Improving access to care

Generating Knowledge: Improving access to care 

We design interventions based on the best global and local evidence, systematically test them to ensure feasibility of delivery by lay health workers and acceptability by patients and families, and evaluate effectiveness and cost-effectiveness through randomised controlled trials. We embed our interventions within routine health care platforms and work closely with local stakeholders to scale up services. On this page we provide a sample of the kinds of projects we are working on in this regard.

ASIA

Common Mental Disorders Care in India

MANAS: MANAshanti Sudhar Shodh

CMH in IndiaThe Manas trial is to date the largest trial of a mental health intervention in any low or middle income country. It was a cluster randomised controlled trial of a stepped care intervention for common mental disorders (CMD) delivered by lay health workers. A range of psychosocial treatments were provided; including psychoeducation, specific psychological treatments, yoga, proactive monitoring of adherence and specialist support.  24 primary health care facilities in Goa, India, were randomised to receive enhanced usual care (control) or stepped care. The primary research question was whether the addition of the Health Counsellor (who delivers all the psychosocial treatments) provides a cost-effective intervention in comparison to simply providing the PHC doctor with diagnostic information and access to antidepressants. Results showed that the intervention led to cost-effective improvements in recovery from CMD among patients attending public health facilities. Manas has also produced a set of manuals for health workers, physicians and counsellors addressing the concepts of stress and depression, the various treatments for depression, and delivery of these treatments in the Manas program.

CGMH Contact: vikram.patel@lshtm.ac.uk

Schizophrenia Care in India

COPSI: Care for People with Schizophrenia in India

COPSI street play to raise awareness about schizophreniaCOPSI was a randomised controlled trial evaluating the clinical and cost effectiveness of collaborative, community based care for people with chronic schizophrenia in three sites in India. The intervention was specifically designed to promote collaboration between the person with schizophrenia, their caregivers, and the treatment team (the psychiatrist and the community health worker) to deliver a flexible, individualised and needs-based intervention. All community health workers were systematically trained over 6 weeks and assessed for adequate competence using a specially-developed intervention manual. A COPSI documentary film entitled “Our Stories: Living and Coping with Schizophrenia in India” has been made and is available on YouTube. It provides a deeply personal and moving account of people with schizophrenia who have been taking part in the COPSI project. In the film, people with schizophrenia and their families tell us about their times before the illness, the problems they have faced, and their experiences of the COPSI project, including what they feel has changed for them since taking part.

CGMH Contact: graham.thornicroft@kcl.ac.uk

Psychosocial intervention in India

PRIDE - Transforming mental health for young people

The global population of young people exceeds one billion with almost 90 % residing in low to middle income countries. Mental disorders account for a considerable burden in the formative years of adolescence and young adulthood. Depressive, anxiety and conduct disorders (the ‘common mental disorders’) account for over 75% of the burden of mental disorders in this age group. There is a considerable body of evidence to suggest that a range of psychological treatments are effective for treating mental disorders in adolescents. However, the vast majority of young people do not receive these treatments. There are many reasons for this ‘treatment gap’. Much of the existing evidence comes from high income countries, and there are questions about how relevant this evidence is for settings where interventions can only be delivered by non-specialized health workers, where the cultural explanations for mental health problems are rarely biomedical, and where the demand for mental health care is low.

CGMH Contact: vikram.patel@lshtm.ac.uk

AFRICA

Depression Care for People Living with HIV in Zimbabwe

Tendai: Improving mental health and adherence to antiretroviral therapy

A Tendai adherence counsellorFunded by The Fogarty International Center at NIH, this study has demonstrated that having one’s mind full of depression-related rumination and worry is a key explanation for finding it hard to adhere to antiretroviral therapy (ART) for people with depression and HIV.  We have developed a behavioural intervention for ART adherence in depressed people called ‘New Direction’, in partnership with Harvard Medical School. New Direction draws on evidence from behavioural psychology and from use of visual aids and technology in adherence interventions, while also being feasible for low-resource settings.

CGMH Contact: melanie.abas@kcl.ac.uk

Depression Care in Zimbabwe

The Friendship Bench

The Friendship BenchThe Zimbabwean Friendship Bench Project is a stepped care approach to depression (commonly expressed as ‘thinking too much’ or ‘Kufungisisa’ in the Shona language) and other common mental disorders in primary care. The Friendship Bench uses a brief psychological approach based on problem-solving therapy and carried out by lay health workers with supervision by higher cadres. The team has recently completed the formative phase of a cluster randomised controlled trial. Initial results from the pilot trial demonstrate decreased symptoms of common mental disorders after 3 sessions of problem-solving therapy, as measured by a locally validated screening tool. The full RCT began in August 2014 and consists of 12 intervention clusters and 12 enhanced usual care.

CGMH Contact: melanie.abas@kcl.ac.uk

Perinatal Depression Care in Nigeria

EXPONATE: EXPanding care fOr periNATal women with dEpression

Funded by Grand Challenges Canada, EXPONATE is a large randomised controlled trial assessing the cost-effectiveness of a clinical management programme for perinatal depression in Ibadan, Nigeria. The programme is delivered by non-physician primary care providers (mostly community health workers), who receive support and supervision from nurses and general doctors through mobile phones. Women are recruited during pregnancy and follow-up continues after delivery. Children of depressed mothers are assessed 12 months after delivery to measure health indicators as well as cognitive development.

