It's a pleasure to be here because it's good to walk down the streets of Oxford, I was here, what, 92, 93 to 95.
And that's also one of the reasons why I got involved with Cochrane because in 92 was when the Cochrane collaboration had their very first colloquium.
Yeah, and it was nice that you gave us your talk and the perspectives from the view of the government and law and policy.
Because Cochrane also had its origins from the challenge thrown by the NHS to Archie Cochrane,
after whom the collaboration his name when he was hitting the Medical Research Council and the NHS wanted to fund medical care in India and asked him,
Give us the evidence for what treatments work and what doesn't work.
And that's when he realised very often there isn't enough evidence and his reflection saying,
Isn't it a pity that we don't have in one place regularly updated evidence that works of what works and what doesn't?
That stimulated the collaboration to do that. So let me just put this in context.
We all know that mental disorders, especially depression, anxiety and substance use disorders are very common.
And along with schizophrenia and developmental disabilities, because considerable distress and disability in adults and children.
And over the past few years, we're finding that developing countries and the developed world are hit with double and triple
whammy where you have infectious diseases and you have common common mental disorders,
as well as you have chronic physical conditions and overall mental disorders contribute
significantly to the global burden and have serious implications for families,
individuals and the entire social development cycle of many nations and putting into the stock.
Nearly three fourths of the burden caused by mental disorders affect people in low and middle income countries.
So the good news is there is a lot of treatment available.
Over the years, we've documented evidence for the effectiveness of pharmacological and non-pharmacological interventions.
But the problem is delivery,
where you have a total mismatch between the need and the people who can actually satisfy this need in terms of trained mental health professionals.
And even if they are there, there's a lot of inequitable distribution of where these people choose to practise.
In addition, as we just heard this morning, stigma is a huge problem and access, as well as the costs associated with access,
as well as getting care because in many parts of the developing world,
medical care is not paid for entirely by the government, and a lot of people have to bear it out of their own pocket.
So that's a big barrier as well.
Now, if you look at the global disparities in the mental health workforce from the W.H.O. Mental Health Atlas in 2017,
you'd see that the median number of mental health workers 100000 population across W.H.O.
regions is 0.9 per 100000 in the Afro region and 2.5 in the southeast region that we come from.
And if you look at the World Bank groupings, you find low and middle income countries are starkly different from high income countries,
where it's seventy one point seven per 100000 population.
Looking at the composition of the breakdown of this workforce, the green bands are psychiatrists.
The yellow or the light green bands are psychiatric nurses.
The orange all represent the psychologist, and you can see across the world between 30 to 50 percent of mental health workforce come from nurses.
But there are huge variations. For example, in low income countries, the median number of nurses is 0.3 three per 100000,
and it gets better as you go up to high income countries where you have twenty three point four nine per cent, no but 100000 nurses.
But psychologists, occupational therapy speech therapist and child psychiatrist all over the world really are unable to match the need for it.
And unfortunately, if you look at psychiatrists who need mental health care delivery across the world, it's not going to change.
If you look at the mental health atlas in 2011, 14 and 17,
the proportion of available psychiatrists for the populations they need to search is woefully inadequate.
In fact, I think some countries are said to have 120 times more psychiatrists, 100000 people in low and middle income countries.
So how do we bridge the gap? Now, common sense tells you that psychiatrists and trained mental health nurses staff cannot solve the problem.
So can we get other people to get involved who may not require as intensive training or as such,
I I fluting degrees, but I'm not able to meet the need.
Could we use non-specialist health workers or even lay health people, not even in the health services?
Can they be trained with short, more intense focus training to meet this unmet need?
And now people are realising why only addressed the need for mental health and create
another silo workers about integrating all kinds of health care at the primary level,
utilising the services of non specialists. But this also requires existing health professional health workers who change their mindset and
move from providing care to supervising setting up programmes and actually building capacity,
which is actually something they're not trained to do. But that's what you have to do now in this new paradigm that we're looking at.
So there are a lot of uncertainties because much of the evidence in the role of non-specialist workers
in integrating mental health services into primary and community care come from high income countries.
And we all know there are lots of differences in socio cultural factors in the health systems, resources,
governance and organisation that you can't just generalise that it work in high
income countries and it'll work as well in low and middle income countries.
