very few receive psychological interventions

10 Can something be done about the lack of doctors and psychiatrists in LMIC?

11 Closing the specialist resource gap through task-shifting in LMIC The strategy of rational redistribution of tasks among health workforce team members Specific tasks are moved, where and when appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources

12

13 The Economist Physician assistants in America can do about 85% of the work of a general practitioner Resources are slowly being reallocated. Nurses and other health workers will put their training to better use Doctors, meanwhile, will devote their skill to the complex tasks worthy of their highly trained abilities For one thing, to treat the 21 st century s problems with a 20 th century approach to health care would require an impossible number of doctors. For another, caring for chronic conditions is not what doctors are best at. For both these reasons doctors look set to become much less central to health care a process which, in some places, has already started

14 Does it work in mental health?

15 15 The effectiveness of non-specialist health workers in delivering mental health care in developing countries

16 16 The evidence base 17 Randomised controlled trials 2 Non-randomised controlled trials 9 Controlled, before and after studies

17 Non-specialist health worker led Collaborative Care 17

18 STUDIES Stepped, collaborative care Chile Improved primary care treatment for depressed low-income women (2003, 2007) India Improved treatment in primary care and medical out-patient clinics for common mental disorders (2010) Psychological treatments alone Pakistan Individual CBT depressed mothers (2008)

19 Chile SEVERITY OF DEPRESSION MODERATE (HDRS <20) INTERVENTION Group intervention + Case Management PERSON RESPONSIBLE Social worker/ nurse SEVERE (HDRS >20) Group intervention + Case Management + Antidepressant Social Worker/ nurse + GP Araya et al. Lancet 2003

20 RCT findings % Recovered Usual Care Improved Care DIFFERENCE 3-MONTH 15% 49% 34% 6-MONTH 30% 70% 40%

21 COST-EFFECTIVENESS ANALYSIS The additional cost for an extra depressionfree day with Improved Care $216 What could you buy with $216 in Chile in 2003? 3/4 litre of Coca-Cola Araya et al. Am J Psychiatry 2006

22 Depression in PHC Programme Number of people treated by year Araya et al. Lancet 2009

23 MANAS Study Goa, India 2,800 Adults who screened positive for Common Mental Disorders (CMD) Randomised to Collaborative Stepped Care (CSC) or Usual Care primary care facilities (12 public, 12 private) Participants were assessed at 2, 6 and 12 months after recruitment Patel et al, Lancet 2010

24 Collaborative Stepped Care Intervention

25 25

26 Lady health visitors using CBT to treat postnatal depression in rural Pakistan Rahman et al. Lancet 2008

27 HIGHLIGHTS CBT for depressed pregnant women delivered by trained and supervised lady health workers At 6 months, 77% vs 47% of mothers in the intervention and control groups were recovered Similar differences were found across groups at 12 months

28 THE FRIENDSHIP BENCH, ZIMBABWE 28

29 29 PROGRAVIDA, BRAZIL

30 WAR DISPLACED POPULATIONS: BOGOTA, COLOMBIA

31 WOMEN S CIRCLES FOR MOTHERS WITH CHILDREN AT RISK: GUATEMALA

32 Community mental health workers delivering care for schizophrenia (Chatterjee et al. Br J Psych 2003, 2009; Lancet, in press) 32

33 POTENTIAL PROBLEMS NSHWs already overloaded with other duties NSHWs not properly rewarded for additional duties NSHWs not adequately trained, supported or supervised NSHWs not legally permitted to carry out certain tasks Powerful groups opposed to task shifting Tensions within teams due to changing roles The absence or lack of a regulatory framework for its implementation.

34 POTENTIAL PROBLEMS Piecemeal approach without proper integration, collaboration, and communication among staff within teams Changes in practice sometimes challenge entrenched habits, and hierarchical relationships within teams Medical staff sometimes feel anxious around liability and accountability when tasks are shifted down especially when overall responsibility for care remains at a higher level

35 Assisting task-assisting through the use of technology

36 Assisting task-assisting through the use of technology

37 What could be the role of psychiatrists? As clinicians to see the most complex cases or those resistant to treatment at lower levels of care 37 To train, supervise, and support other personnel To lead in promoting scaling up and advocating for more resources Have we been trained to do this?

38 CENTRE FOR GLOBAL MENTAL HEALTH London School of Hygiene and Tropical Medicine & Institute of Psychiatry, London Projects in more than 30 countries Investigators have raised nearly US$100 million in grants MSc in Global Mental Health Partnerships with other academic institutions throughout the world

39 Mental Health Innovation Network The first repository of mental health innovations Over 50 innovations listed to date Project overview and key publications, tools and multimedia resources

40 THE END

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