CITATION: Quality care for people with severe mental disorders in low-resource settings
Oye Gureje, Bibilola D Oladeji
Lancet Psychiatry. Comment| volume 9, issue 1, p3-5, january 01, 2022
Published: January, 2022
Findings from efforts to address the treatment gap for mental health conditions in low-income and middle-income countries (LMIC) suggest that non-specialist health providers can deliver effective evidence-based care for people with common mental disorders. Severe mental disorders (SMD) are relatively less common, however, there is some evidence that parts of sub-Saharan Africa might have had one of the largest percentage increases in the prevalence of schizophrenia, the prototypical severe mental health condition, over the period 1990 to 2016...
As Charlotte Hanlon and colleagues noted in their Article published in Lancet Psychiatry [ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00384-9/fulltext ], the task-shared model specified in the mhGAP has been evaluated only for common mental disorders and not for SMD. To fill this gap, the authors present the report of a phase 3, randomised, controlled, non-inferiority trial (TaSCS) conducted in Ethiopia comparing two models of mental health care for people with SMD. Participants with SMD were recruited from an ongoing cohort with enduring symptoms and complex needs. They were randomly assigned to two groups: one group continued with ongoing care delivered by psychiatric nurses at Butajira hospital (the PSY group) and the other consisted of patients who were referred back to primary health centres for follow-up care provided by the trained primary health care workers based on mhGAP specifications and supervised by psychiatric nurses (the TSC group). Outcomes at the 12 month primary endpoint showed that TSC was not inferior to PSY...
The results of the trial are of major relevance to any attempt to expand quality care to this underserved population of patients. People with SMD often require long-term, personalised, and integrated care, which is best delivered closer to where they live. Primary health-care workers providing such service need supervision and support from mental health specialists and psychiatric nurses are more readily available in LMIC to fulfill that role than are psychiatrists. Future studies should explore more closely some of the features of this study to see in what way they could affect the outcomes. First, given that it is unlikely to be routinely sustainable, what would the results be if, unlike in this trial, participants in the PSY group were not reimbursed for travel expenses? Second, given that psychological intervention is an important part of the mhGAP care specifications, what effect would a more specific set of skills to deliver adjunct psychological intervention by the primary health-care providers have on improving patients' compliance to follow-up and retention in care? And third, as most of the public health-care workers in TaSCS had degree-level education, it would be interesting to see whether these findings can be replicated in settings in sub-Saharan Africa in which the average public health-care worker has received no more than 2 years of training in the health service after high school.