And the bottom line is this if we can show that non-specialists led mental health interventions can be as effective as those led by specialists,
then there is the possibility they could be considered, but got to show that at least as good.
And finally, we should also consider that it may be cheaper to employ non specialist health workers upfront,
but we also need to look and consider what would happen downstream if this greater
resource use because of the inadequate services provided by the non specialist workers.
Then, as was pointed out, there are lots of other things we need to know about the competencies,
the competence and the acceptability of the non-specialists led teams and what are the barriers and facilitators but scaling up such interventions.
All of these are the uncertainties, but I can't address all of them in the time that I have.
So I'll focus on looking at the evidence from systematic review and meta analysis for
the effects of non-specialist health workers providing mental health care and LMI CS.
And I also am where I was reminded of this during the introduction in the morning,
when I talk about evidence in the sitting in the circles that I normally talk about,
which are usually people from Cochrane, we are looking at evidence from the quantitative research paradigm where evidence means there is one truth.
One reality. But looking at people who come from anthropology and other disciplines, I realise the qualitative research paradigm.
The evidence I present doesn't necessarily mean the same thing, because in that paradigm, there are many realities.
So anyway, I'll try and see if I can find some supplement to what this kind of objective evidence is and look at what we can learn from the consulate.
Very brief interventions which have been shown to be effective for alcohol and depression from India,
and also look at the ongoing studies on integrating health care in many countries of the world.
And what were the stakeholder perceptions of this whole paradigm of using a non-specific health workers?
And finally, try and see what is the evidence that after so many years of the W that you are saying you need to train people in this kind of work,
how many training programmes are there and what are they doing? So that's just a big focus of this.
So we start with this Cochrane review, which was authored by an idea of one Gilligan, who is from the UK and now works in Liverpool.
But it came to India and lived there for many years in Bangalore and requested my help in helping us to do the systematic review,
which is part of our doctoral dissertation.
She's also done other bits where she went and mapped out all the agencies in the country, which provide integrated services for using non-specialists.
And she's published 72 case studies, which includes Bannu on what models are being used so that supplements the quantitative evidence from this.
Anyway, what we did in this review was we sought evidence from randomised trials and on randomised trials control before and after studies,
interrupted time series studies,
as well as economic studies conducted alongside these designs that assessed the effectiveness of the delivery of mental,
neurological, basically epilepsy and substance abuse interventions.
And he chose these because this is what our mental health programme had said were priority for community work,
and this intervention should be delivered by non-specialists health workers, which are basically anybody who not been trained in psychiatric services.
But it could be doctors without any special training on general nurses,
as well as other professionals at health roles like teachers and laypeople who are volunteering their time doing this
work in low and middle income countries amongst adults and children who are seeking care in the primary setting,
or carers of people with disabilities because it might be an intervention looking at care burden and interventions to alleviate that.
And the interventions that we included were you looking for areas where any sexual abuse could be used in detection, recognition and diagnosis,
including screening programmes or in providing acute interventions drug, as well as non-drug like psychological therapies or psychosocial?
Education counselling or doing any kind of follow up or rehabilitation services.
And we compared the these interventions done by these non-specialist with other people like usual
care or with other non specialists who've been given the best training compared to specialists.
So how do they compare all within themselves? Higher levels of training was just a little bit of training.
These are the things we wanted to look for and our outcomes were improvement of symptoms, psychosocial functioning and impairment and quality of life.
These are primary outcomes, but we had a whole host of secondary outcomes that you were looking at,
including patient or keto oriented outcomes and societal outcomes like satisfaction,
health behaviour, adverse event suicides, service, social outcomes like returning to work and career outcomes.
Then for health provider and service delivery outcomes, we look for a lot of things related to processes.
And if we found economic studies,
we hope that we be able to look at direct and indirect costs to patients and health services, as well as a resource used.
So these were our intentions when we searched and we followed standard Cochrane methodology for searching,
as well as for assessing and doing the review. After the screening, eleven thousand eight hundred and twenty five titles and abstracts,
we excluded twenty two hundred and ninety eight potentially eligible studies and into thirty primary studies,
out of which 17 were randomised, 10 were cluster randomised, nine were controlled before and after studies and two were non randomised trials.
