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