Integrating mental health into the chronic disease service delivery platform in South Africa
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1 Integrating mental health into the chronic disease service delivery platform in South Africa Inge Petersen, PhD. programme for improving mental health care
2 Contributers PRIME-SA team Lara Fairall Arvin Bhana One Selohilwe Tasneem Kathree Carrie Brook-Sumner Palesa Mathibedi Nomvula Sibanyoni
3 Outline of presentation Why integrate mental health with chronic care? Example of integration using the collaborative chronic care model in HIC. PRIME (Programme for Improving Mental Health Care) in South Africa as an example of integration of mental health with chronic conditions in low- and middle-income countries (LAMIC).
4 Transition in health burden to chronic conditions Transition of communicable diseases (HIV/AIDS) to chronic condition Rising burden of non-communicable diseases (NCDs) in Africa 1 1. Marquez PV, Farrington, JL. The challenge of non-communicable diseases and road traffic injuries in sub- Saharan Africa: An overview. Washington, DC: The World Bank, 2013.
5 High co-morbidity of CMDs with chronic conditions Between 9 3% and 23 0% of people with NCDs had comorbid depression 1. Twofold greater risk of major depressive disorder in people living with HIV/AIDS 2 Sub-Saharan Africa ranges between 20-35% 3 Higher prevalence of alcohol misuse among PLWHA 4 1. Moussavi, S., S. Chatterji, et al. (2007). "Depression, chronic diseases, and decrements in health: results from the World Health Surveys." Lancet 370(9590): Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry May;158(5): Brandt R. The mental health of people living with HIV/AIDS in Africa: a systematic review. African Journal of AIDS Research 2009;8: Neuman MG, Schneider M, Nanau RM, Parry C. Alcohol Consumption, Progression of Disease and Other Comorbidities, and Responses to Antiretroviral Medication in People Living with HIV. AIDS Research And Treatment;2012:
6 Why is comorbid CMDs a public health problem? Comorbid depression & alcohol misuse compromises fight against rising burden of chronic conditions Prevention exacerbate modifiable risk factors Treatment - compromise adherence & self-care HIV 1,2 CVD & diabetic patients 3 1. Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr Oct 1;58(2): Neuman MG, Schneider M, Nanau RM, Parry C. Alcohol Consumption, Progression of Disease and Other Comorbidities, and Responses to Antiretroviral Medication in People Living with HIV. AIDS Research And Treatment;2012: Moussavi, S., S. Chatterji, et al. (2007). "Depression, chronic diseases, and decrements in health: results from the World Health Surveys." Lancet 370(9590):
7 Solution: Integrated Chronic Care Depression & alcohol use disorders ripe for integration 1 Prevalence Evidence of effectiveness of task shared care 1.Patel, V., G. S. Belkin, et al. (2013). "Grand challenges: integrating mental health services into priority health care platforms." PLoS Med 10(5): e
8 TEAMcare trial in the United States 1 Depression comorbid with poorly controlled diabetes and/or heart disease More cost-effective than usual care
9 Collaborative Chronic Care Model Nurse-led team based approach Combined pharmacotherapy with psychosocial interventions to solve problems and set goals to improve adherence and self-care. Wagner, E. H., et al. (1996). Improving Outcomes in Chronic Illness. Managed Care Quarterly 4 (2): 12 25
10 How do we implement such a collaborative chronic care approach in scarce resource settings?
11 Integrating mental health into ICDM in South Africa Through the programme for improving mental health care PARTNERS Centre for Public Mental Health WHO Centre for Global Mental Health Basic Needs Perinatal Mental Health Project Ethiopia South Africa Uganda India Nepal
12 South African National Department of Health model Asmall, S and Mahomed OH. The Integrated Chronic Disease Management Manual. Pretoria; National Department of Health. 2013
13
14 How? Formative Phase Service Users and Caregivers Lay Health Workers Primary Health Care Workers Specialists and Policy Makers Total FGD IDI FGD IDI FGD IDI FGD IDI FGD IDI (19) 3 1 (3) (22) 87
15 The PRIME -SA collaborative care model for depression If severe depression with suicide risk refer for out patient/ specialist care 9 to 10 weeks re-assessment by PHC nurse using PC101 post the psychosocial interventions Back referral to local clinic for continued management Referral to PC doctor for assessment & diagnosis and initiation of psychopharmacological treatment and/ or upward referral if suicide risk Referral for counselling (individual/ group ) facilitated by HIV counselors and supervised by district hospital psychology outreach team Severe/moderate depression Moderate /severe depression PHC nurse identifies depression and other mental disorders as well as other noncommunicable diseases (NCDs) using PC101+. Initiates initial management of other NCDs. Other mental disorders and NCDs including diseases of lifestyle which are inadequately controlled referred to PC doctor/ other referral sources
16 The PRIME-SA collaborative care model for Alcohol misuse Referral to rehabilitation services SBI protocol to be initiated if mild to moderate risk (harmful/ hazardous risk pattern) Alcohol dependency - referral to district hospital for detox PHC nurse identifies alcohol misuse and other non-communicable diseases (NCDs) using PC101+. Initiates initial management of other NCDs. Other mental disorders and communicable and NCDs including diseases of lifestyle which are inadequately controlled referred to PC doctor/ other referral sources
