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Rimal P, Shrestha S, Khatri R, Sapkota S, Swar SB, Basnet M, Sigdel K, Jirel S, Acharya B. Addressing Challenges for Psychotherapy Supervision in Global Mental Health: Experiential Learnings From Rural Nepal. RESEARCH SQUARE 2024:rs.3.rs-4499074. [PMID: 38978610 PMCID: PMC11230512 DOI: 10.21203/rs.3.rs-4499074/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Background As the field of global mental health grows, many psychotherapy trainees will work across cultures in low-resource settings in high-income countries or in low- and middle-income countries. Faculty members and mentors may face several challenges in providing supervision for psychologists in low-resource settings. As such, there is a need to develop best practices for psychotherapy supervision in global mental health. Methods We describe the common challenges and potential strategies in psychotherapy supervision based on our research, clinical, and academic partnerships between academic institutions, a nonprofit organization, and the Nepali government. Results The strategies and considerations we have found helpful include focusing on therapies with strong behavioral and interpersonal (rather than emotional or cognitive) components and using locally validated therapies or standard manuals that have been endorsed by the WHO for low-resource settings. Other strategies include providing psychotherapy training for local psychiatrists who may be in supervisory roles and gaining competence in navigating different expectations of social structures and family dynamics. Conclusion Supervisors face many challenges while supporting trainees and early psychologists in global mental health settings. While ensuring local adaptation, key considerations can be developed into best practices to support psychiatrists, supervisors, and trainees based in low- and middle-income countries.
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Gourab G, Sarwar G, Khan MNM, Hasan AMR, Irfan SD, Saha TK, Rahman L, Rana AKMM, Khan SI. Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh. BMC Health Serv Res 2023; 23:979. [PMID: 37697263 PMCID: PMC10496154 DOI: 10.1186/s12913-023-09996-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/31/2023] [Indexed: 09/13/2023] Open
Abstract
INTRODUCTION In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs. METHODS This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks. RESULTS This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges. CONCLUSION The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.
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Affiliation(s)
- Gorkey Gourab
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Golam Sarwar
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mohammad Niaz Morshed Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
- Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - A M Rumayan Hasan
- Universal Health Coverage, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Samira Dishti Irfan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Tarit Kumar Saha
- Institute of Public Health (IPH), Dhaka, Bangladesh
- Ministry of Health and Family Welfare, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Lima Rahman
- HIV/AIDS Programme, Health, Nutrition and HIV/AIDS Sector, Save the Children, House 35, Road 43, Gulshan-2, Dhaka, Bangladesh
| | - A K M Masud Rana
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Sharful Islam Khan
- Programme for HIV and AIDS, Infectious Diseases Division, International Centre for Diarrhoeal Diseases Research, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
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Whitfield J, Owens S, Bhat A, Felker B, Jewell T, Chwastiak L. Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review. Glob Ment Health (Camb) 2023; 10:e11. [PMID: 37854388 PMCID: PMC10579696 DOI: 10.1017/gmh.2022.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/01/2022] [Accepted: 11/22/2022] [Indexed: 03/19/2023] Open
Abstract
Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication; standardized protocols for evidence-based treatments; systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings.
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Affiliation(s)
- Jessica Whitfield
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Shanise Owens
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Amritha Bhat
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Bradford Felker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Teresa Jewell
- University of Washington Health Sciences Library, University of Washington, Seattle, WA, USA
| | - Lydia Chwastiak
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington School of Public Health, Seattle, WA, USA
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Steinman LE, Gasca A, Hoeft TJ, Raue PJ, Henderson S, Perez R, Huerta A, Fajardo A, Vredevoogd MA, James K, Hinton L, Rath L, Unutzer J. "We are the sun for our community:" Partnering with community health workers/promotores to adapt, deliver and evaluate a home-based collaborative care model to improve equity in access to quality depression care for older U.S. Latino adults who are underserved. Front Public Health 2023; 11:1079319. [PMID: 36817932 PMCID: PMC9932325 DOI: 10.3389/fpubh.2023.1079319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/11/2023] [Indexed: 02/05/2023] Open
Abstract
