Lancet Psychiatrist: Task sharing: stopgap or end goal?

26 January, 2019

Dear HIFA colleagues,

I have quoted liberally from this Lancet Psychiatry editorial on the use of CHWs and lay people to provide mental health care. This approach has been pioneered by HIFA member Vikram Patel, author of Where There is No Psychiatrist. The editorial appears to me to be somewhat defensive of the 'completely different' nature of mental health as compared with physical conditions such as HIV/AIDS. But surely the proof of the pudding is whether or not it works?

The editorial accompanies two research papers in the same issue of the journal (both from Vikram Patel and colleagues):

1. Delivering the Thinking Healthy Programme for perinatal depression through peers: an individually randomised controlled trial in India

Daniela C Fuhr et al.

Published:February, 2019

DOI:https://doi.org/10.1016/S2215-0366(18)30466-8

'THPP had a moderate effect on remission from perinatal depression over the 6-month postnatal period. THPP is relatively cheap to deliver and is cost-saving through reduced health-care, time and productivity costs.'

2. Delivering the Thinking Healthy Programme for perinatal depression through peers: an individually randomised controlled trial in India

Daniela C Fuhr et al.

Lancet Psychiatry| volume 6, issue 2, p115-127, february 01, 2019

Published:February, 2019DOI:https://doi.org/10.1016/S2215-0366(18)30466-8

'THPP had no effect on symptom severity or remission from perinatal depression at 6 months after childbirth, but we found that it was beneficial on some other metrics of severity and disability and that it was cost-effective. THPP could be a step towards use of an unused human resource to address the treatment gap in perinatal depression.'

The editorial follows...

CITATION: Task sharing: stopgap or end goal?

The Lancet Psychiatry volume 6, issue 2, p81, february 01, 2019

Published:February, 2019DOI:https://doi.org/10.1016/S2215-0366(19)30006-9

The disparity between the burden of mental ill health and the resources available to address it is well known. One solution is task sharing — a process developed in global health fields such as HIV management that involves training community health workers to do specific jobs. On Oct 26, 2018, WHO launched its guideline on health policy and system support to optimise community health worker programmes. The guideline aims to improve the selection, training, and payment of community health workers. Competency-based certification forms the basis for the recognition of community health workers as a respected part of the workforce, with their own career structure. [https://www.who.int/hrh/community/guideline-health-support-optimize-hw-p...

In The Lancet Psychiatry, Kyin Maung Gee describes how community health workers are raising awareness and knowledge of depression in Hlaing Thar Yar, a township in Myanmar...

A proven example of successful service provision by community health workers is the Thinking Healthy Programme, a psychological intervention that has been adopted by WHO for perinatal depression. When delivered by female community health workers, the programme more than halved the prevalence of perinatal depression among women in a large community-based randomised controlled trial in Pakistan. However, competing demands of community health workers have hampered efforts to scale up delivery. Therefore, Vikram Patel and colleagues have taken task sharing a step further and tested whether the programme can be delivered by lay people. Lay women who had shown an interest in helping other women within their community were given classroom-based training that focused on intervention content and relationship-building skills, followed by a clinical internship, after which their competence was assessed. The Thinking Healthy Programme was adapted for delivery by peers, with more emphasis on behavioural activation than on cognitive behavioural therapy and fewer sessions. In India, the revised programme was delivered through individual sessions, whereas in Pakistan it was delivered through both individual and group sessions.

These projects are certainly improving access to basic treatment for many people who would otherwise have remained untreated and possibly undiagnosed. Broadening the knowledge of mental illness among the general population in countries where stigma is still high could also have a beneficial effect. But what is the ultimate goal? The WHO guideline seems to be an admission that basic care in many countries will continue to be provided by community health workers. But should the next generation growing up in low-income countries expect that some aspects of mental health care will be provided mainly by peers? Should medical schools in these countries be training psychiatrists, ensuring that mental health is an essential component of GP training, or simply educating a small group of people to manage referred patients with serious mental illness and to act as trainers for community health workers and interested peer groups?...

HIV-AIDS might be lifelong problems, but the solutions are known and the role of the lay workers is to promote awareness and monitor adherence to treatment. Mother and baby care is more complex but covers a defined period. Mental illness is completely different. The range of disorders is extensive: even for the common mood disorders, multiple types exist with a myriad of causes, and the effects can be lifelong. Does a short course of psychotherapy and psychoeducation address the causes or just provide temporary symptomatic relief?

For the WHO guidelines on health policy see http://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng...

Best wishes, Neil

Coordinator, HIFA Project on Community Health Workers

http://www.hifa.org/projects/community-health-workers

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org