CGMH Contact: ricardo.araya@lshtm.ac.uk

Schizophrenia Care in Ethiopia

RISE: Rehabilitation Intervention for people with Schizophrenia in Ethiopia

A RISE research team meeting

The RISE project involved the development and evaluation of a community-based rehabilitation (CBR) intervention for people with schizophrenia in Ethiopia. This Wellcome Trust funded project had three phases: an intervention development phase, a 12-month pilot and a 12-month cluster randomized trial. A theory of change approach was used to structure the work through each phase. The RISE trial aimed to determine the impact of CBR in addition to facility based care, compared to facility based care alone, on disability in people with schizophrenia. CBR was delivered by trained non-specialist workers and involved both home-based support (psychoeducation, family intervention, support returning to work and community activities) and community mobilization (awareness raising and targeted mobilization of community resources). The trial was completed in April 2017.

CGMH Contact: laura.asher@lshtm.ac.uk

Severe Mental Disorders Care in Ethiopia

TASCS Trial: Task Sharing for the Care of Severe Mental Disorders

Typical houses in the Sodo districtTaSCS is a randomised controlled trial run by the Addis Ababa University Department of Psychiatry and funded by NIMH. This trial is evaluating whether mental health care delivered by trained and supervised primary health care workers is as good as that delivered by centralised, hospital-based, psychiatric nurse-led care. The intervention group is receiving treatment at community-based clinics close to their homes, while the control group receives ongoing care from a centralised clinic staffed by psychiatric nurses and based in a more urban area.

CGMH Contact: charlotte.hanlon@kcl.ac.uk

SOUTH AMERICA

Antenatal Depression Care in Brazil

PROGRAVIDA: A psychological management programme for depressed pregnant women

An auxiliary nurse delivering the PROGRAVIDA interventionPROGRAVIDA was a randomised controlled trial testing the efficacy of a psychological intervention for depressed pregnant women in Sao Paulo, Brazil. This primary care intervention is based on problem-solving techniques and delivered at home by auxiliary nurses. 680 women were randomised to the intervention or usual care and almost 90% completed follow up assessments 3 months after the intervention phase was completed. Recovery rates in the intervention group were 15% higher than in the control group, as measured by the Patient Health Questionnaire (PHQ-9).

CGMH Contact: ricardo.araya@lshtm.ac.uk

MULTI-COUNTRY

Mental Health Care in Six Low- and Middle-Income Countries

EMERALD: Emerging mental health systems in low- and middle-income countries

An EMERALD data analysis exercise in NepalEMERALD is a five-year programme (2012-17) to improve mental health outcomes in six low- and middle-income countries (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). It aims to strengthen mental health system performance by identifying key barriers to the effective delivery of mental health services and offering solutions for improvement. There is a strong focus on capacity-building of researchers, policy-makers and planners to implement system improvements for mental health care services, and on working towards greater involvement of service users and caregivers.

CGMH Contact: graham.thornicroft@kcl.ac.uk

Internet-based treatment for depression in 11 European Countries

E-COMPARED: European Comparative Effectiveness Research on Online Depression treatment

E-COMPARED is a 4-year project (2013-17) funded by the European Commission which is conducting comparative effectiveness research in UK mental health services on the effectiveness of internet-based treatment for depression. E-COMPARED is multidisciplinary (psychology, HTA, ICT, care) and its members are frontrunners in internet-based treatment for common mental health disorders in Europe. CGMH members involved in this project include; Prof Ricardo Araya, Dr. Arlinda Cerga Pashoja and Asmae Doukani. 

CGMH Contact: ricardo.araya@lshtm.ac.uk

eHealth implementation in Europe

ImpleMentaLL: Towards evidence-based tailored implementation strategies for eHealth

ImpleMentaLL (www.implementall.eu/) is a European collaboration of 13 countries, which is funded by the European Commission under Horizon 2020 and will run from January 2017-March 2021. This study aims to develop, apply, and evaluate tailored implementation strategies of on-going eHealth implementation initiatives. The UK site is responsible for carrying out implementation research work on e-interventions for depression in the Balkans i.e. Albania and Kosovo.  CGMH members involved in this project include; Dr. Arlinda Cerga Pashoja and Prof Ricardo Araya. 

CGMH Contact: Arlinda.Cerga-Pashoja@lshtm.ac.uk

UK

Psychosis care in the UK

Co-Production of a Therapeutic Skills Training Programme for Carers, Relatives and Friends with Psychosis

This is a qualitative study funded by The Camden and Islington NHS Foundation Trusts that aims to explore the views of people with psychosis as well as clinicians and carers in regards to wellbeing and recovery outcomes that are considered important and should be prioritised by a carer-focused therapeutic skills training programme. CGMH members involved in this project include; Dr. Arlinda Cerga Pashoja, Prof Ricardo Araya, and Asmae Doukani.  

CGMH Contact: Arlinda.Cerga-Pashoja@lshtm.ac.uk