STUDY SHOWS THAT COUNSELLING-LED BY A LAY PERSON WORKS WELL
FOR DEPRESSION AND ANXIETY IN PUBLIC HEALTH FACILITIES IN
GOA, INDIA, (MANAS trial)
A study published Online First by The Lancet shows that a
trained lay counsellor-led collaborative care intervention
can lead to an improvement in recovery from common disorders
(CMD, such as depression and anxiety) among patients
attending public primary care facilities, but a positive
effect was not shown in patients at private facilities.
The article is by Professor Vikram Patel, Sangath Centre,
Goa, India, and London School of Hygiene and Tropical
Medicine, UK, and colleagues. The research was funded by The
Wellcome Trust.
The prevalence of CMD in the people attending primary health
centre is estimated at around 20% in developing countries.
But there are several obstacles to providing effective
interventions to real-world primary care settings in
developing countries.
These obstacles include the lack of skilled health
workers, low recognition rate of these disorders by
primary care doctors, the inadequate use of
antidepressant drugs or psychosocial treatments,
and low adherence to treatments. In this study, the
MANAS trial, the authors aimed to test the
effectiveness of an intervention led by lay health
counsellors in primary care settings to improve
outcomes of people with these disorders.
In this cluster randomised trial, primary care facilities in
Goa, India, were assigned to intervention or control
(enhanced usual care) groups.
Some 24 study clusters, with an equal proportion of public
and private facilities, were included. All adults who
screened positive for CMD were eligible. The collaborative
stepped-care intervention offered case management and
psychosocial interventions, provided by a trained lay health
counsellor, supplemented by antidepressant drugs by the
primary care physician for patients with moderate or severe
CMD and monthly supervision by a mental health specialist.
The primary outcome was recovery from common mental disorders
as defined by the International Statistical Classification of
Diseases and Related Health Problems -- 10th revision
(ICD-10) at 6 months.
The researchers found that 1160 of 1360 (85%) patients in the
intervention group and 1269 of 1436 (88%) in the control
group completed the outcome assessment. Patients with CMD in
the intervention group were more likely to have recovered at
six months than were those in the control group (65% vs 53%),
and absolute difference of 12% meaning that patients in the
intervention group were 22% more likely to recover than
control group patients.
In public facilities, the difference in recovery rates was
even greater (66% vs 43%), while in the private facilities,
recovery rates were similar (64% vs 66%). The intervention
also showed a preventive effect amongst those patients who
had symptoms of depression and anxiety just under the level
to meet diagnostic severity.
There were three deaths and four suicide attempts in the
collaborative stepped-care group and six deaths and six
suicide attempts in the enhanced usual care group. None of
the deaths were from suicide.
The results in private care facilities suggest that the
standard of care in those private clinics that took part in
the MANAS study were already at a standard as high as that
provided by the intervention.
The authors say: "Results from the MANAS trial indicate the
effectiveness of a lay health counsellor-led collaborative
stepped-care intervention for common mental disorders in
public primary health-care facility attenders in India. This
evidence should be used to improve services for common mental
disorders in settings for which mental health professionals
are scarce."
They conclude: "We recommend that the collaborative
stepped-care intervention should be extended to clinics run
by public primary health-care facilities."
In a linked comment, Dr Charles F Reynolds III and Dr Steven
M Albert, University of Pittsburgh, PA, USA, say: "The
cost-effectiveness of collaborative care led by lay health
counsellors to treat and prevent common mental disorders
deserves further investigation. Web-based delivery of
learning-based depression-specific psychotherapies might be
feasible, effective, and inexpensive, as treatment for
anxiety and depression in primary care, or as prevention. The
MANAS trial opens new possibilities for early intervention to
reduce the global health and economic burden of common mental
disorders."
Professor Vikram Patel, Sangath Centre, Goa, India, and
London School of Hygiene and Tropical Medicine, UK. T)
+91-9822132038 E) [email protected]
Dr Charles F Reynolds III, University of Pittsburgh, PA, USA.
T) +1 412 246 6414 E) [email protected]
See
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61508-5/abstract
