Innovation summary

Common mental disorders (CMD) such as depression and anxiety are a leading cause of the global burden of disease. Yet in many low-resource settings, access to specialist services is limited. The aim of MANAS was to develop and evaluate a package of care delivered primarily by non specialist health workers, in collaboration with primary care physicians and mental health specialists, in order to reduce the treatment gap for common mental disorders in primary care in Goa, India.

The MANAS trial evaluated the clinical and cost-effectiveness of a collaborative stepped care intervention for the treatment of common mental disorders in primary health centers. The two arms of the trial received the following:

Collaborative stepped care

  • Case management and psychosocial interventions by trained lay health counsellor
  • Pharmacological treatment by primary care physician
  • Supervision and referral intake by mental health specialist

 Enhanced usual care

  • Primary care physician provided with screening results and treatment manual; administers treatment of choice

Impact summary

  • 2,796 people with common mental disorders participated in the trial3
  • Of the participants with a diagnosable depressive or anxiety disorder in public primary health care settings, 65.9% of those who received the collaborative stepped care intervention recovered after 6 months, compared to just 42.5% of those who received enhanced usual care3
  • No outcome difference was found between the intervention and control arms in private settings as the private sector patients in the control arm did as well as those in the intervention arm3
  • The intervention arm achieved considerable cost savings in relation to enhanced usual care, with total annual costs per subject treated in public health care facilities averaging US $177 and $229 respectively4

 

Innovation details

MANAshanti Sudhar Shodh (MANAS) means “project to promote mental health” in Konkani. The intervention was developed through extensive consultation with local stakeholders, formative research and piloting.1-2 Two models of care were developed and tested against one another at public primary health centers and private general practitioner facilities in Goa.

In both models, a health assistant was enlisted to screen clients at the clinic or facility for depression and/or anxiety. Clients were then randomized to either enhanced usual care or collaborative stepped care, as described further below. Low-cost generic antidepressant medication was made available by the MANAS project in the public primary health care facilities, in order to ensure that drug supply and affordability issues did not impact the utilization of drug treatment in the two arms. Drugs were not provided in either arm of the private sector facilities. These differences between the public and private sector facilities are consistent with drug prescription practice in these facilities.

Enhanced Usual Care

In enhanced usual care, the results of the screening were communicated to the clinician, who had been provided with a booklet of basic information on diagnosis and medical treatment of anxiety and depression. The clinician then chose how to proceed.

Collaborative Stepped Care

Case management formed the back bone of the collaborative stepped care intervention. A non-specialist health worker was recruited and trained to deliver psychosocial interventions alongside the enhanced usual care interventions. Psychosocial interventions included psychoeducation, yoga, interpersonal therapy, and proactive monitoring of adherence. Specialist support was also provided to the clinicians. These intervention components were delivered in a stepped care fashion. A stepped care model initially offers service users the lowest treatment tier deemed appropriate to meet their clinical needs, only ‘stepping up’ to more intensive or specialist services if initial treatment is unsuccessful.

 

Key drivers

  • Participatory and systematic process of intervention development
  • Utilization of low cost, easily available human resources for front-line delivery
  • Utilization of evidence-based treatments and delivery model (collaborative care)
  • Evaluation through a randomised controlled trial (RCT)
  • Multidimensional evaluation, including economic evaluation
  • Nesting of the program in routine primary care in both public and private sectors

 

Challenges

  • This is a research project and thus there is no in-built mechanism or goal for scale up
  • Facilities in the private sector were not representative of typical private care facilities due to selection bias; thus findings from the trial are not generalizable to this sector
  • The intervention involved additional human resources for which allocation will need to be made for scaling up

 

Continuation

Extensive efforts have been made to disseminate findings to policy-makers, researchers, and communities in India, in order to encourage scale-up. The MANAS trial is one of the key drivers for a major revision of India’s District Mental Health Program to include a new human resource in primary health centers for case management of mental disorders. This approach is now being used in the implementation of the PRIME program in Madhya Pradesh state of India. 

 

Partners

Funder

 

Evaluation methods

MANAS was rigorously evaluated using a mixed methods approach. A two-phase cluster-randomized controlled trial was conducted from 2007 to 2009 to assess the clinical effectiveness and cost-effectiveness of the collaborative stepped care intervention in both primary care and private general practitioner settings.5 Qualitative methods were used to further assess impact on service users and the experiences of providers.6-7

 

Cost of implementation

  • Mean total human resource costs for collaborative stepped care was $2 USD per person4
  • Total cost per case recovered in public facilities was USD $120 lower among clients receiving collaborative stepped care compared to those in the control arm4
  • Total cost per case recovered in private general practice was USD $86 lower among clients receiving collaborative stepped care compared to those in the control arm4

 

Impact details

  • 2796 participants were recruited from 24 primary care facilities (12 public, 12 private) in Goa, India5
  • These 24 facilities were randomly allocated to providing either collaborative stepped care or enhanced usual care to adults screening positive for CMD5
  • Of the group with a diagnosable depressive or anxiety disorder at baseline in public primary care facilities, the mean symptom score (measured by an instrument called the Revised Clinical Interview Schedule (CIS-R)) fell from 22.20 to 9.67 in 12 months among recipients of the collaborative stepped care intervention, and from 22.69 to 13.85 among recipients of enhanced usual care. This represents a significant mean difference of -3.90 5
  • No significant difference was found for the mean reduction in symptom scores achieved in private facilities when comparing the effectiveness of the stepped care intervention with that of enhanced usual care5

 

References

1. Andrew G et al. (2012) The explanatory models of depression and anxiety in primary care: a qualitative study from India. BMC Research Notes, 5: 499.

2. Chatterjee S et al. (2008) Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India. World Psychiatry, 7(1): 45-53.

3. 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): 2086-2095.

4. Buttorff C et al. (2012) Economic evaluation of a task-shifting intervention for common mental disorders in India. Bulletin of the World Health Organization, 90: 813-821.

5. Patel V et al. (2011) Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. British Journal of Psychiatry, 199: 459-466.

6. Shinde S et al. (2013) The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: A qualitative evaluation nested in the MANAS trial in Goa, India. Social Science & Medicine, 88: 48-55.

7. Pereira et al. (2011) The integration of the treatment for common mental disorders in primary care: experience of healthcare providers in the MANAS trial in Goa, India. International Journal of Mental Health System, 5(26): 2-9.

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