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      Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months


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          This paper has been corrected post-publication in deviation from print and in accordance with a correction printed in the February 2012 issue of the Journal.


          Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare.


          To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders.


          Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinicaltrials.gov (NCT00446407).


          A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53–0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59–0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR = 0.64, 95% CI 0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities.


          Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities.

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          Most cited references 12

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          Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.

          Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment. Face-to-face household surveys were undertaken with 84,850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services. The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less. Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.
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            Educational and organizational interventions to improve the management of depression in primary care: a systematic review.

            Depression is commonly encountered in primary care settings yet is often missed or suboptimally managed. A number of organizational and educational strategies to improve management of depression have been proposed. The clinical effectiveness and cost-effectiveness of these strategies have not yet been subjected to systematic review. To systematically evaluate the effectiveness of organizational and educational interventions to improve the management of depression in primary care settings. We searched electronic medical and psychological databases from inception to March 2003 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane Controlled Trials Register, United Kingdom National Health Service Economic Evaluations Database, Cochrane Depression Anxiety and Neurosis Group register, and Cochrane Effective Professional and Organisational Change Group specialist register); conducted correspondence with authors; and used reference lists. Search terms were related to depression, primary care, and all guidelines and organizational and educational interventions. We selected 36 studies, including 29 randomized controlled trials and nonrandomized controlled clinical trials, 5 controlled before-and-after studies, and 2 interrupted time-series studies. Outcomes relating to management and outcome of depression were sought. Methodological details and outcomes were extracted and checked by 2 reviewers. Summary relative risks were, where possible, calculated from original data and attempts were made to correct for unit of analysis error. A narrative synthesis was conducted. Twenty-one studies with positive results were found. Strategies effective in improving patient outcome generally were those with complex interventions that incorporated clinician education, an enhanced role of the nurse (nurse case management), and a greater degree of integration between primary and secondary care (consultation-liaison). Telephone medication counseling delivered by practice nurses or trained counselors was also effective. Simple guideline implementation and educational strategies were generally ineffective. There is substantial potential to improve the management of depression in primary care. Commonly used guidelines and educational strategies are likely to be ineffective. The implementation of the findings from this research will require substantial investment in primary care services and a major shift in the organization and provision of care.
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              Is Open Access

              Packages of Care for Depression in Low- and Middle-Income Countries

              In the first in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Neerja Chowdary and colleagues discuss the treatment of depression.

                Author and article information

                Br J Psychiatry
                The British Journal of Psychiatry
                Royal College of Psychiatrists
                December 2011
                1 December 2011
                : 199
                : 6
                : 459-466
                Department of Nutrition and Public Health Intervention Research, London School of Hygiene & Tropical Medicine, UK and Sangath, Goa, India
                MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
                Sangath, India and London School of Hygiene & Tropical Medicine, UK
                Sangath, India
                Sangath, India
                Sangath, India and London School of Hygiene & Tropical Medicine, UK
                Sangath, India
                Division of Psychiatry, University of Bristol, UK
                Department of Mental Science at Royal Free Campus, University College London Medical School, London, UK
                Centre for Health Studies, Group Health Cooperative, Seattle, USA
                Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, USA
                Department of Nutrition and Public Health Intervention Research, London School of Hygiene & Tropical Medicine, London UK
                Author notes
                Correspondence: Vikram Patel, Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India. Email: Vikram.patel@ 123456lshtm.ac.uk
                Royal College of Psychiatrists

                Royal College of Psychiatrists, This paper accords with the Wellcome Trust Open Access policy and is governed by the licence available at http://www.rcpsych.ac.uk/pdf/Wellcome%20Trust%20licence.pdf


                Clinical Psychology & Psychiatry


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