Fifteen of these were conducted in seven low and middle low income countries and 23 were from 15 middle income countries.
Two of these are from India. I think one in Myanmar, Vikram Patel's Manus trial in Goa and the others from Dias, again from Google and dementia care.
So most of these studies looked at adults 27 of them, and most of them looked at common mental disorders.
Although we are well looking at post-traumatic stress disorder and the cadre of non specialists were in 22, studies will may help people.
They were not mental health specialism, health specialists per and in others.
We are doctors, nurses, teachers and social workers. Amongst the lay health workers, it's important to know what is their educational status.
How educated should they be wasn't very well documented, but when they did documented,
they said that many of them had a minimum of secondary school education. Some were illiterate and some included people at primary school.
Education wasn't very clear how much remuneration was given and and the degree of training and supervision varied quite a bit.
So the interventions eight of them looked at and this age ws helping doctors to improve pharmacological treatments,
which is one way of using them and the other or 21st studies where they provided psychological interventions,
which included psychoeducation, support, etc. and 16 of them either led teams providing CBD or interpersonal therapy or motivational interviewing.
All were part of collaborative care teams. We didn't find any studies where they're being used to detect or screen for mental illness,
and all these studies for them had economic outcomes, all of which three had data available for inclusion.
So we followed eight sets of comparisons that we could group them under where you had non-specialists led interventions versus usual
care about evidence coming from trials or we had collaborative care model of any sexual abuse with the specialists was his usual care.
Again, from trials and cluster trials, then we had special non-specialists versus usual care for maternal depression per say again,
our CDs and some control before and after studies where these paid non-specialists were compared with specialists in treating common mental disorders.
And again, some asked looked at non-specialists was the usual care for PTSD in adults and then looked at improving dementia,
patient carers outcomes and also delivering interventions for alcohol use disorders.
There were some which looked at non-specialists or teachers, other workers providing care for children with post-traumatic stress disorders.
I'll give you the main findings.
There was evidence that the health worker led psychological interventions may increase the number of adults who recover from
depression and anxiety within a two to six month period after treatment and the prevalence of the risk of it coming down.
According to that is these interventions.
The risk was reduced by about 70 percent of having depression at the end of treatment in people who were treated by health workers.
The best estimate is about 90 or 86 percent reduction, and the least estimate is about a 36 percent reduction.
This comes from three studies with thousand eighty two participants looks very impressive.
But when we applied the agreed criteria to see how certain all that this evidence will translate into your kind
of practise and comes from good quality studies are the biases are low and where the results are consistent.
Our overall confidence in this in this evidence is low, which means this is why we use the word.
It may mean 100 percent sure that will give you the same results because of heterogeneity and risk of bias.
Similarly, found that non-specialists health workers plus specialists in collaborative care
model may increase the number of adults who recover from depression or anxiety,
and two to six months compared to enhanced usual care get revisions.
Hereto the results.
We were non-specialist quite appreciably, clinically appreciably, with the minimum expected improvement being a 10 percent reduction in numbers.
But here again, the evidence of low certainty due to heterogeneity and risk of bias and one of these studies,
which has become Patel's studying the way he looked at two groups of people those
collaborative care with doctors in public hospitals and with private hospitals.
And what he found was that the benefits were largely seen when non-specialists work with public health doctors.
That's why you got better outcomes compared to usual again, not so much in the private sector.
And the explanation is that doctors in the private sector treat people of depression,
spend a lot of time with them because it's their bread and butter.
They need money, so they have a lot of involvement and empathy for people in the private sector.
And the effects of this was not so apparent when you when you help private sector doctors treat people with depression in the community.
And they followed this up with some other qualitative studies, which again showed that patient perceptions were that in the government setting.
When you have more specialist health workers, patients felt supported and were able to engage better with the treatment than in the private sector.
So this is very interesting illuminating results from that study.
Non-specialist led interventions may slightly reduce symptoms from other perinatal depression compared to usual care.
We use the word slightly because in this model, the standard I mean mean difference we April, he said.
Normally when you look at continuous outcomes, it means and standard deviations.
You just look at the problem and you see a p value system is very effective as you do.
The P value only tells you whether those differences are due to Johnson. And we need to know how much better it is.
