Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal
Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal
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DOI：
10.1192/bjp.2018.300
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发表时间：
2019-08-01
影响因子：
10.5
通讯作者：
Patel, Vikram
中科院分区：
文献类型：
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作者：
Jordans, Mark J. D.;Luitel, Nagendra P.;Patel, Vikram
背景证据表明，在资源匮乏的国家，心理治疗是有好处的，但很少有政府卫生系统包括心理服务。目的评价心理健康差距行动计划(MhGAP)建议在以初级保健为基础的抑郁症和酒精使用障碍(AUD)心理健康服务的基础上增加由社区咨询师提供的心理治疗的临床价值。方法采用随机对照试验，分别治疗抑郁症和AUD。参与者被随机分配到(1：1)由mhGAP培训的初级保健人员提供的精神保健(如有指示，精神教育和精神药物)，或相同的服务加个人心理治疗(抑郁症健康活动计划和酒精问题咨询)。主要结果是在登记后12个月使用抑郁症患者健康问卷-9项(PHQ-9)和AUD酒精使用障碍识别测试来衡量症状严重程度，以及使用世界卫生组织残疾评估量表(WHODAS)来衡量功能损害。结果干预组(n=60)抑郁症患者的PHQ-9和WHODAS评分较对照组(n=60)显著降低(PHQ-9：m=-5.9，95%CI-7.55~-4.25，beta=-3.68，95%CI-5.68~-1.67，P<；0.001，Cohen‘s d=0.66；WHODAS：M=-12.21，95%CI-19.58~-4.84，β=-10.74，95%CI-19.96~-1.53，P=0.022，Cohen‘s d=0.42。对于AUD试验，当比较对照组(n=80)和干预参与者(n=82)时，没有发现显著的影响。结论在治疗12个月后，增加由社区辅导员提供的心理治疗可提高抑郁症的治疗效果，而不是仅由基层卫生工作者提供基于mhGAP的服务。没有利益申报。
Background Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services. Aim Evaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). Method Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. Results Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, beta = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, beta = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). Conclusion Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment. Declaration of interest None.