1 00:00:07,900 --> 00:00:16,840 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. 2 00:00:16,840 --> 00:00:24,370 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. 3 00:00:24,370 --> 00:00:33,160 Yeah, and it was nice that you gave us your talk and the perspectives from the view of the government and law and policy. 4 00:00:33,160 --> 00:00:39,940 Because Cochrane also had its origins from the challenge thrown by the NHS to Archie Cochrane, 5 00:00:39,940 --> 00:00:50,710 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, 6 00:00:50,710 --> 00:00:54,970 Give us the evidence for what treatments work and what doesn't work. 7 00:00:54,970 --> 00:00:59,590 And that's when he realised very often there isn't enough evidence and his reflection saying, 8 00:00:59,590 --> 00:01:06,500 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? 9 00:01:06,500 --> 00:01:13,450 That stimulated the collaboration to do that. So let me just put this in context. 10 00:01:13,450 --> 00:01:19,630 We all know that mental disorders, especially depression, anxiety and substance use disorders are very common. 11 00:01:19,630 --> 00:01:28,960 And along with schizophrenia and developmental disabilities, because considerable distress and disability in adults and children. 12 00:01:28,960 --> 00:01:36,880 And over the past few years, we're finding that developing countries and the developed world are hit with double and triple 13 00:01:36,880 --> 00:01:42,160 whammy where you have infectious diseases and you have common common mental disorders, 14 00:01:42,160 --> 00:01:47,590 as well as you have chronic physical conditions and overall mental disorders contribute 15 00:01:47,590 --> 00:01:52,690 significantly to the global burden and have serious implications for families, 16 00:01:52,690 --> 00:01:59,800 individuals and the entire social development cycle of many nations and putting into the stock. 17 00:01:59,800 --> 00:02:07,090 Nearly three fourths of the burden caused by mental disorders affect people in low and middle income countries. 18 00:02:07,090 --> 00:02:10,480 So the good news is there is a lot of treatment available. 19 00:02:10,480 --> 00:02:17,470 Over the years, we've documented evidence for the effectiveness of pharmacological and non-pharmacological interventions. 20 00:02:17,470 --> 00:02:19,840 But the problem is delivery, 21 00:02:19,840 --> 00:02:29,860 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. 22 00:02:29,860 --> 00:02:35,710 And even if they are there, there's a lot of inequitable distribution of where these people choose to practise. 23 00:02:35,710 --> 00:02:43,420 In addition, as we just heard this morning, stigma is a huge problem and access, as well as the costs associated with access, 24 00:02:43,420 --> 00:02:47,440 as well as getting care because in many parts of the developing world, 25 00:02:47,440 --> 00:02:53,000 medical care is not paid for entirely by the government, and a lot of people have to bear it out of their own pocket. 26 00:02:53,000 --> 00:02:54,980 So that's a big barrier as well. 27 00:02:54,980 --> 00:03:01,930 Now, if you look at the global disparities in the mental health workforce from the W.H.O. Mental Health Atlas in 2017, 28 00:03:01,930 --> 00:03:07,510 you'd see that the median number of mental health workers 100000 population across W.H.O. 29 00:03:07,510 --> 00:03:16,210 regions is 0.9 per 100000 in the Afro region and 2.5 in the southeast region that we come from. 30 00:03:16,210 --> 00:03:23,140 And if you look at the World Bank groupings, you find low and middle income countries are starkly different from high income countries, 31 00:03:23,140 --> 00:03:27,100 where it's seventy one point seven per 100000 population. 32 00:03:27,100 --> 00:03:33,040 Looking at the composition of the breakdown of this workforce, the green bands are psychiatrists. 33 00:03:33,040 --> 00:03:38,290 The yellow or the light green bands are psychiatric nurses. 34 00:03:38,290 --> 00:03:47,050 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. 35 00:03:47,050 --> 00:03:55,690 But there are huge variations. For example, in low income countries, the median number of nurses is 0.3 three per 100000, 36 00:03:55,690 --> 00:04:04,950 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. 37 00:04:04,950 --> 00:04:14,550 But psychologists, occupational therapy speech therapist and child psychiatrist all over the world really are unable to match the need for it. 38 00:04:14,550 --> 00:04:22,260 And unfortunately, if you look at psychiatrists who need mental health care delivery across the world, it's not going to change. 