Background While depression is a leading cause of poor health, less than half of older adults receive adequate care. Inequities in both access and outcomes are even more pronounced for socially disadvantaged older adults. The collaborative care model (CCM) has potential to reduce this burden through community-based organizations (CBOs) who serve these populations. However, CCM has been understudied in diverse cultural and resource-constrained contexts. We evaluated the implementation and effectiveness of PEARLS, a home-based CCM adapted with and for community health workers/promotores (CHWs/Ps). Methods We used an instrumental case study design. Our case definition is a community-academic partnership to build CHW/P capacity for evidence-based depression care for older U.S. Latino adults in the Inland Empire region of California (2017-2020). We aimed to understand adaptations to fit local context; acceptability, feasibility, and fidelity; clinical effectiveness; and contextual determinants of implementation success or failure. Data sources included quantitative and qualitative administrative and evaluation data from participants and providers. We used descriptive statistics and paired t-tests to characterize care delivery and evaluate effectiveness post-intervention, and deductive thematic analysis to answer other aims. Findings This case study included 152 PEARLS participants and nine data sources (N = 67 documents). The CBO including their CHWs/Ps partnered with the external implementation team made adaptations to PEARLS content, context, and implementation strategies to support CHWs/Ps and older adults. PEARLS was acceptable, feasible and delivered with fidelity. Participants showed significant reductions in depression severity at 5 months (98% clinical response rate [mean (SD), 13.7 (3.9) drop in pre/post PHQ-9; p < 0.001] and received support for 2.6 social needs on average. PEARLS delivery was facilitated by its relative advantage, adaptability, and trialability; the team's collective efficacy, buy-in, alignment with organization mission, and ongoing reflection and evaluation during implementation. Delivery was challenged by weak partnerships with clinics for participant referral, engagement, reimbursement, and sustainability post-grant funding. Discussion This case study used existing data to learn how home-based CCM was adapted by and for CHWs/Ps to reduce health inequities in late-life depression and depression care among older Latino immigrants. The CBOs and CHWs/Ps strong trust and rapport, addressing social and health needs alongside depression care, and regular internal and external coaching and consultation, appeared to drive successful implementation and effectiveness.
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Affiliation(s)
- Lesley E. Steinman
- Department of Health Systems and Population Health, Health Promotion Research Center, School of Public Health, University of Washington, Seattle, WA, United States
| | - Amelia Gasca
- El Sol Neighborhood Educational Center, San Bernardino, CA, United States
| | - Theresa J. Hoeft
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| | - Patrick J. Raue
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| | - Stuart Henderson
- School of Medicine Office of Research, University of California Davis, Sacramento, Sacramento, CA, United States
| | - Rosa Perez
- El Sol Neighborhood Educational Center, San Bernardino, CA, United States
| | - Alfredo Huerta
- El Sol Neighborhood Educational Center, San Bernardino, CA, United States
| | - Alex Fajardo
- El Sol Neighborhood Educational Center, San Bernardino, CA, United States
| | - Melinda A. Vredevoogd
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| | - Katherine James
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| | - Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, Sacramento, CA, United States
| | - Laura Rath
- Archstone Foundation, Long Beach, CA, United States
| | - Jurgen Unutzer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
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Petagna M, Marley C, Guerra C, Calia C, Reid C. Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review. Community Ment Health J 2023; 59:192-204. [PMID: 35579725 PMCID: PMC9813022 DOI: 10.1007/s10597-022-00981-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted. AIMS We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation. METHODS Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health. RESULTS Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers. CONCLUSIONS Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.
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Affiliation(s)
- Marta Petagna
- School of Health in Social Sciences, The University of Edinburgh, Edinburgh, UK
| | - Charles Marley
- School of Allied Health Science and Practice, The University of Adelaide, Engineering & Mathematical Sciences Building, North Terrace, 5001, Adelaide, Australia.
| | | | - Clara Calia
- School of Health in Social Sciences, The University of Edinburgh, Edinburgh, UK
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Haack SA, Rehuher D, Ghiasuddin A, Kiyota T, Alik TP. Implementation of an Adapted Collaborative Care Model. Psychiatr Serv 2022; 73:1186-1189. [PMID: 35440161 DOI: 10.1176/appi.ps.202100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kosrae is an island state in the Federated States of Micronesia, a low- to middle-income country. Kosrae Community Health Center, an independent nonprofit organization, partnered with the Department of Psychiatry at the University of Hawai'i to integrate behavioral health services by using the collaborative care model (CoCM). The partnership encountered logistic and cultural challenges, but regular communication, case reviews, and training sessions enabled successful CoCM implementation. This success indicates that CoCM can be adapted in a remote island nation with finite resources. Findings indicate that planning for a longer implementation period may be required for international collaborations with limited previous experience in behavioral health.
