Research Article: Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation

Date Published: February 14, 2019

Publisher: Public Library of Science

Author(s): Mark J. D. Jordans, Nagendra P. Luitel, Brandon A. Kohrt, Sujit D. Rathod, Emily C. Garman, Mary De Silva, Ivan H. Komproe, Vikram Patel, Crick Lund, Elvin H. Geng

Abstract: 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).

Partial Text: Mental health is part of the Sustainable Development Goals, which set an agenda for improved treatment coverage by 2030 [1]. Treatment contact coverage is defined by the ratio of people who have contacted the service to the total target population in need of that service [2]. Increasing treatment coverage addresses the vast gap between availability of, and needs for, mental healthcare, especially in low- and middle-income countries (LMICs) [3,4]. The question is how to go about increasing coverage at a population level, especially in rural areas where there is little to no mental healthcare infrastructure. In keeping with the framework established by Tanahashi, which presents different levels of coverage related to the different stages of service provision [2], the fundamental issues underlying this question are (1) the allocation of resources in order to serve the maximum number of people, (2) the extent to which services are reaching the people they are intended for, and (3) the extent to which the services meet the people’s needs [2].

These combined outcomes demonstrate promising results of a district-level MHCP in a low-resource community and primary care setting. We see improvements in actual contact coverage, detection of mental illness by trained health workers, the initiation of minimally adequate treatment, and treatment outcomes. Together these results show the potential of a district MHCP to increase effective coverage for MNS disorders. However, there are also important areas that require further attention, such as preventing attrition in AUD detection rates over time, improving detection rates for depression, maintaining adequacy of treatment over time, and achieving better treatment outcomes for some disorders.



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