39 00:04:22,260 --> 00:04:27,240 If you look at the mental health atlas in 2011, 14 and 17, 40 00:04:27,240 --> 00:04:33,220 the proportion of available psychiatrists for the populations they need to search is woefully inadequate. 41 00:04:33,220 --> 00:04:40,890 In fact, I think some countries are said to have 120 times more psychiatrists, 100000 people in low and middle income countries. 42 00:04:40,890 --> 00:04:49,900 So how do we bridge the gap? Now, common sense tells you that psychiatrists and trained mental health nurses staff cannot solve the problem. 43 00:04:49,900 --> 00:04:55,570 So can we get other people to get involved who may not require as intensive training or as such, 44 00:04:55,570 --> 00:04:59,470 I I fluting degrees, but I'm not able to meet the need. 45 00:04:59,470 --> 00:05:06,310 Could we use non-specialist health workers or even lay health people, not even in the health services? 46 00:05:06,310 --> 00:05:11,890 Can they be trained with short, more intense focus training to meet this unmet need? 47 00:05:11,890 --> 00:05:16,600 And now people are realising why only addressed the need for mental health and create 48 00:05:16,600 --> 00:05:22,540 another silo workers about integrating all kinds of health care at the primary level, 49 00:05:22,540 --> 00:05:33,160 utilising the services of non specialists. But this also requires existing health professional health workers who change their mindset and 50 00:05:33,160 --> 00:05:39,760 move from providing care to supervising setting up programmes and actually building capacity, 51 00:05:39,760 --> 00:05:47,110 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. 52 00:05:47,110 --> 00:05:52,780 So there are a lot of uncertainties because much of the evidence in the role of non-specialist workers 53 00:05:52,780 --> 00:05:57,910 in integrating mental health services into primary and community care come from high income countries. 54 00:05:57,910 --> 00:06:02,830 And we all know there are lots of differences in socio cultural factors in the health systems, resources, 55 00:06:02,830 --> 00:06:08,440 governance and organisation that you can't just generalise that it work in high 56 00:06:08,440 --> 00:06:12,550 income countries and it'll work as well in low and middle income countries. 57 00:06:12,550 --> 00:06:23,920 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, 58 00:06:23,920 --> 00:06:28,810 then there is the possibility they could be considered, but got to show that at least as good. 59 00:06:28,810 --> 00:06:34,990 And finally, we should also consider that it may be cheaper to employ non specialist health workers upfront, 60 00:06:34,990 --> 00:06:39,610 but we also need to look and consider what would happen downstream if this greater 61 00:06:39,610 --> 00:06:46,930 resource use because of the inadequate services provided by the non specialist workers. 62 00:06:46,930 --> 00:06:50,500 Then, as was pointed out, there are lots of other things we need to know about the competencies, 63 00:06:50,500 --> 00:06:59,800 the competence and the acceptability of the non-specialists led teams and what are the barriers and facilitators but scaling up such interventions. 64 00:06:59,800 --> 00:07:04,510 All of these are the uncertainties, but I can't address all of them in the time that I have. 65 00:07:04,510 --> 00:07:09,340 So I'll focus on looking at the evidence from systematic review and meta analysis for 66 00:07:09,340 --> 00:07:14,740 the effects of non-specialist health workers providing mental health care and LMI CS. 67 00:07:14,740 --> 00:07:20,350 And I also am where I was reminded of this during the introduction in the morning, 68 00:07:20,350 --> 00:07:24,100 when I talk about evidence in the sitting in the circles that I normally talk about, 69 00:07:24,100 --> 00:07:32,590 which are usually people from Cochrane, we are looking at evidence from the quantitative research paradigm where evidence means there is one truth. 70 00:07:32,590 --> 00:07:40,570 One reality. But looking at people who come from anthropology and other disciplines, I realise the qualitative research paradigm. 71 00:07:40,570 --> 00:07:47,230 The evidence I present doesn't necessarily mean the same thing, because in that paradigm, there are many realities. 72 00:07:47,230 --> 00:07:57,640 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. 