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Affiliation(s)
- Sara A Haack
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu (Haack, Rehuher, Ghiasuddin, Kiyota); Kosrae Community Health Center, Kosrae, Federated States of Micronesia (Alik)
| | - Davis Rehuher
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu (Haack, Rehuher, Ghiasuddin, Kiyota); Kosrae Community Health Center, Kosrae, Federated States of Micronesia (Alik)
| | - Asad Ghiasuddin
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu (Haack, Rehuher, Ghiasuddin, Kiyota); Kosrae Community Health Center, Kosrae, Federated States of Micronesia (Alik)
| | - Tiffinie Kiyota
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu (Haack, Rehuher, Ghiasuddin, Kiyota); Kosrae Community Health Center, Kosrae, Federated States of Micronesia (Alik)
| | - Tholman P Alik
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu (Haack, Rehuher, Ghiasuddin, Kiyota); Kosrae Community Health Center, Kosrae, Federated States of Micronesia (Alik)
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Jackson J, Dangal R, Dangal B, Gupta T, Jirel S, Khadka S, Rimal P, Acharya B. Implementing Collaborative Care in Low-Resource Government, Research, and Academic Settings in Rural Nepal. Psychiatr Serv 2022; 73:1073-1076. [PMID: 35172595 DOI: 10.1176/appi.ps.202100421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The collaborative care model (CoCM) is a strategy of integrating behavioral health into primary care to expand access to high-quality mental health services in areas with few psychiatrists. CoCM is multifaceted, and its implementation is accelerating in high-resource settings. However, in low-resource settings, it may not be feasible to implement all CoCM components. Guidance is lacking on CoCM implementation when only some of its components are feasible. In this column, the authors used a cost-benefit approach to refine strategies for addressing common implementation challenges, incorporating the authors' experiences in what was gained and what was lost at each implementation step in three CoCM programs in diverse clinical settings in rural Nepal.
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Affiliation(s)
- James Jackson
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Rajkumar Dangal
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Binod Dangal
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Tula Gupta
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Sunita Jirel
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Sangeeta Khadka
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Pragya Rimal
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
| | - Bibhav Acharya
- Department of Medicine, HEAL Initiative, University of California, San Francisco (Jackson, Gupta, Rimal, Acharya); Department of Psychiatry and Behavioral Sciences, University of California, San Francisco (Jackson, Acharya); Dhulikhel Hospital, Kathmandu University, Dhulikhel, Nepal (R. Dangal, Khadka); Charikot Provincial Public Hospital, Dolakha, Nepal (B. Dangal, Jirel); Possible, Kathmandu, Nepal (Rimal). Kathleen M. Pike, Ph.D., Matías Irarrázaval, M.D., M.P.H., and Lola Kola, Ph.D., are editors of this column
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Menear M, Girard A, Dugas M, Gervais M, Gilbert M, Gagnon MP. Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review. PLoS One 2022; 17:e0268649. [PMID: 35687610 PMCID: PMC9187074 DOI: 10.1371/journal.pone.0268649] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care. METHODS We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings. RESULTS In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making. CONCLUSION This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.
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Affiliation(s)
- Matthew Menear
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Ariane Girard
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Michèle Dugas
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
| | - Michel Gervais
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
| | - Michel Gilbert
- Centre National d’Excellence en Santé Mentale, Quebec, Quebec, Canada
| | - Marie-Pierre Gagnon
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Faculty of Nursing, Université Laval, Quebec, Quebec, Canada
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Shaligram D, Skokauskas N, Aragones E, Azeem MW, Bala A, Bernstein B, Cama S, Canessa L, Silva FD, Engelhard C, Garrido G, Guerrero APS, Hunt J, Jadhav M, Martin SL, Miliauskas C, Nalugya J, Nazeer A, Ong SH, Robertson P, Sassi R, Seker A, Watkins M, Leventhal B. International perspective on integrated care models in child and adult mental health. Int Rev Psychiatry 2022; 34:101-117. [PMID: 35699101 DOI: 10.1080/09540261.2022.2059346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.
