Innovation summary

Depression has been found to be a prevalent condition in Vietnam with characteristics that are similar to those found in the rest of the world.1 Whilst primary healthcare services are accessible to the general population, the capacity of primary health care staff to identify and treat depression is low. The goal of this innovation is to improve the capacity and quality of primary healthcare service.

This innovation selected and adapted measures of depression (SRQ-20) and disability (WHODAS 2.0) for use in Vietnam and also adapted a “supported self-management” model of depression management into the Vietnamese context. The feasibility of recruiting and training primary healthcare staff was tested, as well as the validity and acceptability of the measures and approaches for use in Vietnam. The project took place from 2013 to 2015.

Impact summary

  • 20 primary health care staff recruited, trained and involved in testing the enhances model 
  • 81% of patients post-treatment who had demonstrated depression on the Self Reporting Questionnaire-20 (SRQ-20, scores of >8) had scores in the normal range (<8) post-intervention. The SSM intervention was successful in reducing symptoms of depression in 87% of patients included in the study
  • Cost: $248,000 CAD funding (2013 – 2015)

“While primary healthcare services are accessible to the general population in Vietnam, there is very limited access to specialist services for common mental disorders such as depression."

 

- Dr Elliot Goldner, Centre for Applied Research in Mental Health and Addictions (CARMHA)

This innovation is funded by Grand Challenges Canada.

Innovation details

Research has shown that an effective means of implementing improvements to the quality of mental health services for common mental health problems, such as depression, is through interventions aimed at changes in primary healthcare practice (3-6). This study examines the feasibility of an approach that aimed to effect changes to primary care through a carefully coordinated and supported detection and intervention program designed specifically to enhance the quality of mental health services amongst primary healthcare practitioners. Similar approaches have been proven effective in other countries, providing a strong rationale for the study in Vietnam (6-8). The goal of this study was to test the feasibility of conducting a cluster randomized controlled trial of enhanced primary healthcare services for depression, with the long-term goal of having a transformative effect on the quality of mental health services in Vietnam.

The rationale for primary mental healthcare enhancements include the:

  • Extensive contact and ‘reach’ that primary healthcare providers have with large numbers of people with common mental disorders
  • Clinical effectiveness of relatively small behavioural changes by primary healthcare providers in addressing mental health issues
  • Low cost and high return on investment of activities which aim to enhance primary care practice
  • Well-developed evidence base to guide successful knowledge translation and implementation of educational interventions in primary care

Commune health workers who work at the level of primary healthcare were the target of the study which aimed to achieve specific changes in their practice, including:

  • Improved detection and assessment of common mental health conditions
  • Brief intervention for people experiencing distress associated with common mental health conditions
  • Implementation of a supported self-management strategy and the subsequent engagement of patients, families and communities

Vietnam has made substantive policy and legislative changes over the past few decades to replace institutional care with community-based mental health services. Consequently, this study intended to contribute to this system’s transformation, building the capacity of primary care providers to support better detection and treatment for common mental health problems. In order to lay the foundation for a full-randomized control trial, the feasibility study collected pilot data that would provide the evidence base for successful scale-up of the program.

The study undertook careful field-testing of materials and measures to contribute to the refinement of procedures and approaches that optimized the program’s success.

On completion of the study, investigators were able to establish that a full study of primary mental health care enhancement can be successfully undertaken and implemented in Vietnam. This includes materials and measures that have been tested for acceptability and validity. PHAD continues to build strong relationships and structures with key stakeholders in Vietnam, and this work has contributed to the full randomized trial and implementation study that is currently being implemented (Mental Health in Adults and Children: Frugal Innovations).

 

Key drivers

Integrated primary health care

Using a task-shifting model, the intervention integrated with current primary health care system of Vietnam

Increased Investment and Interest in Mental Health by Vietnamese Government

The Vietnamese government is starting to invest more in mental health and is also integrating mental health with community-based services in the health and social services sectors

Partnerships with Key Stakeholders

Effective partnerships with key stakeholders in Vietnam promotes buy-in from local organizations and the health and social services sectors

Supported Self-Management

The Supported Self-Management intervention is evidence-based, simple, and low-cost. The results of this study suggest that it is acceptable to both patients and primary care providers in Vietnam

Support by Vietnamese Ministry of Labour, Invalids and Social Affairs (MOLISA)

During the feasibility study, MOLISA demonstrated its support for the model by expanding it to two additional provinces (Thanh Hoa and Ben Tre). MOLISA has since invested matching funds to support the scale-up and testing of the intervention in eight additional provinces.