73 00:07:57,640 --> 00:08:03,760 Very brief interventions which have been shown to be effective for alcohol and depression from India, 74 00:08:03,760 --> 00:08:11,470 and also look at the ongoing studies on integrating health care in many countries of the world. 75 00:08:11,470 --> 00:08:18,310 And what were the stakeholder perceptions of this whole paradigm of using a non-specific health workers? 76 00:08:18,310 --> 00:08:26,500 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, 77 00:08:26,500 --> 00:08:31,960 how many training programmes are there and what are they doing? So that's just a big focus of this. 78 00:08:31,960 --> 00:08:39,280 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. 79 00:08:39,280 --> 00:08:46,270 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, 80 00:08:46,270 --> 00:08:48,670 which is part of our doctoral dissertation. 81 00:08:48,670 --> 00:08:58,900 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. 82 00:08:58,900 --> 00:09:09,290 And she's published 72 case studies, which includes Bannu on what models are being used so that supplements the quantitative evidence from this. 83 00:09:09,290 --> 00:09:16,450 Anyway, what we did in this review was we sought evidence from randomised trials and on randomised trials control before and after studies, 84 00:09:16,450 --> 00:09:18,310 interrupted time series studies, 85 00:09:18,310 --> 00:09:25,750 as well as economic studies conducted alongside these designs that assessed the effectiveness of the delivery of mental, 86 00:09:25,750 --> 00:09:29,980 neurological, basically epilepsy and substance abuse interventions. 87 00:09:29,980 --> 00:09:36,640 And he chose these because this is what our mental health programme had said were priority for community work, 88 00:09:36,640 --> 00:09:44,530 and this intervention should be delivered by non-specialists health workers, which are basically anybody who not been trained in psychiatric services. 89 00:09:44,530 --> 00:09:48,970 But it could be doctors without any special training on general nurses, 90 00:09:48,970 --> 00:09:55,090 as well as other professionals at health roles like teachers and laypeople who are volunteering their time doing this 91 00:09:55,090 --> 00:10:01,960 work in low and middle income countries amongst adults and children who are seeking care in the primary setting, 92 00:10:01,960 --> 00:10:09,700 or carers of people with disabilities because it might be an intervention looking at care burden and interventions to alleviate that. 93 00:10:09,700 --> 00:10:17,800 And the interventions that we included were you looking for areas where any sexual abuse could be used in detection, recognition and diagnosis, 94 00:10:17,800 --> 00:10:26,110 including screening programmes or in providing acute interventions drug, as well as non-drug like psychological therapies or psychosocial? 95 00:10:26,110 --> 00:10:32,310 Education counselling or doing any kind of follow up or rehabilitation services. 96 00:10:32,310 --> 00:10:42,810 And we compared the these interventions done by these non-specialist with other people like usual 97 00:10:42,810 --> 00:10:49,470 care or with other non specialists who've been given the best training compared to specialists. 98 00:10:49,470 --> 00:10:54,870 So how do they compare all within themselves? Higher levels of training was just a little bit of training. 99 00:10:54,870 --> 00:11:03,060 These are the things we wanted to look for and our outcomes were improvement of symptoms, psychosocial functioning and impairment and quality of life. 100 00:11:03,060 --> 00:11:07,680 These are primary outcomes, but we had a whole host of secondary outcomes that you were looking at, 101 00:11:07,680 --> 00:11:13,230 including patient or keto oriented outcomes and societal outcomes like satisfaction, 102 00:11:13,230 --> 00:11:23,250 health behaviour, adverse event suicides, service, social outcomes like returning to work and career outcomes. 103 00:11:23,250 --> 00:11:29,430 Then for health provider and service delivery outcomes, we look for a lot of things related to processes. 