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Affiliation(s)
| | | | - Enric Aragones
- Institut de Recerca en Atencio Primaria Jordi Gol, Spain
| | | | | | | | - Shireen Cama
- Cambridge Health Alliance/Harvard Medical School, USA
| | - Laura Canessa
- Facultad de Medicina, Universidad de la República, Uruguay
| | | | | | | | | | - Jeffrey Hunt
- Brown University Warren Alpert Medical School, USA
| | | | - Sarah L Martin
- Texas Tech University Health Science Center El Paso, Texas, USA
| | | | - Joyce Nalugya
- Makerere University College of Health Sciences, Uganda
| | | | | | - Paul Robertson
- Department of Psychiatry, The University of Melbourne, Australia
| | - Roberto Sassi
- University of British Columbia, BC Children's Hospital, Canada
| | - Asilay Seker
- Cambridgeshire and Peterborough NHS Foundation Trust, UK
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- The University of Texas System, Texas, USA
| | - Michael Watkins
- The University of Texas Health Science Center at Tyler, Texas, USA
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Henrique MG, de Paula Couto MCP, Araya R, Mendes AV, Nakamura CA, Hollingworth W, van de Ven P, Peters TJ, Scazufca M. Acceptability and fidelity of a psychosocial intervention (PROACTIVE) for older adults with depression in a basic health unit in São Paulo, Brazil: a qualitative study. BMC Public Health 2021; 21:2278. [PMID: 34903192 PMCID: PMC8670151 DOI: 10.1186/s12889-021-12402-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/30/2021] [Indexed: 11/18/2022] Open
Abstract
Background Depression is a common condition in older adults, being often detected and treated initially in primary care. Collaborative care models including, for example, task-shifting and stepped-care approaches have been investigated to overcome the current scarcity of strategies and trained mental health professionals to treat depression. The PROACTIVE study developed a psychosocial intervention, which makes extensive use of technology in an intervention delivered mainly by non-specialists to treat older adults with depression. The aim of this qualitative study is to assess: 1. Health workers’ fidelity to the intervention protocol; 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants; and 3. Perceptions of the psychosocial intervention by the health workers. Methods Qualitative methods were used to achieve our aims. The sample included participants (N = 31) receiving the intervention in the pilot trial and health workers (N = 11) working in a Basic Health Unit in the northern area of São Paulo, Brazil. Focus group, non-participant observation and structured interviews were used. Data were analysed using a thematic analysis approach. Results 1. Health workers’ fidelity to the intervention protocol: training, supervision and the structured intervention were crucial and guaranteed health workers’ fidelity to the protocol. 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants: Collaborative care, task-shifting, and stepped-care approaches were well accepted. The structured protocol of the intervention including different activities and videos was important to adherence of older adult participants 3. Perceptions of the psychosocial intervention by the health workers: It was feasible to have the home psychosocial sessions conducted by health workers, who are non-mental health specialists and received 3-day training. Training and supervision were perceived as crucial to support health workers before and during the intervention. Technology served as a tool to structure the sessions, obtain and store patient data, present multi-media content, guarantee fidelity to the protocol and facilitate communication among members of the team. However, extra burden was mentioned by the health workers indicating the need of adjustments in their daily duties. Conclusions The PROACTIVE intervention was demonstrated to be feasible and accepted by both health workers and older adult participants. The qualitative assessments suggested improvements in training and supervision to ensure fidelity to protocol. To assess effectiveness a randomised controlled trial of the intervention will be conducted with the addition of improvements suggested by this qualitative study. Trial registration The pilot study of which the present study gives support to was registered at the Brazilian Clinical Trials, UTN code: U1111-1218-6717 on 26/09/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12402-3.
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Affiliation(s)
- Maiara Garcia Henrique
- LIM-23, Instituto de Psiquiatria, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Ricardo Araya
- Centre of Global Mental Health, Institute of Psychiatry, Psychology, and Neurosciences, King's College, London, UK
| | - Ana Vilela Mendes
- LIM-23, Instituto de Psiquiatria, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carina Akemi Nakamura
- LIM-23, Instituto de Psiquiatria, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Pepijn van de Ven
- Health Research Institute, University of Limerick, Limerick, IE, Ireland
| | - Tim J Peters
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcia Scazufca
- LIM-23, Instituto de Psiquiatria, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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11
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Ortega AC, Valtierra E, Rodríguez-Cuevas FG, Aranda Z, Preciado G, Mohar S. Protecting vulnerable communities and health professionals from COVID-19 associated mental health distress: a comprehensive approach led by a public-civil partnership in rural Chiapas, Mexico. Glob Health Action 2021; 14:1997410. [PMID: 34889715 PMCID: PMC8667903 DOI: 10.1080/16549716.2021.1997410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/21/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has stricken mental health worldwide. Marginalized populations in low- and middle-income countries have been the most affected, as they were already experiencing barriers to accessing mental health care prior to the pandemic and are unequally exposed to the stressors associated with the health emergency, such as economic ravages or increased risk of complicated disease outcomes. OBJECTIVE The aim of this paper is to describe a comprehensive initiative resulting from a public-civil partnership to address the increased burden of mental health illness associated with the COVID-19 pandemic in rural Chiapas, Mexico. METHODS To address the emerging health needs of the general population and health professionals resulting from the pandemic, Compañeros En Salud (CES), a non-profit civil society organization based in Chiapas, implemented a comprehensive strategy to compensate for the shortage of mental health services in the region in collaboration with the Chiapas Ministry of Health. The strategy included three components: capacity building in mental health care delivery, psychosocial support to the general population, and provision of mental health care to CES collaborating staff. In this capacity building article, implementers from CES and the government share descriptive information on the specific interventions carried out and their beneficiaries, as well as a critical discussion of the strategy followed. RESULTS Through this strategy, we have been successful in filling the gaps in the public health system to ensure that CES-served populations and CES-collaborating health professionals have access to mental health care. However, further studies to quantify the impact of this intervention in alleviating the burden of mental health illnesses associated with the pandemic are needed. CONCLUSIONS The current situation represents an opportunity to reimagine global mental health. Only through the promotion of community-based initiatives and the development of integrated approaches will we ensure the well-being of marginalized populations.
