Lay Health Workers Cut Mental Heath Costs in Developing Countries
A new World Health Organization report shows that a"task-shifting" is effective in treating patients with mental disorders at lower cost
-- by Alexia Severson
In countries where resources are scarce, a “task-shifting” strategy in which community members acting as "lay" health workers provide front-line care—instead of physicians or trained nurses—can be both cost-effective and cost-saving in treating patients with common mental disorders, according to a new study by researchers in Goa, India.
The research was published yesterday in the Bulletin of the World Health Organization (WHO).
It's becoming more and more obvious that mental disorders account for a growing burden on the health systems of developing countries. Depression, in particular, is predicted to become the leading cause of disability-adjusted life years by the year 2030. However, the effective management of these diseases often requires a collaborative effort across the health workforce, sucking up huge amounts of resources. Even more problematic is that the continuing care required for managing mental health issues can take anywhere from several months to several years.
This WHO study suggests that collaborative care led by lay health workers can be effective in the primary care of depression and anxiety in low- or middle-income countries. This approach encourages the most effective sharing of tasks between medical specialists and non-medical staff. This strategy involves various “steps” or levels of treatment, with the most intensive treatments reserved for the most severe cases.
When the stepped-care components of this strategy are combined with the collaborative-care components, it can maximize the efficient use of scarce resources—this matters significantly in public health facilities where case (and resource) management has previously been poor. However, many people fear that the widespread implementation of this method of treatment would bring down the quality of care provided to patients.
The Expert Take
In this study, researchers divided participants with depression and/or anxiety into two groups: a control arm and an intervention arm. Subjects in the control arm received “enhanced usual care” in which the primary-care physician in the facility was provided with the results of the initial screening and a treatment manual. Physicians were permitted to administer the treatments of their choice but did not have access to any additional trial-related human resources.
Subjects under the intervention arm received both collaborative care and stepped care. The collaborative care of each subject was provided by three key health-care providers:
- the existing, full-time physician at the facility
- a full-time lay health worker trained to provide psychosocial interventions
- a mental health specialist who visited each study facility once or twice a month.
Over the 12 months of follow-up, researchers found that the subjects in the intervention arm used and/or lost less cash and showed greater improvement in their mental state than the control subjects in public facilities. And while there was no significant difference in any of the health outcomes investigated in private facilities, the care of the subjects with depression and/or anxiety was cheaper in the intervention arm than in the control arm.
Source and Method
Cost effectiveness was analyzed based on generalized linear models and performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy, and/or antidepressants by lay health workers.
Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months.
This research shows that the use of lay workers in care of patients with common mental disorders is very efficient in developing countries.
The method of treatment could also apply to the management of other conditions, including infection with the HIV, AIDS, and diabetes—and could prove to be very valuable in countries where resources are slim.
But according to researchers, more research comparing the health outcome of patients attended by lay health workers to that of patients attended by physicians and trained nurses is needed in order to truly determine the validity of the results of this study.
Several studies have examined similar topics related to mental health and treatment in developing countries. Research published in Global Mental Health in September of 2007 reviewed the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Researchers concluded that social interventions to support mental health in the midst of emergencies might be effective, as might social interventions for the prevention of depression, substance abuse, and delays in child development. However, most of the evidence for the prevention of mental disorders in adults is from high-income countries.
And an article published in Psychological Medicine in July 2000, pointed out the need for treatment evidence for mental disorders in developing countries, saying that “the logical next step is to identify efficacious and cost-effective health services interventions that can tackle the all-important ‘so-what’ question that is posed by doctors and policy makers in developing countries when confronted with startling prevalence statistics.”
A study published in BMC Public Health in September 2009 argued that a framework for a programmatic "public health approach" could improve on the current unstructured approach to primary care of people with chronic non-communicable diseases (NCDs), such as depression or anxiety. Research that establishes the cost, value and feasibility of implementing such a framework could also pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.