104 00:11:29,430 --> 00:11:31,620 And if we found economic studies, 105 00:11:31,620 --> 00:11:37,950 we hope that we be able to look at direct and indirect costs to patients and health services, as well as a resource used. 106 00:11:37,950 --> 00:11:43,320 So these were our intentions when we searched and we followed standard Cochrane methodology for searching, 107 00:11:43,320 --> 00:11:50,860 as well as for assessing and doing the review. After the screening, eleven thousand eight hundred and twenty five titles and abstracts, 108 00:11:50,860 --> 00:11:57,760 we excluded twenty two hundred and ninety eight potentially eligible studies and into thirty primary studies, 109 00:11:57,760 --> 00:12:05,980 out of which 17 were randomised, 10 were cluster randomised, nine were controlled before and after studies and two were non randomised trials. 110 00:12:05,980 --> 00:12:13,870 Fifteen of these were conducted in seven low and middle low income countries and 23 were from 15 middle income countries. 111 00:12:13,870 --> 00:12:24,430 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. 112 00:12:24,430 --> 00:12:30,880 So most of these studies looked at adults 27 of them, and most of them looked at common mental disorders. 113 00:12:30,880 --> 00:12:38,530 Although we are well looking at post-traumatic stress disorder and the cadre of non specialists were in 22, studies will may help people. 114 00:12:38,530 --> 00:12:42,610 They were not mental health specialism, health specialists per and in others. 115 00:12:42,610 --> 00:12:50,140 We are doctors, nurses, teachers and social workers. Amongst the lay health workers, it's important to know what is their educational status. 116 00:12:50,140 --> 00:12:55,180 How educated should they be wasn't very well documented, but when they did documented, 117 00:12:55,180 --> 00:13:03,250 they said that many of them had a minimum of secondary school education. Some were illiterate and some included people at primary school. 118 00:13:03,250 --> 00:13:12,190 Education wasn't very clear how much remuneration was given and and the degree of training and supervision varied quite a bit. 119 00:13:12,190 --> 00:13:19,810 So the interventions eight of them looked at and this age ws helping doctors to improve pharmacological treatments, 120 00:13:19,810 --> 00:13:26,230 which is one way of using them and the other or 21st studies where they provided psychological interventions, 121 00:13:26,230 --> 00:13:36,700 which included psychoeducation, support, etc. and 16 of them either led teams providing CBD or interpersonal therapy or motivational interviewing. 122 00:13:36,700 --> 00:13:44,500 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, 123 00:13:44,500 --> 00:13:51,610 and all these studies for them had economic outcomes, all of which three had data available for inclusion. 124 00:13:51,610 --> 00:14:00,250 So we followed eight sets of comparisons that we could group them under where you had non-specialists led interventions versus usual 125 00:14:00,250 --> 00:14:08,350 care about evidence coming from trials or we had collaborative care model of any sexual abuse with the specialists was his usual care. 126 00:14:08,350 --> 00:14:15,880 Again, from trials and cluster trials, then we had special non-specialists versus usual care for maternal depression per say again, 127 00:14:15,880 --> 00:14:25,330 our CDs and some control before and after studies where these paid non-specialists were compared with specialists in treating common mental disorders. 128 00:14:25,330 --> 00:14:33,610 And again, some asked looked at non-specialists was the usual care for PTSD in adults and then looked at improving dementia, 129 00:14:33,610 --> 00:14:39,600 patient carers outcomes and also delivering interventions for alcohol use disorders. 130 00:14:39,600 --> 00:14:47,590 There were some which looked at non-specialists or teachers, other workers providing care for children with post-traumatic stress disorders. 131 00:14:47,590 --> 00:14:50,230 I'll give you the main findings. 132 00:14:50,230 --> 00:14:58,240 There was evidence that the health worker led psychological interventions may increase the number of adults who recover from 133 00:14:58,240 --> 00:15:06,820 depression and anxiety within a two to six month period after treatment and the prevalence of the risk of it coming down. 134 00:15:06,820 --> 00:15:09,850 According to that is these interventions. 135 00:15:09,850 --> 00:15:18,160 The risk was reduced by about 70 percent of having depression at the end of treatment in people who were treated by health workers. 136 00:15:18,160 --> 00:15:25,660 The best estimate is about 90 or 86 percent reduction, and the least estimate is about a 36 percent reduction. 137 00:15:25,660 --> 00:15:30,880 This comes from three studies with thousand eighty two participants looks very impressive. 