Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation
Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation
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DOI：
10.1371/journal.pmed.1002748
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发表时间：
2019-02-01
期刊：
影响因子：
15.8
通讯作者：
Lund, Crick
中科院分区：
文献类型：
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作者：
Jordans, Mark J. D.;Luitel, Nagendra P.;Lund, Crick
在低收入国家，对精神、神经和物质使用障碍患者的护理在很大程度上是缺失的，特别是在农村地区。为扩大治疗覆盖面，建议将精神卫生服务纳入社区和初级卫生保健机构。虽然这一战略正在全球推广，但从发现到开始治疗再到个别护理结果，在服务提供途径的每个阶段都没有对结果进行严格评估。作为尼泊尔奇旺地区改善精神卫生保健方案（PRIME）的一部分，采用了多种方法来评估地区精神卫生保健计划对抑郁症、精神病、酒精使用障碍（AUD）和癫痫的影响。我们评估了服务提供途径的4个组成部分：(1)通过社区研究（所有社区调查的N = 3,482）和服务利用数据（N = 727）评估初级保健精神卫生服务的接触覆盖率；(2)在初级保健机构就诊的参与者的精神疾病检出率，通过一项设施研究进行评估（N = 3,627，所有设施调查的总和）；(3)诊断后开始最低限度的适当治疗，通过同一设施研究进行评估；(4)接受以初级保健为基础的精神卫生服务的患者的治疗结果，通过队列研究进行评估（总共N = 449例）（抑郁症，N = 137； AUD, N = 175；精神病，N = 95；癫痫，N = 42）。缺乏结构化的诊断评估（而不是筛选工具），一些研究组成部分的样本量相对较小，以及研究的非受控性质都是值得注意的局限性。所有数据收集于2013年1月15日至2017年2月15日之间。当使用超过12个月的服务利用数据时，澳元的接触覆盖率增加了7.5%（从基线时的0%），抑郁症增加了12.2%（从0%），癫痫增加了11.7%（从1.3%），精神病增加了50.2%（从3.2%）；社区调查结果并没有显示出随时间的显著变化。培训后6个月卫生工作者抑郁症检出率增加15.7%（从8.9%增加到24.6%），培训后24个月增加10.3%（从8.9%增加到19.2%）；澳元在6个月和24个月期间分别增长了58.9%（从1.1%增长到60.0%）和11.0%（从1.1%增长到12.1%）。在诊断为抑郁症后提供最低限度适当治疗的比例在6个月时为93.9%，在24个月时为66.7%；对于澳元，这些值分别为95.1%和75.0%。在治疗后12个月，治疗结果的变化显示了小到中等的效应大小（澳元症状减少9.7分[d = 0.34]，精神病症状减少6.4分[d = 0.43]，抑郁症状减少7.2分[d = 0.58]）。结论这些综合结果表明，通过综合地区精神卫生保健计划提供以社区和初级保健为基础的服务在缩小治疗差距和增加MNS疾病有效覆盖率方面的可行性和影响是有希望的。虽然综合精神卫生保健方法确实在大多数结果指标上带来了明显的好处，但仍有重要的领域需要进一步关注（例如，社区一级接触覆盖率没有变化，澳元检出率随着时间的推移而减少，抑郁症的检出率相对较低）。
BackgroundIn low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing.Methods and findingsA combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment.ConclusionsThese combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).