Rethinking the service delivery system of psychological interventions in low and middle income countries
To date, much of the research and implementation of mental health interventions in
LMIC has followed an approach similar to some high-income countries (HIC). Mental
health in HIC is often trained and delivered via “silos” for certain symptoms and/or
severities. For example, a designated clinic may treat a particular problem (e.g.,
a clinic for substance use), and/or have a group of counselors that each has expertise
in treating certain disorders. This “silo” model requires a complex system of triage,
referrals, and extensive well-trained personnel. It necessitates accurate assessment,
followed by referral to either: (a) specific providers depending on the problem, (b)
a provider who had trained on and mastered multiple EBTs, or (c) another clinic that
specializes in a particular problem or severity (e.g., anxiety disorder clinic, psychiatric
clinic).
Many randomized controlled trials in LMIC that have shown strong effectiveness on
mental health symptomatology have evaluated interventions that originated from high-income
settings (e.g., IPT; Cognitive Processing Therapy, CPT) and that are disorder-specific
(i.e., they were designed and tested to treat one primary disorder) 15]–23]. Within these trials, a group of lay providers may be trained to treat depression,
for example, but would not know how to address trauma, anxiety or other comorbid or
common mental health symptoms. The implication of this is that either: (a) the same
lay service providers are required to (eventually) be competent in multiple different
interventions to serve at a population level, or (b) each provider would have a specialty
to only treat one disorder, and therefore many different providers and referral links
would be needed.
We suggest that the segregation of services into “silos”, either related to symptoms/diagnoses
or severity, increases the barriers to scale-up and sustainability in LMIC and hinders
the ability to reduce the treatment gap. (See Additional file 1: Figure S1) First, having disorder specific interventions suggests (and requires
to a degree) a “fit” into Western diagnostic categories as exemplified in the Diagnostic
and Statistic Manual (DSM) and International Classification of Disorders (ICD), which
some argue is questionable cross-culturally 31], 38], 39]. Second, comorbidity is the rule – not the exception – along with other problems
that can affect the course of intervention (e.g., relationship problems), although
these may not meet a diagnostic category. As Weisz (2015) 39] puts it, “stated simply, most EBTs are more narrowly focused, and more linear in
design, than the everyday clinical practice they are designed to enhance”. Third,
with task-shifting being advocated as a strategy to address limited human resources
in LMIC 34], 40], it is questionable whether this approach is feasible for ultimate scale-up and sustainability
since it would require either large numbers of lay providers each focused on a particular
mental health problem or that individuals with limited education learn multiple EBT.
Both of these would be difficult with task-sharing. Finally, silo’ed care requires
options for referral to other providers or settings that are rarely available in many
lower resource settings.
A different delivery system conceptualization
To more effectively reap the benefits of science to practice and scale up of EBTs,
a different mental health systems approach may be needed in certain contexts. We suggest
consideration of an “internal stepped care model” that allows for the same non-professional service provider (or
number of providers) to navigate between different intervention elements based on
the severity (i.e. continuous from low to moderate-to-severe) and type of problems
(i.e. diverse symptom clusters focused on common mental disorders) of the client.
Based on navigating common elements
Common elements approaches, also known as transdiagnostic, are increasingly being
used, studied and suggested as an alternative way to approach mental health scale
up 37], 41]–44]. A common elements approach is derived from research showing that most EBTs are actually
comprised of many of the same elements or components 42]. In this way, elements are taught (rather than a particular manual), including how to combine them to use
for different symptoms and severity levels 43], 44]. Therefore, providers need be trained in only one approach (consisting of common elements and their flexible use), and each provider
would be able to treat a range of presenting problems as well as varying severities
of common mental health problems depending on the transdiagnostic approach taught
(e.g., depression, trauma, anxiety, externalizing symptoms, substance use).
Data on effectiveness of common element approaches is emerging both in high-income
countries and LMIC. In the United States and Europe, studies are showing positive
results across both adult 45]–49] and child populations 50]. These approaches are performing at or better than single disorder treatments. However,
this work in HIC has been done by mental health professionals. Thus, a significant
question about the use of common elements approaches in LMIC is if non-professional
providers can be trained to select elements based on the needs of a client, both in
terms of severity and type of problem and deliver them adequately. The desire to use
a common elements approach for scale-up and sustainability would be a mute point if
non-professional providers with limited education could not learn the multiple elements
included in the approach, and know how to put them together for a range of client
presentations.
A modular common elements approach was developed specifically for LMIC that was based
off current research in the United States with MATCH and the Unified Protocol (UP),
45], 50] but with a reduced number of elements and simplified decision rules to account for
the training of non-professionals (Common Elements Intervention Approach or CETA)
37]. Briefly, CETA developers utilized distillation research 51] and consultation with developers of multiple evidence-based treatments in an attempt
to choose the most frequently used elements, and those that seemed to be the “mechanism
of action”. Two trials (Iraq and Thailand/Myanmar border) on adult populations that
were trauma-affected were completed with CETA – both showing strong effectiveness
on symptoms of depression, trauma and anxiety with effect sizes 1) 52], 53]. In Iraq, CETA performed better than single disorder treatments. One open trial of
CETA for youth was completed in Ethiopia with significant results 54]. Although more studies are needed, these studies suggest that: (1) para-professionals
are able to learn a simplified common elements approach (inclusive of 9 elements only)
with an apprenticeship model of training and ongoing supervision 55], and, (2) that the elements chosen for CETA were collectively as effective or more
for comorbid presentations in comparison to single disorder treatments or control
conditions.
