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Integrating mental health with other NCDs Inge Petersen, PhD.
programme for improving mental health care
Outline of presentation • Why integrate mental health with other NCDs?
• 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 in LMIC.
Why integrate? • Rising burden of mental disorders
• Depression is predicted to be the second leading burden of disease globally in 20201
• High prevalence of depression
comorbid with NCDS • Between 9·3% and 23·0% of people with
NCDs had comorbid depression2.
1. World Health Organization. (2008). The global burden of disease: 2004 update. Geneva: World Health Organization 2. Moussavi, S., S. Chatterji, et al. (2007). "Depression, chronic diseases, and decrements in health: results from the World Health Surveys." Lancet 370(9590): 851-858
Why integrate? • Common mental disorders (CMDs) compromise
fight against rising burden of NCDs2 • Prevention – exacerbate modifiable risk factors • Treatment - compromise adherence
• Depression comorbid with NCDs has worse health
outcomes compared to: • Depression alone • Any other NCD alone • Any combination of NCD without depression2
1. Ngo, V. K., A. Rubinstein, et al. (2013). "Grand challenges: Integrating mental health care into the non-communicable disease agenda." PLoS Med 10(5): e1001443 2. Moussavi, S., S. Chatterji, et al. (2007). "Depression, chronic diseases, and decrements in health: results from the World Health Surveys." Lancet 370(9590): 851-858.
Mental Disorders in South Africa
Photo: Mental Health & Poverty Project (MHaPP)
• Neuropsychiatric disorders rank 3rd after HIV/AIDS and other infectious diseases1
• One in six adults experience a common mental disorder (CMD) within a 12 month period2
• Only one in four receive treatment of any kind3
1..Bradshaw, D., et al. (2007). A clarion 4call for action based on refined DALY estimates for South Africa. [Editorial]. S Afr Med J, 97(6), 438, 440. 2. Herman, A. A. et al. (2009). The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J, 99(5 Pt 2), 339-344. 3. Seedat, S. et al. (2009). Mental health service use among South Africans for mood, anxiety and substance use disorders.. S Afr Med J, 99(5 Pt 2), 346-352.
CMDs in chronic conditions in SA • Integrated chronic care users:
• 31% of mixed chronic disease group (N=252) met diagnostic criteria for major depressive disorder
(Large PHC facility in North West)
Solution: Integrated Chronic Care • Depression & alcohol use disorders ripe for
integration1 • Prevalence
• Evidence of effectiveness of “task shared” care
• TEAMcare trial in the United States2 • Depression co-morbid with poorly controlled diabetes
and/or heart disease
• More cost-effective than usual 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): e1001448. 2. Katon, W. J., E. H. Lin, et al. (2010). "Collaborative care for patients with depression and chronic illnesses." N Engl J Med 363(27): 2611-2620.
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
How do we implement such a collaborative chronic care approach in scarce resource settings?
Integrating mental health into ICDM in South Africa
• THROUGH the programme for improving mental health care
• Purpose is to generate world class research on the implementation and scaling up of treatment programmes for priority mental disorders in primary and maternal health care contexts in low resource settings.
• PARTNERS • Centre for Public Mental Health • WHO • Centre for Global Mental Health • Basic Needs • Perinatal Mental Health Project
• Ethiopia • India • Nepal • South Africa • Uganda
South Africa
Ethiopia
Uganda
India
Nepal
South African National Department of Health model
Asmall, S and Mahomed OH. The Integrated Chronic Disease Management Manual. Pretoria; National Department of Health. 2013
How? Development of district mental health care plan
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
0 63 4 (19) 3 1 (3) 11 0 10 5 (22) 87
Facility level
Back referral to local clinic for continued management
PHC nurse identifies depression and other mental disorders as well as other non-
communicable 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
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
Referral for counselling (individual/ group ) facilitated by HIV counselors and supervised by district hospital
psychology outreach team
Referral to PC doctor for assessment & diagnosis and initiation of
psychopharmacological treatment and/ or upward referral if suicide risk
Moderate /severe depression
Severe/moderate depression
The PRIME -SA collaborative care model for depression
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
Referral to rehabilitation services
Alcohol dependency - referral to district hospital for detox
SBI protocol to be initiated if mild to moderate risk (harmful/ hazardous
risk pattern)
The PRIME-SA collaborative care model for Alcohol misuse
Tools: PC 101 + • Strengthened mhGAP guidelines for adult mental
disorders included in the PC 101 guidelines
• Depression
• Alcohol misuse
Step by step lay counsellor guidelines
• 8 sessions
• Draws on evidence-based psychological therapies1:
• Adapted from an intervention shown to have good outcomes in a non-randomized trial in South Africa2
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 member who were going to act on their problem how it went in 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): e1001122. 2. 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): 336-341.
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 No
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
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
SESSION 2
‘I have no resources’
POVERTY
SESSION 4 SESSION 5 SESSION 6 PLWHA only
SESSION 3 SESSION 7 PLWHA only
‘Relationship trouble’
INTERPERSONAL CONFLICT
‘I avoid people’
SOCIAL ISOLATION
Mourning for a loved one’
GRIEF AND LOSS
‘People discriminate against me’
EXTERNALISED STIGMA
‘People are talking about me’
INTERNALISED STIGMA
Problem management
Problem management
Getting active
Problem management
Problem management
Healthy thinking
SESSION 8: CLOSURE
Refer back to nurse or doctor for clinical review
Signs of Suicide (Same day referral for clinical
review): Talking & having
thoughts of suicide
Group dynamics (Speak to the person
afterwards): Member dominates Member doesn’t say
anything
Community level
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
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
Training & supervision structure for PC 101+
Specialist trainer of master trainers/Specialist district teams
Master trainers/Chronic care coordinator
Facility trainer
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
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
First message: Integrating mental health is smart. • Optimize & protect investment in NCD
• Prevention
• Treatment
• Improve health outcomes
• Reduce stigma
• Strengthen health systems for chronic care
• Counselling in particular is important to promote patient self management
• Provides advantages of treatment and health promotion
Second message: Adopt task sharing to integrate mental health
• Strengthen decision support for mental health for PHC nurses & doctors
• PC101+ • Diversify roles of existing HIV counsellors to
provide counselling for CMDs √ Manualized counselling guidelines
X Need a clear job description
X Standardized training programme
X Standardized supervision & support structure
Acknowledgements • PRIME-SA team
• Lara Fairall • Arvin Bhana • One Selohilwe • Tasneem Kathree • Palesa Mathibedi • Nomvula Sibanyoni
• PRIME is funded by the UK Department for International Development (DFID) for the benefit of developing countries.
• DoH • Shaidah Asmall • Ozayer Mahomed