Abstract
BackgroundThe rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. The aim of this study was thus to evaluate a task shared integrated collaborative care package of care for chronic patients with co-existing depressive and alcohol use disorder (AUD) symptoms.MethodsThe complex intervention strengthened capacity of primary care nurse practitioners to identify, diagnose and review symptoms of CMDs among chronic care patients; and implemented a stepped up referral system, that included clinic-based psychosocial lay counsellors, doctors and mental health specialists. Under real world conditions, in four PHC facilities, a repeat cross-sectional Facility Detection Survey (FDS) assessed changes in capacity of nurses to correctly detect CMDs in 1310 patients before implementation and 1246 patients following implementation of the intervention at 12 months; and a non-randomly assigned comparison group cohort study comprising 373 screen positive patients with depressive symptoms using the Patient Health Questionnaire-9 (PHQ9) at baseline, evaluated responses of patients correctly identified and referred for treatment (intervention arm) or not identified and referred (control arm) at three and 12 months.ResultsThe FDS showed a significant increase in the identification of depression and AUD from pre-implementation to 12-month post-implementation. Depression: (5.8 to 16.4%) 95% CI [2.9, 19.1]); AUD: (0 to 13.8%) 95% CI [0.6–24.9]. In the comparison group cohort study, patients with depressive symptoms having more than a 50% reduction in PHQ-9 scores were greater in the treatment group (n = 69, 55.2%) compared to the comparison group (n = 49, 23.4%) at 3 months (RR = 2.10, p < 0.001); and 12 months follow-up (intervention: n = 57, 47.9%; comparison: n = 60, 30.8%; RR = 1.52, p = 0.006). Remission (PHQ-9 ≤ 5) was greater in the intervention group (n = 32, 26.9%) than comparison group (n = 33, 16.9%) at 12 months (RR = 1.72, p = 0.016).ConclusionA task shared collaborative stepped care model can improve detection of CMDs and reduce depressive symptoms among patients with chronic conditions under real world conditions.
Highlights
The rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing Common Mental Disorder/s (CMD) to improve health outcomes
It comprised the following five components: i) primary health care (PHC) nurses functioned as case managers and were oriented to the Integrated Clinical Services Management (ICSM), trained in clinical communication skills to facilitate person-centered care, and provided with supplementary mental health training in basic adult care guidelines [14]; ii) Doctors were oriented to the importance of mental health and upskilled to prescribe antidepressant medications; iii) Referral pathways for psychosocial counselling for patients with mild to moderate depressive symptoms were strengthened with the introduction of clinic-based lay counsellors trained and supervised to deliver individual and group-based counselling drawing on cognitive behavioural therapy techniques which have international evidence of effectiveness [15]; and v) A referral form to monitor nurse referrals to the counsellor was introduced
For each study round we report the number of participants who screened positive on Alcohol Use Disorder Identification Test (AUDIT) and Patient Health Questionnaire-9 (PHQ-9), the number of screen positive participants who completed the exit interview, and the proportion who were classified as having been detected for alcohol use disorder (AUD), or for depression using both narrow and broad criteria
Summary
The rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. South Africa is one of a growing number of low- and middle-income countries (LMICs) experiencing a rising burden of multi-morbid chronic conditions [7] This is a consequence of the transition of HIV to a chronic condition with the scale-up of antiretroviral treatment; as well as the intensifying non-communicable disease (NCD) burden. While there is evidence of the effectiveness of collaborative care models for the treatment of common mental disorders (CMDs) comorbid with chronic physical conditions from high-income countries [11], there is little evidence of the effectiveness of task-shared collaborative care models for physical and mental multi-morbidity from LMICs
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