A study published Online First by The Lancet shows that a trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from common disorders (CMD, such as depression and anxiety) among patients attending public primary care facilities, but a positive effect was not shown in patients at private facilities. The Article is by Professor Vikram Patel, Sangath Centre, Goa, India, and London School of Hygiene and Tropical Medicine, UK, and colleagues. The research was funded by The Wellcome Trust.
The prevalence of CMD in the people attending primary health centre is estimated at around 20% in developing countries. But there are several obstacles to providing effective interventions to real-world primary care settings in developing countries. These obstacles include the lack of skilled health workers, low recognition rate of these disorders by primary care doctors, the inadequate use of antidepressant drugs or psychosocial treatments, and low adherence to treatments. In this study, the MANAS trial, the authors aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders.
In this cluster randomised trial, primary care facilities in Goa, India, were assigned to intervention or control (enhanced usual care) groups. 24 study clusters, with an equal proportion of public and private facilities, were included. All adults who screened positive for CMD were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician for patients with moderate or severe CMD and monthly supervision by a mental health specialist.
The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems—10th revision (ICD-10) at 6 months.
The researchers found that1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with CMD in the intervention group were more likely to have recovered at 6 months than were those in the control group (65% vs 53%), and absolute difference of 12% meaning that patients in the intervention group were 22% more likely to recover than control group patients. In public facilities, the difference in recovery rates was even greater (66% vs 43%), while in the private facilities, recovery rates were similar (64% vs 66%). The intervention also showed a preventive effect amongst those patients who had symptoms of depression and anxiety just under the level to meet diagnostic severity. There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide.
The results in private care facilities suggest that the standard of care in those private clinics that took part in the MANAS study were already at a standard as high as that provided by the intervention.
The authors say: "Results from the MANAS trial indicate the effectiveness of a lay health counsellor-led collaborative stepped-care intervention for common mental disorders in public primary health-care facility attenders in India. This evidence should be used to improve services for common mental disorders in settings for which mental health professionals are scarce."
They conclude: "We recommend that the collaborative stepped-care intervention should be extended to clinics run by public primary health-care facilities."
In a linked Comment, Dr Charles F Reynolds III and Dr Steven M Albert, University of Pittsburgh, PA, USA, say: "The cost-effectiveness of collaborative care led by lay health counsellors to treat and prevent common mental disorders deserves further investigation. Web-based delivery of learning-based depression-specific psychotherapies might be feasible, effective, and in¬expensive, as treatment for anxiety and depression in primary care, or as prevention. The MANAS trial opens new possibilities for early intervention to reduce the global health and economic burden of common mental disorders."
Professor Vikram Patel, Sangath Centre, Goa, India, and London School of Hygiene and Tropical Medicine, UK. T) +91-9822132038 E) Vikram.patel@lshtm.ac.uk
Dr Charles F Reynolds III, University of Pittsburgh, PA, USA. T) +1 412 246 6414 E) reynoldscf@upmc.edu For full Article and Comment, see: http://press.thelancet.com/indiacmd.pdf
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Journal
The Lancet