Reducing Barriers to Mental Health Task Sharing

描述(申请人提供)：从1990年到2010年，可归因于抑郁症的全球疾病负担上升了37%。在低收入和中等收入国家(LMIC)，未来预计的增长幅度最大。然而，在LMIC提供精神卫生服务需要120万卫生工作者的缺口。任务分担，即让非专业卫生工作者参与提供精神卫生服务，是缩小这一差距的一个重要方面。包括心理治疗在内的任务分担干预的随机对照试验(RCT)显示，许多LMIC患者的抑郁症状有所减轻。扩大随机对照试验的障碍包括非专科卫生工作者对精神病患者的消极态度和歧视行为。K01指导研究职业发展奖的目标是扩大候选人在任务分担倡议的复杂干预试验中的专业知识，重点是减少承担新的精神卫生保健提供责任的卫生工作者的负面态度和歧视行为。通过研究、课程作业和结构化的指导活动，候选人将在复杂干预研究方面发展新的能力，包括(1)复杂干预和变革理论的概念知识；(2)设计、实施和分析卫生系统中的集群随机对照试验的方法技术；(3)在LMIC进行卫生系统干预研究的伦理行为以及与精神卫生保健消费者的合作；以及(4)职业发展，以成为NIMH资助的独立研究员。凯瑟琳·西克马博士、维克拉姆·帕特尔博士、克里克·伦德博士和贝妮丝·佩斯科利多博士将在这四个目标上指导候选人。这项研究将通过NIMH U19南亚精神卫生倡导、研究和教育中心(SHARE)和任务分担倡议改善精神卫生保健方案(PRIME)的基础设施在尼泊尔进行。候选人将评估补充培训模块的可行性和可接受性，以改善对精神疾病患者的态度和社会参与，目标是超越耻辱和减少耻辱干预的传统概念。这一模块将被添加到心理健康差距行动计划(MhGAP)培训中，以提高循证实践(EBP)中的提供者能力，并降低患者抑郁的严重程度。将对初级保健工作者进行社会参与培训的试点分组-RCT，以评估内容、程序、不良事件监测和分析方法的可行性和可接受性。这一试验性随机对照试验的目标包括适应和预试社会参与培训模块，试验随机对照试验，并进行定量描述性分析，以准备适当动力的R01，该R01将评估初级保健工作者减少负面态度和歧视行为对EBP质量和患者结局的影响。在尼泊尔，这项研究将有助于建立可扩展的培训模式，促进高质量的临床服务，并最大限度地减少由于提供者长期存在的偏见和歧视而造成的实施障碍。这项研究涉及全球精神卫生领域的重大挑战，目标C是促进将精神卫生纳入初级保健，目标D是改进减少耻辱的方法，目标E是开发可持续的培训模式，以提供EBP。这些目标推进了NIMH战略目标4，通过扩大知识库，在不同的提供者群体中推广EBP，并通过与精神病患者合作，为NIMH前方之路的使命做出贡献，以改善EBP的传播和实施。

DESCRIPTION (provided by applicant): The global burden of disease attributable to depression rose 37% from 1990 to 2010. The future projected rise is greatest in low- and middle-income countries (LMIC). However, there is a gap of 1.2 million health workers needed to provide mental health services in LMIC. Task-sharing, the involvement of non-specialist health workers to deliver mental health services, is an essential aspect of reducing this gap. Randomized controlled trials (RCTs) of task-sharing interventions including psychotherapy have demonstrated depression symptom reduction in numerous LMIC. Barriers to scaling up RCTs include negative attitudes and discriminatory behaviors among non-specialist health workers against persons with mental illness. The goal of this K01 Mentored Research Career Development Award is to broaden the candidates expertise in complex intervention trials of task-sharing initiatives with a focus on reducing negative attitudes and discriminatory behaviors among health workers assuming new responsibilities in mental health care delivery. Through research, coursework, and structured mentorship activities, the candidate will develop new competencies in complex intervention research including (1) conceptual knowledge of complex interventions and theory of change; (2) methodological techniques for design, implementation and analysis of cluster-RCTs in health systems; (3) ethical conduct of health systems intervention research in LMIC and collaboration with mental healthcare consumers; and (4) professional development to become an independent NIMH-funded investigator. Drs. Kathleen Sikkema, Vikram Patel, Crick Lund, and Bernice Pescosolido will mentor the candidate in these four objectives. The research will be conducted in Nepal through infrastructure of the NIMH U19 South Asia Hub for Advocacy, Research, and Education for Mental Health (SHARE) and the task-sharing initiative Programme for Improving Mental Health Care (PRIME). The candidate will evaluate the feasibility and acceptability of a supplemental training module to improve attitudes toward and social engagement with persons with mental illness, with the goal of moving past traditional concepts of stigma and stigma-reduction interventions. This module will be added to a mental health Gap Action Programme (mhGAP) training to of improve provider competence in evidence based practices (EBP), and reduce patient depression severity. A pilot cluster-RCT of social engagement training for primary care workers will be conducted to assess feasibility and acceptability of content, procedures, adverse event monitoring, and analytic approaches. The aims of this pilot cluster-RCT include adaptation and pre-piloting a social engagement training module, piloting a cluster-RCT, and performing quantitative descriptive analysis to prepare for an appropriately powered R01, which would evaluate the impact of reducing negative attitudes and discriminatory behaviors among primary care workers on EBP quality and patient outcomes. In Nepal, this research will contribute to scalable training models that promote quality clinical services and minimize barriers to implementation stemming from biases and discrimination perpetuated by providers. The study addresses Grand Challenges in Global Mental Health Goal C to foster integration of mental health into primary care, Goal D to advance methods to reduce stigma, and Goal E to develop sustainable training models to deliver EBP. These goals advance NIMH Strategic Aim 4 by expanding the knowledge base to promote EBP among diverse provider groups and contribute to the mission of the NIMH Road Ahead through collaboration with persons living with mental illness to improve dissemination and implementation of EBP.