138 00:15:30,880 --> 00:15:37,360 But when we applied the agreed criteria to see how certain all that this evidence will translate into your kind 139 00:15:37,360 --> 00:15:43,870 of practise and comes from good quality studies are the biases are low and where the results are consistent. 140 00:15:43,870 --> 00:15:49,240 Our overall confidence in this in this evidence is low, which means this is why we use the word. 141 00:15:49,240 --> 00:15:56,200 It may mean 100 percent sure that will give you the same results because of heterogeneity and risk of bias. 142 00:15:56,200 --> 00:16:00,490 Similarly, found that non-specialists health workers plus specialists in collaborative care 143 00:16:00,490 --> 00:16:04,750 model may increase the number of adults who recover from depression or anxiety, 144 00:16:04,750 --> 00:16:09,900 and two to six months compared to enhanced usual care get revisions. 145 00:16:09,900 --> 00:16:11,110 Hereto the results. 146 00:16:11,110 --> 00:16:21,280 We were non-specialist quite appreciably, clinically appreciably, with the minimum expected improvement being a 10 percent reduction in numbers. 147 00:16:21,280 --> 00:16:26,500 But here again, the evidence of low certainty due to heterogeneity and risk of bias and one of these studies, 148 00:16:26,500 --> 00:16:33,640 which has become Patel's studying the way he looked at two groups of people those 149 00:16:33,640 --> 00:16:38,650 collaborative care with doctors in public hospitals and with private hospitals. 150 00:16:38,650 --> 00:16:45,310 And what he found was that the benefits were largely seen when non-specialists work with public health doctors. 151 00:16:45,310 --> 00:16:49,900 That's why you got better outcomes compared to usual again, not so much in the private sector. 152 00:16:49,900 --> 00:16:54,550 And the explanation is that doctors in the private sector treat people of depression, 153 00:16:54,550 --> 00:16:56,830 spend a lot of time with them because it's their bread and butter. 154 00:16:56,830 --> 00:17:03,880 They need money, so they have a lot of involvement and empathy for people in the private sector. 155 00:17:03,880 --> 00:17:10,960 And the effects of this was not so apparent when you when you help private sector doctors treat people with depression in the community. 156 00:17:10,960 --> 00:17:18,670 And they followed this up with some other qualitative studies, which again showed that patient perceptions were that in the government setting. 157 00:17:18,670 --> 00:17:25,810 When you have more specialist health workers, patients felt supported and were able to engage better with the treatment than in the private sector. 158 00:17:25,810 --> 00:17:30,880 So this is very interesting illuminating results from that study. 159 00:17:30,880 --> 00:17:37,450 Non-specialist led interventions may slightly reduce symptoms from other perinatal depression compared to usual care. 160 00:17:37,450 --> 00:17:46,390 We use the word slightly because in this model, the standard I mean mean difference we April, he said. 161 00:17:46,390 --> 00:17:49,780 Normally when you look at continuous outcomes, it means and standard deviations. 162 00:17:49,780 --> 00:17:54,730 You just look at the problem and you see a p value system is very effective as you do. 163 00:17:54,730 --> 00:18:00,520 The P value only tells you whether those differences are due to Johnson. And we need to know how much better it is. 164 00:18:00,520 --> 00:18:06,160 So a standardised mean difference of point two means that it's a minimal improvement, 165 00:18:06,160 --> 00:18:14,770 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. 166 00:18:14,770 --> 00:18:18,970 Definitely there's a difference, but it's only a slight reduction in the symptoms. 167 00:18:18,970 --> 00:18:25,420 We don't have any idea what the effects of non-specialist are compared to specialists in giving pharmacological treatment, 168 00:18:25,420 --> 00:18:32,410 because the evidence from one study was extremely low quality, which basically means we don't know if this result is valid. 169 00:18:32,410 --> 00:18:38,860 Non-specialist led interventions may slightly reduce the symptoms of adults with post-traumatic stress disorder compared to usual care. 170 00:18:38,860 --> 00:18:44,620 Here again, it's slightly reduced low certainty evidence non-specialist probably slightly improves 171 00:18:44,620 --> 00:18:48,820 the symptoms of people with dementia in terms of severity of various symptoms. 