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Affiliation(s)
- Ana Cecilia Ortega
- Mental Health Program, Partners In Health Mexico/Compañeros En Salud, Ángel Albino Corzo, México
| | - Erika Valtierra
- Mental Health Program, Partners In Health Mexico/Compañeros En Salud, Ángel Albino Corzo, México
| | - Fátima Gabriela Rodríguez-Cuevas
- Mental Health Program, Partners In Health Mexico/Compañeros En Salud, Ángel Albino Corzo, México
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Zeus Aranda
- Research and Impact Program, Partners in Health Mexico/Compañeros En Salud, Ángel Albino Corzo, México
| | - Gisela Preciado
- Mental Health Program, Partners In Health Mexico/Compañeros En Salud, Ángel Albino Corzo, México
| | - Sebastián Mohar
- Hospital Básico Comunitario de Ángel Albino Corzo, Chiapas Ministry of Health, Ángel Albino Corzo, México
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Technology-Assisted Collaborative Care Program for People with Diabetes and/or High Blood Pressure Attending Primary Health Care: A Feasibility Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212000. [PMID: 34831756 PMCID: PMC8618659 DOI: 10.3390/ijerph182212000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 01/09/2023]
Abstract
The comorbidity of depression with physical chronic diseases is usually not considered in clinical guidelines. This study evaluated the feasibility of a technology-assisted collaborative care (TCC) program for depression in people with diabetes and/or high blood pressure (DM/HBP) attending a primary health care (PHC) facility in Santiago, Chile. Twenty people diagnosed with DM/HBP having a Patient Health Questionnaire-9 score ≥ 15 points were recruited. The TCC program consisted of a face-to-face, computer-assisted psychosocial intervention (CPI, five biweekly sessions), telephone monitoring (TM), and a mobile phone application for behavioral activation (CONEMO). Assessments of depressive symptoms and other health-related outcomes were made. Thirteen patients completed the CAPI, 12 received TM, and none tried CONEMO. The TCC program was potentially efficacious in treating depression, with two-thirds of participants achieving response to depression treatment 12 weeks after baseline. Decreases were observed in depressive symptoms and healthcare visits and increases in mental health-related quality of life and adherence to treatment. Patients perceived the CPI as acceptable. The TCC program was partially feasible and potentially efficacious for managing depression in people with DM/HBP. These data are valuable inputs for a future randomized clinical trial.
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13
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Speaking Up: How Family Members Advocate for Relatives Living with a Mental Illness. Community Ment Health J 2021; 57:1547-1555. [PMID: 33486676 DOI: 10.1007/s10597-021-00775-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
Consumers with a mental health condition often feel powerless and overwhelmed in interactions with mental healthcare providers. Consumer self-advocacy and advocacy actions undertaken by their family members on the behalf of their relative contribute to a sense of empowerment for both consumers and their family members. This qualitative study explored family member perspectives of advocacy actions they took on behalf of their relatives and themselves. Data analysis of interviews with 20 family members, including parents, partners/spouses, siblings, and adult children, yielded three themes of family member advocacy actions: advocating for a relative's mental healthcare, normalizing mental illness, and engaging in social and political actions. Advocacy frameworks offer useful guidelines for speaking up for individuals who live with a mental illness.
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Rimal P, Choudhury N, Agrawal P, Basnet M, Bohara B, Citrin D, Dhungana SK, Gauchan B, Gupta P, Gupta TK, Halliday S, Kadayat B, Mahar R, Maru D, Nguyen V, Poudel S, Raut A, Rawal J, Sapkota S, Schwarz D, Schwarz R, Shrestha S, Swar S, Thapa A, Thapa P, White R, Acharya B. Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study. BMJ Open 2021; 11:e048481. [PMID: 34400456 PMCID: PMC8370561 DOI: 10.1136/bmjopen-2020-048481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings. METHODS We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period. RESULTS Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001). CONCLUSION Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.