So a standardised mean difference of point two means that it's a minimal improvement,
and the standards mean difference of about 0.5 2.8 is what you are going to see appreciably good rates from this, we can say.
Definitely there's a difference, but it's only a slight reduction in the symptoms.
We don't have any idea what the effects of non-specialist are compared to specialists in giving pharmacological treatment,
because the evidence from one study was extremely low quality, which basically means we don't know if this result is valid.
Non-specialist led interventions may slightly reduce the symptoms of adults with post-traumatic stress disorder compared to usual care.
Here again, it's slightly reduced low certainty evidence non-specialist probably slightly improves
the symptoms of people with dementia in terms of severity of various symptoms.
Here we use the word. Probably because there was only one of the issues was the imprecision in the estimates,
and there is this evidence is quite robust that non-specialist can help in this.
Even alcohol disorders as well non-specialist can help decrease the amount of alcohol consumed by people with alcohol use disorders.
We don't know whether teachers are good in reducing symptoms.
The children, the PTSD and the economic data within each study suggested that these interventions are cost effective.
But there are a lot of biases in the way those studies were conducted to those data.
Adults are not that reliable. But there's a general tendency for the studies to say these are cost effective interventions.
The implications are. That if you look at the evidence overall, it says these are encouraging results,
but we must keep in mind that these interventions were delivered in a research setting where the non-specialists are carefully selected,
the project leaders are motivated. I was on the board of the modern Australian.
I know how much work went into putting up the trial. The remuneration is more available because there's research funding and training.
Supervision and monitoring are really, really rigorous because you want to show something.
So I'm not sure. I don't know whether you can reproduce these results when you scale it up across the country.
That's my only misgiving. But definitely the evidence is if you give it a shot, you get reasonably good results.
It depends on how much you invest and what intensity you continue.
The other thing is that these study designs are not really appropriate to give us answers to questions
like Is there going to be downstream increased resource use because they aren't long term enough?
We don't know what will happen further down. So you need much more longitudinal studies and economic evaluations undertaken in real time basis.
Because research studies, you tend to leave aside a lot of the other costs,
which are because you presume the system is already there as usual, know to set up the entire system.
And we need a lot more qualitative data on you from the users perspective.
And depending on the country itself, has got a different baseline morbidity rates in different health system approaches.
So unless we know what this has to be made, as you said, for each state or each district within a steep.
And the financial implications of such intervention is really unclear.
There's another Vietnam that this is looking at very naval interventions, which produce very similar results,
I won't go to the the detailed methods again showed that non-specialist health workers
can give psychosocial treatments like cognitive therapy and interpersonal therapy,
which are actually better than just getting health promotion studies.
So that's another thing again, sort of suggesting that health workers can be usefully used.
But this has had a small number of studies and the lot of heterogeneity.
Now let's think about it, OK, if you've got some evidence to say that, it could work.
What about the evidence for if you upskill when you want to upskill,
you don't know a research study where you have health workers doing just one thing. That person will have to do a lot of other things.
Right, so if it's in the programme, we can only treat depression is to treat anxiety,
as with alcohol problems, is veto many of the problems can one non-specialist do that?
That's what we can. Patel and his group address in two studies published in The Lancet in one day, we're looking at counselling for alcohol problems.
A counsellor delivered brief psychological intervention for harmful drinking in men, and in the other they looked at a lake,
some the same lake Onslow, delivering brief psychological treatments with severe depression, using a very brief intervention in primary care.
And these are companion studies, and what is unique about them was they came under a large programme looking at can we
do research and scale up these interventions across L and see how affordable they are?
So the V psychological interventions and what drew samples in primary care.
The first were males who are harmful drinking history.
Three hundred and seventy seven of them were randomised 50 to either get usual,
get enhanced usual care, which is normally when you say usually that means nothing.
So here they usually get at least got something.
Plus this counselling for alcohol programme initiatives work together versus usual care, and in the second trial,
the randomised 495 male and female patient to moderate and severe depression to their healthy activities programme.
Plus use enhanced user Carrero Usual Care Alone 50 50 Randomisation.
The important thing was that the kind of counsellors who delivered the
interventions were adult members from local community at secondary school level,
but no training prior to a three week course in mental health delivered by the specialists only three weeks.