172 00:18:48,820 --> 00:18:54,070 Here we use the word. Probably because there was only one of the issues was the imprecision in the estimates, 173 00:18:54,070 --> 00:18:59,160 and there is this evidence is quite robust that non-specialist can help in this. 174 00:18:59,160 --> 00:19:08,950 Even alcohol disorders as well non-specialist can help decrease the amount of alcohol consumed by people with alcohol use disorders. 175 00:19:08,950 --> 00:19:12,590 We don't know whether teachers are good in reducing symptoms. 176 00:19:12,590 --> 00:19:20,860 The children, the PTSD and the economic data within each study suggested that these interventions are cost effective. 177 00:19:20,860 --> 00:19:24,580 But there are a lot of biases in the way those studies were conducted to those data. 178 00:19:24,580 --> 00:19:31,390 Adults are not that reliable. But there's a general tendency for the studies to say these are cost effective interventions. 179 00:19:31,390 --> 00:19:38,160 The implications are. That if you look at the evidence overall, it says these are encouraging results, 180 00:19:38,160 --> 00:19:45,570 but we must keep in mind that these interventions were delivered in a research setting where the non-specialists are carefully selected, 181 00:19:45,570 --> 00:19:49,230 the project leaders are motivated. I was on the board of the modern Australian. 182 00:19:49,230 --> 00:19:56,580 I know how much work went into putting up the trial. The remuneration is more available because there's research funding and training. 183 00:19:56,580 --> 00:20:02,220 Supervision and monitoring are really, really rigorous because you want to show something. 184 00:20:02,220 --> 00:20:08,760 So I'm not sure. I don't know whether you can reproduce these results when you scale it up across the country. 185 00:20:08,760 --> 00:20:15,630 That's my only misgiving. But definitely the evidence is if you give it a shot, you get reasonably good results. 186 00:20:15,630 --> 00:20:20,730 It depends on how much you invest and what intensity you continue. 187 00:20:20,730 --> 00:20:25,980 The other thing is that these study designs are not really appropriate to give us answers to questions 188 00:20:25,980 --> 00:20:31,530 like Is there going to be downstream increased resource use because they aren't long term enough? 189 00:20:31,530 --> 00:20:40,170 We don't know what will happen further down. So you need much more longitudinal studies and economic evaluations undertaken in real time basis. 190 00:20:40,170 --> 00:20:44,370 Because research studies, you tend to leave aside a lot of the other costs, 191 00:20:44,370 --> 00:20:49,350 which are because you presume the system is already there as usual, know to set up the entire system. 192 00:20:49,350 --> 00:20:54,330 And we need a lot more qualitative data on you from the users perspective. 193 00:20:54,330 --> 00:21:01,650 And depending on the country itself, has got a different baseline morbidity rates in different health system approaches. 194 00:21:01,650 --> 00:21:08,530 So unless we know what this has to be made, as you said, for each state or each district within a steep. 195 00:21:08,530 --> 00:21:13,090 And the financial implications of such intervention is really unclear. 196 00:21:13,090 --> 00:21:18,730 There's another Vietnam that this is looking at very naval interventions, which produce very similar results, 197 00:21:18,730 --> 00:21:24,580 I won't go to the the detailed methods again showed that non-specialist health workers 198 00:21:24,580 --> 00:21:30,760 can give psychosocial treatments like cognitive therapy and interpersonal therapy, 199 00:21:30,760 --> 00:21:35,050 which are actually better than just getting health promotion studies. 200 00:21:35,050 --> 00:21:41,920 So that's another thing again, sort of suggesting that health workers can be usefully used. 201 00:21:41,920 --> 00:21:45,970 But this has had a small number of studies and the lot of heterogeneity. 202 00:21:45,970 --> 00:21:50,350 Now let's think about it, OK, if you've got some evidence to say that, it could work. 203 00:21:50,350 --> 00:21:54,040 What about the evidence for if you upskill when you want to upskill, 204 00:21:54,040 --> 00:22:00,830 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. 205 00:22:00,830 --> 00:22:05,330 Right, so if it's in the programme, we can only treat depression is to treat anxiety, 206 00:22:05,330 --> 00:22:10,130 as with alcohol problems, is veto many of the problems can one non-specialist do that? 207 00:22:10,130 --> 00:22:18,350 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. 