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Affiliation(s)
- Pragya Rimal
- Nyaya Health Nepal, Kathmandu, Nepal
- Possible, Kathmandu, Nepal
| | - Nandini Choudhury
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Possible, New York, New York, USA
| | | | - Madhur Basnet
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, BP Koirala Institute of Health Sciences, Dharan, Kathmandu, Nepal
| | | | - David Citrin
- Possible, New York, New York, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Scott Halliday
- Possible, New York, New York, USA
- Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Duncan Maru
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Possible, New York, New York, USA
| | - Viet Nguyen
- Health Services, Los Angeles County Department of Health Services, Los Angeles, California, USA
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Anant Raut
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Possible, New York, New York, USA
| | | | - Sabitri Sapkota
- Possible, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dan Schwarz
- Possible, New York, New York, USA
- Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Ryan Schwarz
- Possible, New York, New York, USA
- Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Srijana Shrestha
- Possible, New York, New York, USA
- Department of Psychology, Wheaton College, Wheaton, Illinois, USA
| | | | | | - Poshan Thapa
- University of New South Wales School of Public Health and Community Medicine, Sydney, New South Wales, Australia
| | | | - Bibhav Acharya
- Possible, New York, New York, USA
- Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
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15
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Haack SA, Engelhard C, Kiyota T, Alik TP. An Analysis of the Sustainability of a Collaborative Care Program Used to Deliver Integrated Mental Health Care Within a Micronesian Island State. Asia Pac J Public Health 2021; 33:786-788. [PMID: 34088242 DOI: 10.1177/10105395211020898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adequate access to mental health care is a global problem, including in the Federated States of Micronesia (FSM). The Collaborative Care Model (CoCM) offers an opportunity to deliver improved access to mental health services in primary care centers, and key factors to program sustainability have been investigated in high-income country settings. This study's objective was to evaluate how well factors associated with sustainability have been incorporated into a CoCM in Kosrae, Federated States of Micronesia. The Kosraean CoCM's strengths included its supportive leadership, team member training, and having a strong care manager and engaged primary care provider champion. Opportunities for growth included further development of its financial viability, information technology systems, change readiness, and operational procedures. Our program found that having a stable and invested staff and leveraging its current strengths were important to its viability. In an international partnership, it is also critical to develop strong relationships among team members and to have stable internet connectivity to facilitate regular communication. These lessons learned can be applicable to other integrated care programs in similar Pacific Island countries.
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Affiliation(s)
- Sara A Haack
- University of Hawai'i at Mānoa, Honolulu, HI, USA
| | | | | | - Tholman Ph Alik
- Kosrae Community Health Center, Kosrae, Federated States of Micronesia
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Bhat A, Goud BR, Pradeep JR, Jayaram G, Radhakrishnan R, Srinivasan K. Can Mobile Health Improve Depression Treatment Access and Adherence Among Rural Indian Women? A Qualitative Study. Cult Med Psychiatry 2020; 44:461-478. [PMID: 31916181 DOI: 10.1007/s11013-019-09664-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Major Depressive Disorder (MDD) is associated with low rates of treatment and medication non-adherence, more so in low- and middle-income countries (LMICs). Mobile mental health (mHealth) interventions offer promise as a tool to address these problems. However, the feasibility and acceptability of mHealth interventions among rural women in LMICs is unknown. We examined barriers to accessing mental health treatment, reasons for non-adherence, and attitudes towards mHealth solutions among women with MDD in rural south India. Six focus groups were conducted among women with MDD (n = 69) who had been in treatment at a rural community health center. The discussion was transcribed and analyzed using a modified grounded-theory approach. Women perceived limited autonomy within their family structure, and experienced financial and systemic barriers as contributing to poor treatment access and non-adherence. Illiteracy, limited personal access to mobile phones, and preference for in-person clinical consultation were identified as barriers to use of mHealth. This is the first qualitative study, to our knowledge, that examines attitude towards mHealth among women with MDD in a rural setting in India. The study identified contextual barriers that will be important to address before implementing mHealth interventions.
