Innovation summary

The National Program for the Detection, Diagnosis and Treatment of Depression was introduced in 2001 and became a national program in 2003. It functions in a network of 500 primary care centers throughout Chile. Each center has a general clinical team composed of primary care doctors, nurses and auxiliary nurses, with specialist supervision for severe cases and access to psychologists in primary care.

  • Detection of depression is carried out by any health professional in the primary health care clinic during regular consultations

  • Possible cases are referred to a primary care physician for further assessment and diagnosis. Severe cases are referred to a mental health specialist
  • Confirmed cases enter a depression-management program with checks every two weeks, antidepressant medication and individual or group psychotherapy
  • Monitoring of confirmed cases is maintained for at least six months. If the persons’ symptoms do not improve, he or she is referred to a specialist

Impact summary

  • >5-fold increase in visits to primary care for a mental health condition5
  • 40% higher recovery rate among service users than among controls receiving usual treatment in trials2
  • Program shown to be cost-effective in trials3

In primary care, there have been many attempts at introducing mental health programs, but they did not have the financial or political backup… This was different… a program with a clinical protocol, financial and political support, [and] itemized resource allocation.

-Head, Primary Care Division, Ministry of Health, Chile1

Innovation details

Detection and referral

  • Any member of the primary care team can detect and refer a potential case of depression to the program1
  • Referrals are seen by general practitioners and/or psychologists who confirm the diagnosis according to ICD-10 criteria; assess the severity of symptoms and psychosocial risk factors; and, if required, enroll the person in the program
  • If depression is severe, the person is referred to a mental health specialized unit for a psychiatric assessment (7% of cases)
  • If depression is of moderate or mild severity, the person is seen and followed up in the primary care setting as described below

Treatment in primary care

  • Mild to moderate cases are treated according to pre-established clinical guidelines that include frequent consultations and assessments, individual or group therapy and psychotropic medication, as needed
  • If follow up assessments show little progress or clinical deterioration, a joint assessment by a team leader and a psychiatrist is undertaken and adjustments to treatment are made
  • Patients responding well to treatment are followed up for at least 6 months before discharge

Key drivers

Four key drivers have been identified that facilitated the scale up of the program to the national level:1

Scientific evidence

  • To show that depression (or indeed any other pressing problem) is or should be an important public health priority and there are cost-effective solutions locally
  • All information needed to be disseminated proactively, succinctly, quickly, and in a language understandable by policymakers

Teamwork and leadership

  • A group of widely respected and politically ‘’friendly’’ professionals joined together by a common goal, acting as leaders in a team effort
  • Leaders capable of communicating effectively with decision makers and negotiating political agreements at all levels
  • Leaders with a capacity to detect emerging opportunities and react accordingly
  • Individuals with at least basic technical knowledge, capable of preparing and defending a solid proposal
  • Trustworthy individuals capable of forming alliances with strategic partners and ensuring these new resources are on fixed contracts

Strategic alliances

  • With key individuals occupying positions of political power at the Ministry of Health
  • Across sectors with strategic partners
  • That can persist over time
  • With other units by which the program can be co-owned, especially those with more power within the organization

Program institutionalization

  • Using well recognized models of health care delivery within the Ministry of Health
  • Placing the program among other well established primary care programs
  • Finding and introducing personnel (psychologists) widely available and at an affordable cost with potential to lead the program locally
  • Fence ringing any new and essential financial resources

Challenges

Political will

  • Establishing mental health as an important issue in the political agenda

Integration

  •  Incorporating a new cadre of health professionals (psychologists) into the primary care budget
  •  Incorporating new activities into the existing workload of health professionals in primary care, who are often overloaded with activities for other programs
  • Overcoming the initial resistance from mental health specialists of primary health care workers treating depression

Continuation

The existence of the program for depression allowed health guarantees related to schizophrenia and substance abuse disorders to be approved in Chile in 2005. These programs were implemented using existing resources in primary care made available through PNDTD. More recently, health guarantees for bipolar disorder were approved. This includes a significant role for primary care in the identification of cases. The Ministry of Health in Chile is currently considering increasing the coverage of the depression program to provide services for children (under age 15).

Partners

Funders

Evaluation methods

A series of clinical trials have been conducted in Chile testing the approach. Routine monitoring and evaluation has been conducted since the program was implemented.

Cost of implementation

  • Clinical trials have shown the approach to be cost-effective, with the incremental cost of obtaining an extra depression free day being just $1.07 USD3
  • In 2005, the budget was $6 million USD1

Impact details

  • The approach has been shown to improve patient outcomes in a series of trials. People on this program achieved a recovery rate of 70% compared to 30% for those receiving usual treatment2
  • The number of full-time psychologists in primary care increased by 344% between 2003 and 2008.4This has resulted in more than a 5-fold increase in visits to primary care for a mental health condition, while visits to psychiatrists have remained relatively stable5
  • The program has grown steadily since its inception in 2001. In 2007 more than 170,000 patients started treatment. The program now covers close to 50% of the population affected by depression5
  • Women and those with less education are more likely to use the program, showing that the introduction of universal health programs for depression can reduce substantially the gap and socioeconomic inequalities in access to health care in middle income countries6

References

1. Araya R et al. (2012) Lessons from scaling up a depression treatment program in primary care in Chile. Rev Panam Salud Publica, 32(3): 234–40.

2. Araya R et al. (2003) Treating depression in primary care in low-income women in Santiago, Chile: a randomized controlled trial. Lancet, 61(9363): 995-1000.

3. Araya R et al. (2006) Cost-effectiveness of a primary care treatment program for depression in low-income women in Santiago, Chile. American Journal of Psychiatry, 163(8): 1379-1387.

4. Pemjean A (2010) Mental health in primary healthcare in Chile. International Psychiatry, 7: 7-8.

5. Minoletti A et al. (2013) Integrating mental health into primary care: lessons from the experience of Chile. Chapter 11 in Sorel E (ed.) 21st Century Global Mental Health. Burlington, MA: Jones & Bartlett Learning.

6. Araya R & Pedro Z (2013) The impact of universal health programs in improving access to health care for depression and other chronic diseases in Chile. Submitted WHO Bulletin.

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