It is important to note that CETA, MATCH, CBT-E, and UP are examples of common elements
approaches that could make an internal stepped care model possible. Although these
transdiagnostic treatments utilize CBT-based elements, other elements could be utilized,
as long as there was evidence supporting them from rigorous research in accordance
with current guidelines on best practices 4], 25].
A common elements approach allows for an internal stepped care model (Fig. 1), which is an attempt to address some of the challenges of implementation, reach,
scale-up and sustainability of mental health programs in LMIC. In practice, a service
provider could be trained in a common elements approach and learn how to put elements
together for different common mental health disorders. Upon assessment, this one provider
could decide to start with a smaller set of elements due to lower symptoms, and only
add elements if there were sustained problems. Alternatively, upon assessment, a provider
may note moderate to severe symptoms and choose an order of elements indicated for
the presenting problems based on existing EBT. In either case the service provider
would be able to add elements and/or dose of elements based on need and client response.
This flexibility, within fidelity to the evidence base, allows the same single provider
to address a wide range of problems and severities, and provide only what the client
needs based on symptom presentation throughout.
Fig. 1. Internal Stepped Care Approach
To our knowledge, CETA is the only common elements approach that has been tested in
LMIC. Nonprofessionals were successfully trained in the choice patterns discussed
above by learning to gleam information from three “data points” throughout treatment:
1) assessment form (client self-report), 2) what the client does and says directly,
and 3) consultation with a supervisor. This helps determine what the main problems
are of the client. There was not a focus on “diagnoses” as one would in Western psychiatry.
Changes could be made to the element choice and dose based on these three information
sources throughout treatment. This is one example of how non-professionals could be
taught. More research is needed on how well and with how much support non-professional
counselors are able to adequately assess the severity and core problems to address
in a range of clients.
How is this different from a stepped care approach?
Stepped care models advocate moving from lower-intensity and least restrictive interventions
to higher-intensity and more restricted access interventions based on the lack of
desired effect of the previous level of care, 56] generally moving from one service provider or organization to the next. One challenge
with this type of stepped care approach in lower-resourced settings is the inherent
assumption that there is a “next step” if someone does not respond to the first step of intervention. In most
LMIC, there are not enough mental health professionals or even lay providers trained
in any EBT that could offer services for moderate to severe common mental disorders.
In our proposed model, this transfer still happens but within one provider utilizing one approach. The individual could still begin by providing a brief intervention
that requires fewer health care resources, but would then be capable of providing
ongoing services if the desired intervention benefits were not obtained. The internal
stepped care model reduces the need for different groups or levels of provider types,
and different specialized settings, which may not be possible in some LMIC settings.
A related challenge with a traditional stepped care model is that it usually includes
referral points (from low to high, or across problem area). Every referral point where
a client needs to change providers or locations increases the likelihood of them being
“lost”. Imagine a depressed client who rarely leaves the house, finally making it
into a clinic in a low resource area. After a likely long wait and being screened,
the lay provider says they do not treat these types of symptoms (e.g., a primary health
care worker is insufficiently trained to provide psychological treatments). Although
a referral is made, it is quite likely that this client will not make the next referral
appointment perhaps due to depressive symptoms, or other reasons such as distance
or stigma.
Next steps to consider
There are numerous research questions that could help determine whether an internal
stepped care delivery system is truly beneficial and feasible. First, understanding
more about what common elements are needed and used, at what levels of symptomatology,
with which symptom clusters, and the doses needed for symptom reduction would further
refine the use of common elements approaches. Secondly, although research suggests
that clinical decision-making within a common elements approach is possible for para-professionals,
52], 53] this model adds variation in symptom presentation and severity beyond these particular
studies. Evaluation of the training and supervision needed for an internal stepped
care delivery system will be critical. This might include evaluation of key indicators
of competency 57] or capacity of trainees in clinical decision making, as well as the amount of resources
needed to obtain “adequate” skill levels. Third, common elements approaches have yet
to be evaluated in groups – which is a delivery system of interest in many LMIC. Learning
how flexibility of element choice and dose fits into group models will need to be
studied. Finally, this internal stepped care model is a service delivery framework
that addresses some of the known challenges with broader implementation and sustainability
of effective mental health interventions. However, it will be important to assess
what settings this may or may not work within. Implementation constructs including
cost-effectiveness, feasibility, acceptability, and appropriateness will need to be
assessed, as well as who provides services and to what degree, to what types and severity
of populations.