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Affiliation(s)
- A Bhat
- Department of Psychiatry and Behavioral Sciences, University of Washington, NE Pacific Street, 1959, Seattle, WA, 98052, USA.
| | - B Ramakrishna Goud
- Department of Community Health, St John's Medical College, Bengaluru, India
| | - J R Pradeep
- Department of Psychiatry, St John's Medical College Hospital, Bengaluru, India
| | - G Jayaram
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Radhakrishnan
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Yale Institute for Global Health, Yale University, New Haven, CT, USA
| | - K Srinivasan
- Department of Psychiatry, St John's Medical College Hospital, Bengaluru, India
- Division of Mental Health and Neurosciences, St Johns Research Institute, Bengaluru, India
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Marshall J, Scott B, Delva J, Ade C, Hernandez S, Patel J, Moreno-Cheek M, Rojas D, Tanner JP, Kirby RS. An Evaluation of Florida's Zika Response Using the WHO Health Systems Framework: Can We Apply These Lessons to COVID-19? Matern Child Health J 2020; 24:1212-1223. [PMID: 32583172 PMCID: PMC7314660 DOI: 10.1007/s10995-020-02969-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES From 2016 to 2018 Florida documented 1471 cases of Zika virus, 299 of which were pregnant women (Florida Department of Health, https://www.floridahealth.gov/diseases-and-conditions/mosquito-bornediseases/surveillance.html , 2019a). Florida's response required unprecedented rapid and continuous cross-sector communication, adaptation, and coordination. Zika tested public health systems in new ways, particularly for maternal child health populations. The systems are now being challenged again, as the Coronavirus COVID-19 pandemic spreads throughout Florida. This qualitative journey mapping evaluation of Florida's response focused on care for pregnant women and families with infants exposed to Zika virus. METHODS Fifteen focus groups and interviews were conducted with 33 public health and healthcare workers who managed outbreak response, case investigations, and patient care in south Florida. Data were thematically analyzed, and the results were framed by the World Health Organization's (WHO) Healthcare Systems Framework of six building blocks: health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance (World Health Organization, https://www.who.int/healthsystems/strategy/everybodys_business.pdf , 2007, https://www.who.int/healthinfo/systems/monitoring/en/ , 2010). RESULTS Results highlighted coordination of resources, essential services and treatment, data collection, communication among public health and healthcare systems, and dissemination of information. Community education, testing accuracy and turnaround time, financing, and continuity of health services were areas of need, and there was room for improvement in all indicator areas. CONCLUSIONS The WHO Framework encapsulated important infrastructure and process factors relevant to the Florida Zika response as well as future epidemics. In this context, similarities, differences, and implications for the Coronavirus COVID-19 pandemic response are discussed.
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Affiliation(s)
- Jennifer Marshall
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA.
| | - Blake Scott
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jennifer Delva
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Cedrick Ade
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Santiago Hernandez
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jaladhikumar Patel
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Mantero Moreno-Cheek
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Dogeli Rojas
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jean-Paul Tanner
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Russell S Kirby
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
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18
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Rimal P, Maru D, Chwastiak L, Agrawal P, Rao D, Swar S, Citrin D, Acharya B. Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal. BMC Psychiatry 2020; 20:46. [PMID: 32024490 PMCID: PMC7003398 DOI: 10.1186/s12888-020-2464-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 01/24/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal. METHODS A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the recommendations are tabulated and discussed in the context of an adapted CoCM in rural Nepal. RESULTS The clinical team discussed 1174 patient encounters (1162 unique patients) during panel reviews throughout the study period. The consultant psychiatrist made 214 recommendations for 192 (16%) patients. The most common recommendations were to revisit the primary mental health diagnosis (16%, n = 34), add or increase focus on counselling and psychosocial support (9%, n = 20), increase the antidepressant dose (9%, n = 20), and discontinue inappropriate medications (6%, n = 12). CONCLUSIONS In this CoCM study, the majority of treatment plans did not require significant change. The recommendations highlight the challenge that non-specialists face in making an accurate mental health diagnosis, the relative neglect of non-pharmacological interventions, and the risk of inappropriate medications. These results can inform interventions to better support non-specialists in rural areas.
