An important paper on a mental health intervention in Myanmar is in the Lancet Psychiatry but it is paywalled so we cannot see it. Does anyone know how I can contact Kyin Maung Gee to ask for a copy of it?
Jamie
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Task sharing: stopgap or end goal?
The Lancet Psychiatry
February, 2019
DOI:https://doi.org/10.1016/S2215-0366(19)30006-9
The disparity between the burden of mental ill health and the resources available to address it is well known. One solution is task sharing—a process developed in global health fields such as HIV management that involves training community health workers to do specific jobs. On Oct 26, 2018, WHO launched its guideline on health policy and system support to optimise community health worker programmes. The guideline aims to improve the selection, training, and payment of community health workers. Competency-based certification forms the basis for the recognition of community health workers as a respected part of the workforce, with their own career structure.
In The Lancet Psychiatry, Kyin Maung Gee describes how community health workers are raising awareness and knowledge of depression in Hlaing Thar Yar, a township in Myanmar. Community health workers receive training in identification of mental disorders and are provided with smartphones equipped with interactive screening questionnaires for psychotic disorders, depression, and epilepsy. Potential patients are referred to general practitioners (GPs), who have been given electronic tablets pre-loaded with the WHO Mental Health Gap Action Program intervention guide. Appropriate individuals are, in turn, referred to psychiatrists.
A proven example of successful service provision by community health workers is the Thinking Healthy Programme, a psychological intervention that has been adopted by WHO for perinatal depression. When delivered by female community health workers, the programme more than halved the prevalence of perinatal depression among women in a large community-based randomised controlled trial in Pakistan. However, competing demands of community health workers have hampered efforts to scale up delivery. Therefore, Vikram Patel and colleagues have taken task sharing a step further and tested whether the programme can be delivered by lay people. Lay women who had shown an interest in helping other women within their community were given classroom-based training that focused on intervention content and relationship-building skills, followed by a clinical internship, after which their competence was assessed. The Thinking Healthy Programme was adapted for delivery by peers, with more emphasis on behavioural activation than on cognitive behavioural therapy and fewer sessions. In India, the revised programme was delivered through individual sessions, whereas in Pakistan it was delivered through both individual and group sessions.
These projects are certainly improving access to basic treatment for many people who would otherwise have remained untreated and possibly undiagnosed. Broadening the knowledge of mental illness among the general population in countries where stigma is still high could also have a beneficial effect. But what is the ultimate goal? The WHO guideline seems to be an admission that basic care in many countries will continue to be provided by community health workers. But should the next generation growing up in low-income countries expect that some aspects of mental health care will be provided mainly by peers? Should medical schools in these countries be training psychiatrists, ensuring that mental health is an essential component of GP training, or simply educating a small group of people to manage referred patients with serious mental illness and to act as trainers for community health workers and interested peer groups?
The Lancet Commission on global mental health and sustainable development called for mental health services to be fully integrated into the global response to other health priorities, including maternal and child health and HIV-AIDS, areas in which task sharing with lay workers has become common practice. HIV-AIDS might be lifelong problems, but the solutions are known and the role of the lay workers is to promote awareness and monitor adherence to treatment. Mother and baby care is more complex but covers a defined period. Mental illness is completely different. The range of disorders is extensive: even for the common mood disorders, multiple types exist with a myriad of causes, and the effects can be lifelong. Does a short course of psychotherapy and psychoeducation address the causes or just provide temporary symptomatic relief? The Thinking Healthy Programme trials showed a waning of effect after 6 months. Patel and colleagues do suggest that the programme might be the first phase in a stepped-care intervention. In the near-term, this might be the best we can provide but as policy makers plan mental health services for the next generation, they need to consider at what point they stop providing temporary solutions and define their end goal.
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30006-9/fulltext
