Advancing Stepped Care for Women's Common Mental Disorders in an LMIC

点击翻译按钮获取中文摘要

Globally, young women bear a disproportionate burden of common mental disorders especially including depression and anxiety. Lifting this burden in low- and middle-income countries (LMICs) requires task sharing, which entails using non-specialists and laypersons to deliver mental health services. Several trials of task sharing interventions in LMICs have shown modest improvement. Obstacles to further progress include lack of evidence regarding what conditions should be treated, with what interventions, by whom, and how to overcome access obstacles. This R21 application advances knowledge about task sharing by developing and testing for feasibility a stepped care model for LMICs using primary care (PC) nurses and mental health peers to treat depression and anxiety. It also integrates neuroscience-based prediction models by investigating how low-cost, brief Research Domain Criteria (RDoC) tools can assist in evaluating and targeting stepped care. RDoC is an NIMH initiative to use dimensional, disease agnostic, brain based tools to better understand the key features of mental illness. The research takes place in Tajikistan, a low-income country, where Dr. Weine has currently funded R01, K24, and D43 research on migration and mental health and health. In Tajikistan, women are exposed to separation from their migrant husbands, violence both within and outside of the home, STIs transmitted by their spouses, as well as high mental illness stigma, restricted service access, and severely limited treatment resources. Aim 1 better characterizes the mental health needs, supports, resources, and barriers to care of women with depression (including with co-occurring anxiety) recruited from one primary care clinic in Dushanbe, through qualitative interviews and focus groups. Aim 2 forms an intervention design team that builds on knowledge gained through Aim 1 and on two existing interventions (BRIDGES and Interpersonal Psychotherapy) to develop a novel stepped care model that includes: 1) PC nurse and physician led screening and triage; 2) peer and PC nurse co-led psycho-education and support groups; 3) peer or PC nurse led Interpersonal Psychotherapy, and; 4) PC physician led medication treatment. Aim 3 assesses the feasibility and acceptability of the stepped care model with 45 women who have depression (including with co-occurring anxiety) recruited from a primary care clinic in Dushanbe, and whether brief tools assessing RDoC subconstructs of acute threat and cognitive control, predict or moderate pre-post changes. It builds on Dr. Weine’s strong collaborative partnerships with Tajik mental health and health leaders and researchers at the Prisma Research Center in Dushanbe, as well as the Tajikistan Ministry of Health and the Republican Psychiatric Center. This study will result in an adapted and piloted stepped care model that we hope to test in a subsequent R01 study. It will also result in increased capacity for mental health research that will augment Weine’s K24 and D43 research training program. The study addresses Grand Challenges in Global Mental Health Goal C to foster integration of mental health into primary care, and NIMH Strategic Aim 3 by developing new and better interventions that incorporate the diverse needs and circumstances of people with mental illness. It will help to build an evidence-based program that can then be introduced into public health services in Tajikistan.