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Affiliation(s)
| | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0001 0670 2351grid.59734.3cDepartments of Global Health System Design and Global Health, Internal Medicine, and Pediatrics, Mount Sinai School of Medicine, New York, NY USA ,0000 0001 0670 2351grid.59734.3cArnhold Institute for Global Health, Mount Sinai School of Medicine, New York, NY USA
| | - Lydia Chwastiak
- 0000000122986657grid.34477.33Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Northwest Mental Health Technology Transfer Center, University of Washington, Seattle, WA USA
| | | | - Deepa Rao
- 0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA USA
| | - Sikhar Swar
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0004 0442 6252grid.415089.1Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal ,0000000122986657grid.34477.33Department of Anthropology, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | - Bibhav Acharya
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0001 2297 6811grid.266102.1Department of Psychiatry, University of California, San Francisco, CA USA
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Unützer J, Carlo AD, Collins PY. Leveraging collaborative care to improve access to mental health care on a global scale. World Psychiatry 2020; 19:36-37. [PMID: 31922696 PMCID: PMC6953542 DOI: 10.1002/wps.20696] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Washington, WA, USA
| | - Andrew D. Carlo
- Department of Psychiatry and Behavioral Sciences, University of Washington, Washington, WA, USA
| | - Pamela Y. Collins
- Department of Psychiatry and Behavioral Sciences, University of Washington, Washington, WA, USA,Department of Global Health, University of Washington, Washington, WA, USA
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20
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Kumar A, Schwarz D, Acharya B, Agrawal P, Aryal A, Choudhury N, Citrin D, Dangal B, Deukmedjian G, Dhimal M, Dhungana S, Gauchan B, Gupta T, Halliday S, Jha D, Kalaunee SP, Karmacharya B, Kishore S, Koirala B, Kunwar L, Mahar R, Maru S, Mehanni S, Nirola I, Pandey S, Pant B, Pathak M, Poudel S, Rajbhandari I, Raut A, Rimal P, Schwarz R, Shrestha A, Thapa A, Thapa P, Thapa R, Wong L, Maru D. Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal. BMJ Glob Health 2019; 4:e001343. [PMID: 31139453 PMCID: PMC6509610 DOI: 10.1136/bmjgh-2018-001343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/02/2019] [Accepted: 04/06/2019] [Indexed: 11/29/2022] Open
Abstract
Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.
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Affiliation(s)
- Anirudh Kumar
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Ariadne Labs, Harvard T H Chan Schoo of Public Health and Brigham and Women's Hospital, Boston, MA, United States
| | - Bibhav Acharya
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | | | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
| | | | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Anthropology, University of Washington, Seattle, WA, United States
- Henry M Jackson School of International Studies, University of Washington, Seattle, WA, United States
| | | | - Grace Deukmedjian
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, Natividad Medical Center, Salinas, CA, United States
| | | | | | - Bikash Gauchan
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal
- Henry M Jackson School of International Studies, University of Washington, Seattle, WA, United States
| | - Dhiraj Jha
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
| | - SP Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal
- College of Business and Leadership, Eastern University, St Davids, PA, USA
| | - Biraj Karmacharya
- Department of Community Programs, Dhulikhel Hospital-Kathmandu University Hospital, Dhulikhel, Nepal
- Nepal Technology Innovation Center, Kathmandu University, Dhulikhel, Nepal
- Sun Yat-sen Global Health Insititute, Sun Yat-sen University, Guangzhou, China
| | - Sandeep Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Young Professionals Chronic Disease Network, New York, NY, United States
| | - Bhagawan Koirala
- Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal
| | - Lal Kunwar
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stephen Mehanni
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Gallup Indian Medical Center, Gallup, NM, United States
| | - Isha Nirola
- Harvard University T H Chan School of Public Health, Boston, MA, USA
| | | | - Bhaskar Pant
- Department of Orthopedic and Trauma, Hospital for Advanced Medicine and Surgery, Kathmandu, Nepal
| | | | | | | | | | - Pragya Rimal
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Brigham and Women's Hospital Department of Medicine, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Archana Shrestha
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, MA, USA
- Division of Research and Development, Dhulikhel Hospital, Dhulikhel, Nepal
| | | | - Poshan Thapa
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Lena Wong
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Tuba City Regional Health Care, Tuba City, AZ, United States
| | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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21
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Swar S, Rimal P, Gauchan B, Maru D, Yang Y, Acharya B. Delivering Collaborative Care in Rural Settings: Integrating Remote Teleconsultation and Local Supervision in Rural Nepal. Psychiatr Serv 2019; 70:78-81. [PMID: 30220241 PMCID: PMC7718719 DOI: 10.1176/appi.ps.201800273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians' low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist's recommendations and the site's capacity to implement them.
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Affiliation(s)
- Sikhar Swar
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
| | - Pragya Rimal
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
| | - Bikash Gauchan
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
| | - Duncan Maru
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
| | - Yanjie Yang
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
| | - Bibhav Acharya
- Possible, Achham, Nepal (Swar, Rimal, Gauchan, Maru, Acharya); Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal (Swar); Department of Health Systems and Global Health, Icahn School of Medicine at Mt. Sinai, New York City (Maru); Department of Psychiatry, University of Calfornia, San Francisco (Acharya); Department of Medical Psychology, Public Health College, Harbin Medical University, Harbin, China (Yang)
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