17 The collaborative care model for schizophrenia Referral to specialist facility for in-patient care Back referral to local clinic for continued management Referral to district hospital for 72 hr observation and initiation of psychopharmacological treatment Psychosocial rehabilitation intervention facilitated by aux social workers supervised by social worker/occupational therapist PHC nurse identifies psychotic disorders and other mental disorders as well as other communicable and non-communicable diseases (NCDs) using PC101. Initiates initial management of other diseases.. Provides ongoing repeat medication for chronic conditions Other mental disorders and communicable and NCDs including diseases of lifestyle which are inadequately controlled referred to PC doctor/ other referral sources
18 Facility level
19 Tools: PC Strengthened mhgap guidelines for adult mental disorders included in the PC 101 guidelines Depression Alcohol misuse
20
21
22 Step by step lay counsellor guidelines 8 sessions Draws on evidencebased psychological therapies 1 : Adapted from an intervention shown to have good outcomes in a non-randomized trial in South Africa 2 Step 1: Feedback from previous session Step 2: Read the story Step 3: Ask participants who identify with the story to share their story draw on the skills learned for understanding a problem (micro-counselling skills) Step 4: Facilitate group members helping one another with the problem (draw on healthy thinking, problem management, and getting active) Step 5: Ask group members to choose a strategy they can try out before the next session 1.Dua, T., C. Barbui, et al. (2011). "Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations." PLoS Med 8(11): e Petersen, I., et al. (2012). "The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa." Community Ment Health J 48(3):
23 REFERRAL from nurse/phc doctor to counsellor: Client with chronic condition who is depressed ASSESSMENT by Counsellor on intake duty whether service user is a candidate for group/individual counselling For group: Can commit time to attend 6-8 one hour long sessions once a week? Comfortable with confidentiality of a group? Comfortable to be in a mixed chronic disease group/hiv+ group only? Yes Book client into a group: 8-10 per group Men and women in separate groups Group service users of similar ages together Provide written reminder with date of first session Provide telephonic reminder day before the session Provide first session immediately Arrange for follow-up appointments See pages for step-by-step guide for individual counselling in guidelines No Group dynamics (Speak to the person afterwards): Member dominates Member doesn t say anything SESSION 1: Introduction Establish group norms (confidentiality etc.) Psychoeducation: What is depression? SESSIONS 2 7 Triggers of depression and strategies to help manage them Not all clients will identify with every cause, but will be able to offer help to others in the group. If there are no HIV+ patients in a group, only facilitate sessions 2-5. If the group has PLWHA, facilitate sessions 6 and 7 as well Signs of Suicide (Same day referral for clinical review): Talking & having thoughts of suicide SESSION 2 I have no resources POVERTY Problem management SESSION 3 SESSION 4 SESSION 5 SESSION 6 SESSION 7 PLWHA only PLWHA only Relationship trouble INTERPERSONAL CONFLICT Problem management I avoid people SOCIAL ISOLATION Getting active Mourning for a loved one GRIEF AND LOSS Problem management People discriminate against me EXTERNALISED STIGMA Problem management People are talking about me INTERNALISED STIGMA Healthy thinking SESSION 8: CLOSURE Refer back to nurse or doctor for clinical review
24 Community level
25 Assisted self-management Provided by community health worker led community outreach teams DoH CHW training programme Screening and identification Follow-up patients who are non-adherent to medication/counselling Provide follow-up medication for stable patients Health promotion
26 Tools DoH CHW training & resource manual Self-help pamphlets Psycho-education to promote self-care for depression and alcohol misuse Information on helpful resources within the community
27 Psychosocial Rehabilitation guidelines for aux social workers
28 Training & supervision structure for PC 101+ Specialist trainer of master trainers/specialist district teams Master trainers/chronic care coordinator Facility trainer
29 Training & Supervision structure for Counselling for CMDs Specialist district teams for mental health District PHC psychologist/district hospital psychology outreach team Peer to peer mentoring
30 Training & Supervision structure for psychosocial rehabilitation Specialist district teams for mental health Social workers from the Mental Health Societies Peer to peer mentoring
31 Pilot site
32 PRIME/COBALT (Comorbid Affective Disorders, AIDS/HIV, and Long Term Health) Trials Pragmatic cluster randomized controlled trials (RCTs) Measure the real-world effectiveness of the PRIME facility-based collaborative care intervention for depression in ART patients NCD patients Assess health and mental health outcomes for depressed ART/NCD patients
33 Key Messages
34 1.Integrating mental health enabling of chronic care Improve health outcomes Optimize & protect investment in ART & contain burgeoning cost of NCD care Strengthen health systems for chronic care Counselling to promote patient-centred care & self management
35 2. Chronic care enabling of integrated mental health care Paradigm shift from task oriented care to patient centred care More aligned with mental health care Improved health outcomes will raise public health priority of mental disorders Reduce stigma
36 Acknowledgements PRIME is funded by the UK Department for International Development (DFID) for the benefit of developing countries. DoH Shaidah Asmall Ozayer Mahomed
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