208 00:22:18,350 --> 00:22:25,550 A counsellor delivered brief psychological intervention for harmful drinking in men, and in the other they looked at a lake, 209 00:22:25,550 --> 00:22:32,990 some the same lake Onslow, delivering brief psychological treatments with severe depression, using a very brief intervention in primary care. 210 00:22:32,990 --> 00:22:39,680 And these are companion studies, and what is unique about them was they came under a large programme looking at can we 211 00:22:39,680 --> 00:22:46,550 do research and scale up these interventions across L and see how affordable they are? 212 00:22:46,550 --> 00:22:51,650 So the V psychological interventions and what drew samples in primary care. 213 00:22:51,650 --> 00:22:55,670 The first were males who are harmful drinking history. 214 00:22:55,670 --> 00:23:00,320 Three hundred and seventy seven of them were randomised 50 to either get usual, 215 00:23:00,320 --> 00:23:04,640 get enhanced usual care, which is normally when you say usually that means nothing. 216 00:23:04,640 --> 00:23:07,390 So here they usually get at least got something. 217 00:23:07,390 --> 00:23:14,360 Plus this counselling for alcohol programme initiatives work together versus usual care, and in the second trial, 218 00:23:14,360 --> 00:23:22,070 the randomised 495 male and female patient to moderate and severe depression to their healthy activities programme. 219 00:23:22,070 --> 00:23:27,790 Plus use enhanced user Carrero Usual Care Alone 50 50 Randomisation. 220 00:23:27,790 --> 00:23:31,330 The important thing was that the kind of counsellors who delivered the 221 00:23:31,330 --> 00:23:36,580 interventions were adult members from local community at secondary school level, 222 00:23:36,580 --> 00:23:43,720 but no training prior to a three week course in mental health delivered by the specialists only three weeks. 223 00:23:43,720 --> 00:23:49,030 And the same counsellor was involved in both the trials and delivered both the interventions. 224 00:23:49,030 --> 00:23:57,430 Now what they deliver, the healthy activity programme is delivered over six to eight sessions and consists of a behavioural activation package. 225 00:23:57,430 --> 00:24:00,280 So it's like motivation with a little bit of this and a little bit of that, 226 00:24:00,280 --> 00:24:05,470 but it gets people positively to think about what they're doing in a framework. 227 00:24:05,470 --> 00:24:13,510 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, 228 00:24:13,510 --> 00:24:19,690 and it seemed to work, and the counselling for alcohol problems is motivational enhancement again for sessions. 229 00:24:19,690 --> 00:24:25,660 Now, the results were very interesting after three months. These counsellors did good whatever they did. 230 00:24:25,660 --> 00:24:28,540 Improved results compared to usual care. 231 00:24:28,540 --> 00:24:37,900 And if you look at the number of patients who achieved remission in alcohol was 36 per percent of people versus 46 percent, 232 00:24:37,900 --> 00:24:43,900 and maintained abstinence is 42 percent in the people who were consular dream, 233 00:24:43,900 --> 00:24:51,030 which is 18 percent in the people who had an usual treatment and percentage of abstinent days also is much better. 234 00:24:51,030 --> 00:24:55,110 And again, amongst the people depression on all the measures they looked at, 235 00:24:55,110 --> 00:25:03,240 the consulate thing was much better using validated skills and cost effectiveness analysis, 236 00:25:03,240 --> 00:25:07,950 they reported, think would these interventions are cost effective for both disorders? 237 00:25:07,950 --> 00:25:13,670 You can also look at the downsides of this and say up to 65 percent of excessive drinkers and 36 percent of people 238 00:25:13,670 --> 00:25:21,060 in depression did not achieve any mission in those drugs and see that as a sign that this guy does not good. 239 00:25:21,060 --> 00:25:22,870 But let's compare it to other studies. 240 00:25:22,870 --> 00:25:30,810 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. 241 00:25:30,810 --> 00:25:37,770 So it seems to answer the question I raised for saying, are they doing as good a job as usual specialist? 242 00:25:37,770 --> 00:25:42,540 And these two studies seem to show, yes, they are. You get similar rates as what you get. 243 00:25:42,540 --> 00:25:47,520 If specialists were doing these gentlemen spin doctors were doing their treatment. 