Challenges

Mental Health Awareness in Primary Care Limited

Training and awareness about common mental health disorders is limited in primary care in Vietnam

Mental Health Cases Treated in Psychiatric Hospitals

Most mental health cases are managed and treated in specialized psychiatric hospitals, with an emphasis on schizophrenia and epilepsy

Lack of Awareness and Stigma around Mental Health

Lack of awareness of mental health issues and associated stigma may contribute to low levels of help-seeking for common mental disorders among the population

Data collection at commune health centres (CHSs)

In urban Hanoi, patients often prefer to access hospital outpatient clinics for health concerns rather than commune health stations. We expanded the project to include outpatient clinics to mitigate this challenge.

Patient recruitment

Because one of the main roles of commune health stations is to deliver health promotion programs (e.g. immunization campaign), they sometime see few adult patients on a day-to-day basis. This challenge was resolved by having health workers implement screening during busy immunization days.

Continuation

The Supported Self-Management intervention is currently being scaled-up and tested using a randomized controlled trial in eight provinces. In response to a critical gap in mental health services for children, we are also piloting a family-based intervention (Strongest Families) for children’s behavioural disorders in our second phase.

Partners

Funder

 

Evaluation methods

Trained health workers screened patients aged 18 to 65 using the SRQ-20. Patients with an SRQ-20 score of >8 were invited to participate in the study. Participating patients were further assessed for functional ability using the WHODAS 2.0. The recruited patients were then provided the Antidepressant Skills Workbook and supported in its use by health workers for two months. During these times, health workers administered the WHODAS 2.0 after one month and after two months to evaluate changes in functional ability. The SRQ-20 was administered again at completion of the study, when scores were calculated to find a change from baseline to the second SRQ-20 measure following treatment. The scores in each of six separate domains on the WHODAS 2.0, and then the overall score based on the separate domain scores were calculated to see changes on mean values indicating illness over time. Each of the domains was analysed as an ANOVA with repeated measures to find significant differences over the three periods.

Impact details

We found that the SSM intervention was successful in reducing symptoms of depression in 87% of patients included in the study. Disability scores among study participants improved statistically significantly. The intervention also reduced the numbers of workdays missed among study participants by half. These results suggest that the SSM is effective to reduce symptoms of depression and improve quality of life among adults with depression in Vietnam and to support the implementation of the scale-up of the intervention and the randomized controlled trial. The intervention also reduced the number of workdays missed among study participants by half.

  • 20 primary health care staff recruited, trained and involved in testing the enhanced model
  • 70 patients recruited to participate in the pilot study
  • Cost: $248,000 CAD funding (2013 – 2015)
  • 62/71 (81%) of patients post-treatment who had demonstrated depression on the SRQ-20 (scores of >8) had scores in the normal range (<8) post-intervention.
  • The mean overall WHODAS 2.0 scores, which may vary from 36-180, dropped from 83.4 at baseline, to 71.9 after one month of treatment and 64.7 after two months
  • The SSM intervention was successful in reducing symptoms of depression in 87% of patients included in the study

References

  1. Vuong DA, et al. (2011) Mental health in Vietnam: Burden of disease and availability of services. Asian Journal of Psychiatry, 4:65-70
  2. Goldner, EM. Knowledge Translation. In Health Research Methods. Oxford University Press.
  3. Gilbody S et al. (2003) Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA. 289(23):3145-51
  4. Griffiths, KM et al. Depression in primary healthcare: from evidence to policy. Med J Aust 2008; 188 (8): 81
  5. Genschen J et al. (2009) Case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Ann Intern Med.;151(6):369-78
  6. Patel V et al. (2010) Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 376(9758):2086-95
  7. Araya R et al. (2003) Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. Lancet, 361: 995–1000
  8. Patel V et al. (2009) Packages of Care for Depression in Low- and Middle-Income Countries. PLoS Med 6(10): e1000159. doi:10.1371/journal.pmed.1000159

Research

Multimedia

Associates

Rebecca Zappelli Project Manager
Jill Murphy Research Coordinator
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