And the same counsellor was involved in both the trials and delivered both the interventions.
Now what they deliver, the healthy activity programme is delivered over six to eight sessions and consists of a behavioural activation package.
So it's like motivation with a little bit of this and a little bit of that,
but it gets people positively to think about what they're doing in a framework.
And they also had a little bit of problem solving. So there is a curriculum which they developed over a period of time before the pilot tested it,
and it seemed to work, and the counselling for alcohol problems is motivational enhancement again for sessions.
Now, the results were very interesting after three months. These counsellors did good whatever they did.
Improved results compared to usual care.
And if you look at the number of patients who achieved remission in alcohol was 36 per percent of people versus 46 percent,
and maintained abstinence is 42 percent in the people who were consular dream,
which is 18 percent in the people who had an usual treatment and percentage of abstinent days also is much better.
And again, amongst the people depression on all the measures they looked at,
the consulate thing was much better using validated skills and cost effectiveness analysis,
they reported, think would these interventions are cost effective for both disorders?
You can also look at the downsides of this and say up to 65 percent of excessive drinkers and 36 percent of people
in depression did not achieve any mission in those drugs and see that as a sign that this guy does not good.
But let's compare it to other studies.
I know it's not in the same population, but if you look at other trials attributed to depression or alcohol, you get the same rates.
So it seems to answer the question I raised for saying, are they doing as good a job as usual specialist?
And these two studies seem to show, yes, they are. You get similar rates as what you get.
If specialists were doing these gentlemen spin doctors were doing their treatment.
So that's the case for that. Now, one of the views of a primary care service provider that is a nurse is people who
are actually going to be in the health system on the use of these non-specialists.
So there is a nice people coming out from the prime study which are looking at scaling up the mental health delivery service.
This is a difficult funded project in India, Nepal, South Africa, Uganda and Ethiopia,
where they did focus group discussions and in-depth interviews to understand perceptions of people about the use of non specialist workers.
And they felt the results of this that task sharing is acceptable and feasible as long as these three conditions are met.
We need more people and we need better access to medications.
Instead, we've got to ensure that their non-specialists would be a great help.
Second is, we need ongoing structured support and supervision of the community and primary care levels.
And the third was we need adequate training and compensation for the health
workers who are going to be involved in shooting because in many countries,
when you use health workers, they are not formally employed, they don't have.
They like our gig drives, gig economy, they get casual. So the incentives to keep them going is not really sustainable.
You can also look at disability or exemptions from the point of view of all the
trials that have been done because many of them were done with quality to work,
looking at what worked and what did not.
And there's a lot of lessons to be learnt from those those kind of evaluations as well on the use of integrating mental health care.
And if you look at all the training programmes, the W.H.O. is, well, very clear set of guidelines and saying this is what you should do to train.
So this systematic review looked at what are the stages of training 2019 publication
and found that these there are training programmes implemented across 16 countries,
with most of them in the last few years. But the majority of them are in high income countries and they all team to evaluate methods and outcomes.
But they have a lot of variability in terms of the courses. Trainees attitudes, knowledge and skills development.
So while people are setting up courses all over the world, most of them are not in the developing world and they do seem to work.
At least some areas exist. But what we need to look at is how can we standardise some of these training approaches
so it can be important across the world in consultation with the people there?
So there's a need for developing these training programmes, which has not yet been done.
So I'd like to conclude with the evidence, with the thing that what we need more evidence for is how do we sustain and upskill?
We really don't have any objective evidence and that maybe some tracking talk a little
bit of what what they're doing out there and the effectiveness of different programmes,
including the kind of incentives and payment systems. This has not been worked out for a lot of our programmes in the country and the
mechanisms for integrating that with other formal programmes in the health sector.
What different skill sets are needed?
And finally, we don't know what the what the impacts of these programmes are, these programmes are aimed at people who attend these services.
There are a lot of homeless people out there and many other disadvantaged people who come nowhere in the ambit of this.
And there are a large proportion of the unmet need in these countries.
So whatever we are doing right now, we're only looking at evidence in these sort of formal programmes,
but it's encouraging that there is a viable alternative to waiting for psychiatrists and trained mental health professionals to fill this gap.
Thank you very much.