Strengthening South Africa's health system through integrating treatment for mental illness into chronic disease care (Project MIND)

将精神保健纳入初级保健服务可以减少慢性传染病和非传染性疾病的影响。与许多低收入和中等收入国家一样，南非面临着如何降低传染病和非传染性疾病的高流行率和影响的挑战，包括服务有限的精神障碍。在慢性病患者中，精神障碍是需要解决的重要问题，因为这些问题与对治疗的依从性差、疾病进展更快和治疗失败有关。由于治疗失败增加了卫生服务的使用和卫生服务成本，LMICs中的慢性病护理必须扩大到包括精神卫生保健。综合提供精神卫生服务和慢性病护理已被证明不仅改善了获得精神卫生保健的机会，而且改善了慢性病患者的精神健康。。然而，对于如何以患者和提供者可以接受的方式将精神卫生保健整合到慢性病服务中并在几乎没有资源的情况下实施是可行的，有限的知识推迟了SA服务的整合。心理健康和慢性病综合服务的提供也因服务应纵向整合还是横向整合的问题而受到拖延。垂直综合服务在同一地点提供，但精神健康和慢性病服务由不同的卫生工作者干部提供。横向综合服务在同一地点由负责心理健康和慢性病护理的相同工作人员提供。该项目的目标是通过评估将精神卫生服务纳入慢性病护理的当前能力和障碍，以及通过比较在南卡罗来纳州开普敦接受艾滋病毒或糖尿病治疗的患者和面临治疗失败风险的患者之间纵向和横向整合服务模式的有效性和成本效益，来回答这些问题。通过这个项目，我们希望找到一种可行的、可接受的和有效的模式，将精神卫生服务整合到慢性病护理中，并适用于其他LMIC。考虑到SA和其他LMIC的疾病负担、治疗人群和治疗系统之间的相似之处，这项研究的结果很可能与其他LMIC的使用高度相关。在第一阶段，我们将对艾滋病毒和糖尿病服务的一系列医疗保健提供者进行深入访谈，以评估整合的障碍以及我们建议的服务整合模式的可行性和可接受性(目标1)。这一阶段的调查结果将用于调整我们以证据为基础的精神健康服务包，以便最佳地融入慢性病服务。在第二阶段，将进行整群随机对照试验。我们将选择24家HIV和24家糖尿病诊所，随机分为垂直整合臂、水平整合臂或照常治疗(不整合)。我们将从每家诊所招募25名有治疗失败风险的患者(总共1200名患者)。在学习登记后，将由现场工作人员完成基线评估。从诊所招募的参与者被随机分配到垂直整合或水平整合的ARM，然后将接受干预治疗。所有参与者，无论他们的干预手臂，将被跟踪进行为期6个月和12个月的后续访谈。在这些访谈中，对干预臂视而不见的现场工作人员将重新进行基线评估，并将收集生物标本以评估慢性病的结果。这一阶段的结果将用于评估我们建议的服务整合模式(目标2-3)的相对有效性和成本效益。

Integrating mental health care into primary health care services could reduce the impact of both chronic communicable and non-communicable diseases (NCDs). Like many low- and middle-income countries (LMICs), South Africa (SA) faces the challenge of how to reduce the high prevalence and impact of communicable diseases and NCDs, including mental disorders where limited services are available. Mental disorders are important to address among patients with chronic diseases as these problems are associated with poor adherence to treatment, more rapid disease progression and treatment failure. As treatment failure increases the use of health services and health service costs, chronic disease care in LMICs must be expanded to include mental health care. The integrated delivery of mental health services and chronic disease care has been shown to not only improve access to mental health care but also the mental health of patients living with a chronic disease. . Yet, limited knowledge of how mental health care can be integrated into chronic disease services in ways that are acceptable to patients and providers and feasible to implement with few resources has delayed the integration of services in SA. The provision of integrated mental health and chronic disease services has also been delayed by questions about whether services should be vertically or horizontally integrated. Vertically integrated services are delivered at the same location, but mental health and chronic disease services are provided by separate cadres of health workers. Horizontally integrated services are delivered at the same location by the same staff are responsible for mental health and chronic disease care. The goal of this project is to answer these questions by assessing current capacity and barriers to integrating mental health services into chronic disease care and by comparing the effectiveness and cost-effectiveness of a vertically and horizontally integrated model of service integration among patients receiving treatment for HIV or diabetes and who are at risk for treatment failure in Cape Town, SA. Through this project we hope to identify a feasible, acceptable and effective model for integrating mental health services into chronic disease care that is applicable to other LMICs. Findings from this study are likely to be highly relevant for use in other LMICs given similarities between the burden of disease, treatment populations, and treatment systems in SA and other LMICs.The study will comprise two phases. In the first phase, we will conduct in-depth interviews with a range of healthcare providers in HIV and diabetes services to assess barriers to integration and the feasibility and acceptability of our proposed models of service integration (Aim 1). Findings from this phase will be used to adapt our evidence-based mental health service package for optimal integration into chronic disease services. In phase two, a clustered randomised controlled trial will be conducted. We will select 24 HIV and 24 diabetes clinics to randomise to a vertically integrated arm, horizontally integrated arm, or treatment as usual (no integration). We will recruit 25 patients at risk for treatment failure from each of these clinics (total 1200 patients). After study enrollment, a baseline assessment will be completed by a fieldworker. Participants recruited from clinics randomised to either the vertically integrated or horizontally integrated arm will then receive their intervention sessions. All participants, irrespective of their intervention arm, will be tracked for 6- and 12-month follow-up interviews. At these interviews, fieldworkers blinded to their intervention arm will re-administer the baseline assessment and biological specimens will be collected to assess for chronic disease outcomes. Findings from this phase will be used to evaluate the relative effectiveness and cost-effectiveness of our proposed models of service integration (Aims 2-3).