Randomized Control Trial on Implementation Strategies for Task-Shifting Depression Care in Vietnam

研究摘要 抑郁症是世界上最大的单一医疗保健负担，没有其他疾病占一半 它的负担。最近，世界银行、世卫组织、加拿大大挑战和NIMH强调了 未解决的抑郁症的经济成本以及在全球范围内扩大抑郁症护理的必要性。在越南，我们 发现合作治疗有效，并进行了一项群集随机对照试验（RCT）， 抑郁症多因素协作护理模型（MCCD）的大效应量，其中抑郁症 护理任务转移到当地社区卫生诊所的初级保健提供者，并由移动的 精神病医生虽然协作护理抑郁症的好处是众所周知的， 目前还没有确定推广这一模式的有效实施战略。为了解决这个 需要，我们的R 01提案将建立在我们团队先前关于MCCD的工作基础上，并利用当前政策 与越南抑郁症护理相关的倡议-加拿大的重大挑战，海湾合作委员会，资金，其中包括 80%的资金与越南卫生保健系统支持的资金相匹配，以支持建立一个中心， 卓越的岘港精神病医院和扩大另一个NIMH R34抑郁症计划（生活- 确定最有可能导致成功执行和维持 在低资源环境下提供有效服务。我们将与当地和国家社区和政府合作 组织进行随机对照试验，比较三种实施模式的有效性：（a）通常 执行，通常包括一个讲习班和工具包;（B）加强监督; 包括UI模型）;以及（c）社区参与学习协作（CELC;包括ES）。根据 RE-AIM实施评估框架，要产生人口层面的影响，EBI必须由 提供者，达到目标患者人群的很大比例，以保真度，有效地实施 改善成果，并在研究资金撤回后予以维持。我们将评估 基于此框架，评估组织、提供者和患者层面的实施结果， 与成功实施相关的组织和提供商因素，并衡量 每项实施战略的成本效益。这样做可以指导关于最佳战略的政策决定， 支持扩大抑郁症和其他EBI的合作护理模式。这种全面而严谨的 实施效果研究将有助于我们理解使用CELC的附加值 战略高于培训的最佳做法，即使在高收入国家也没有这样做。 国家这种及时评估抑郁症护理任务转移将提供急需的知识 什么样的实施战略和因素促进采用，交付和维持高质量的 抑郁症护理在资源匮乏的环境中，那里的精神卫生人力资源有限，因此 解决执行科学和心理健康研究方面的全球优先知识差距。

Research Abstract Depression is the single largest health care burden in the world, with no other illness accounting for even half its burden. Recently, the World Bank, WHO, Grand Challenges of Canada, and NIMH highlighted the crippling economic costs of unaddressed depression and the need to scale up depression care globally. In Vietnam, we found collaborative care effective and conducted a clustered randomized control trial (RCT) that has shown large effect sizes for a Multicomponent Collaborative Care Model for Depression (MCCD), in which depression care was task-shifted to primary care providers in local community health clinics and supported by mobile psychiatrists. While the benefits of collaborative care for depression are well-established, the most appropriate and effective implementation strategies for scaling up this model have not been identified. To address this need, our R01 proposal will build on our team's previous work on the MCCD and leverage current policy initiatives related to depression care in Vietnam—Grand Challenges of Canada, GCC, funding, which includes 80% matched funds supported by the Vietnamese health care system to support establishing a Center of Excellence at Danang Psychiatric Hospital and scaling up another NIMH R34 Depression program (LIFE- DM)—to identify implementation models most likely to lead to successful implementation and sustainment of effective services in low-resource settings. We will partner with local and national community and government organizations to conduct an RCT comparing effectiveness of three implementation models: (a) usual implementation (UI), which typically includes one workshop and toolkit; (b) enhanced supervision (ES; includes model UI); and (c) community-engaged learning collaborative (CELC; includes ES). According to the RE-AIM Implementation Evaluation framework, to have a population-level impact, an EBI must be adopted by providers, reach a large proportion of the targeted patient population, be implemented with fidelity, effectively improve outcomes, and be maintained after research funds are withdrawn. Thus, we will assess implementation outcomes at the organizational, provider, and patient levels based on this framework, assess organizational and provider factors associated with successful implementation, and measure the incremental cost-effectiveness of each implementation strategy. Doing this can guide policy decisions on best strategies to support scale-up of collaborative care models for depression and other EBIs. This comprehensive and rigorous implementation effectiveness study will contribute to our understanding of the added value of using a CELC strategy over and above the best practice in training (ES), which has not been done even in high-income countries. This timely evaluation of an depression care task-shifting will provide much needed knowledge about what implementation strategies and factors promote adoption, delivery, and sustainment of high-quality depression care in low-resource settings where limited mental health human resources are available, thus addressing global priority knowledge gaps in implementation science and mental health research.