244 00:25:47,520 --> 00:25:55,380 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 245 00:25:55,380 --> 00:25:59,970 are actually going to be in the health system on the use of these non-specialists. 246 00:25:59,970 --> 00:26:07,620 So there is a nice people coming out from the prime study which are looking at scaling up the mental health delivery service. 247 00:26:07,620 --> 00:26:13,200 This is a difficult funded project in India, Nepal, South Africa, Uganda and Ethiopia, 248 00:26:13,200 --> 00:26:19,860 where they did focus group discussions and in-depth interviews to understand perceptions of people about the use of non specialist workers. 249 00:26:19,860 --> 00:26:27,450 And they felt the results of this that task sharing is acceptable and feasible as long as these three conditions are met. 250 00:26:27,450 --> 00:26:31,110 We need more people and we need better access to medications. 251 00:26:31,110 --> 00:26:34,830 Instead, we've got to ensure that their non-specialists would be a great help. 252 00:26:34,830 --> 00:26:41,250 Second is, we need ongoing structured support and supervision of the community and primary care levels. 253 00:26:41,250 --> 00:26:45,810 And the third was we need adequate training and compensation for the health 254 00:26:45,810 --> 00:26:49,620 workers who are going to be involved in shooting because in many countries, 255 00:26:49,620 --> 00:26:53,700 when you use health workers, they are not formally employed, they don't have. 256 00:26:53,700 --> 00:27:02,420 They like our gig drives, gig economy, they get casual. So the incentives to keep them going is not really sustainable. 257 00:27:02,420 --> 00:27:06,800 You can also look at disability or exemptions from the point of view of all the 258 00:27:06,800 --> 00:27:11,060 trials that have been done because many of them were done with quality to work, 259 00:27:11,060 --> 00:27:13,670 looking at what worked and what did not. 260 00:27:13,670 --> 00:27:21,050 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. 261 00:27:21,050 --> 00:27:28,220 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. 262 00:27:28,220 --> 00:27:34,130 So this systematic review looked at what are the stages of training 2019 publication 263 00:27:34,130 --> 00:27:39,020 and found that these there are training programmes implemented across 16 countries, 264 00:27:39,020 --> 00:27:47,480 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. 265 00:27:47,480 --> 00:27:54,260 But they have a lot of variability in terms of the courses. Trainees attitudes, knowledge and skills development. 266 00:27:54,260 --> 00:28:02,430 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. 267 00:28:02,430 --> 00:28:08,000 At least some areas exist. But what we need to look at is how can we standardise some of these training approaches 268 00:28:08,000 --> 00:28:13,280 so it can be important across the world in consultation with the people there? 269 00:28:13,280 --> 00:28:17,730 So there's a need for developing these training programmes, which has not yet been done. 270 00:28:17,730 --> 00:28:26,570 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? 271 00:28:26,570 --> 00:28:31,010 We really don't have any objective evidence and that maybe some tracking talk a little 272 00:28:31,010 --> 00:28:36,320 bit of what what they're doing out there and the effectiveness of different programmes, 273 00:28:36,320 --> 00:28:43,010 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 274 00:28:43,010 --> 00:28:48,170 mechanisms for integrating that with other formal programmes in the health sector. 275 00:28:48,170 --> 00:28:51,360 What different skill sets are needed? 276 00:28:51,360 --> 00:28:58,590 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. 277 00:28:58,590 --> 00:29:04,590 There are a lot of homeless people out there and many other disadvantaged people who come nowhere in the ambit of this. 278 00:29:04,590 --> 00:29:09,540 And there are a large proportion of the unmet need in these countries. 279 00:29:09,540 --> 00:29:13,650 So whatever we are doing right now, we're only looking at evidence in these sort of formal programmes, 280 00:29:13,650 --> 00:29:21,010 but it's encouraging that there is a viable alternative to waiting for psychiatrists and trained mental health professionals to fill this gap. 281 00:29:21,010 --> 00:29:29,002 Thank you very much.