Mental health for all

Abstract

Background: Low- and middle-income countries (LMICs) are disproportionately impacted by a high burden of mental illness and a wide mental health treatment gap i.e., the gap among those who would benefit from mental health care and those who receive it. A major challenge to addressing this gap has been a dearth of mental health professionals in these countries. Task-sharing or the involvement of non-specialist health workers (NSHWs) in the delivery of mental health care has been at the forefront of the movement to increase availability and access to mental health care and has shown promising results in controlled trials. However, its impact on mental health outcomes in routine care settings has been less robust, pointing towards the need to focus attention on how to implement and embed this evidence-based model in routine care. This dissertation focuses on two key factors for the implementation of mental health task-sharing i.e., treatment session attendance and quality of psychological treatment (or therapy quality). It investigates the impact of these factors on treatment outcomes within implementation settings and explores their predictors. Methods: This dissertation incorporated a multi-method approach. First, within the cohort study data from the Programme for Improving Mental Health Care (PRIME) in India, we used propensity scores and inverse probability of treatment weighting (IPTW) to investigate the causal impact of the two implementation factors, namely treatment attendance and therapy quality, on patient mental health outcomes for depression and alcohol use disorder (AUD) within mental health task-sharing. In the second study, using cohort study data from PRIME, we ran quasi-Poisson regression models to study the association between users' social support and their treatment attendance in depression and AUD treatment. In the third study, we analyzed qualitative data from n=12 key informants using framework analysis to explore readiness for change which is a hypothesized predictor of NSHWs' performance in regards to the quality of psychological treatment delivered by them. Results: In the first study, we found that among those with depression, higher treatment attendance led to lower symptom severity at 3-month follow-up but not at 12-month follow-up. We did not find statistical evidence for such an association among those with AUD. Furthermore, we reported insufficient statistical evidence for an impact of therapy quality of symptom severity among those with depression at 3- or 12-month follow up. Lastly, due to large standardized differences in measured confounders after using IPTW, causal comparisons were not warranted and we were unable to assess the impact of therapy quality on symptom severity among those with AUD. In study #2, we found that higher social support was associated with higher treatment session attendance among those with depression, however, we again found insufficient statistical evidence for such an association among those with AUD. In study #3, participants endorsed three major components of readiness for change: change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they also highlighted some unique socio-cultural, contextual, and gender influences. Conclusions: Our findings highlight the importance of treatment attendance as a key implementation factor within mental health task-sharing, especially among those with depression. Further, they have implications for designing strategies to increase treatment attendance in task-sharing based interventions for depression and suggest utilizing users' sources of social support for the same. Further research with larger sample sizes is needed to understand the impact of treatment attendance on mental health outcomes among those with AUD, and study the determinants of treatment attendance in this group. Similarly, more research is needed to study the impact of therapy quality on mental health outcomes for depression and AUD. The results of the qualitative study have implications for adapting and validating tools to measure readiness for change and to build readiness for change among NSHWs. Overall, this dissertation generates knowledge on the importance of implementation factors within mental health task-sharing and how they may be addressed to enhance its implementation in India and other LMICs.--Author's abstract