Graciela Rojas

Treatment and prevention of mental disorders in low-income and middle-income countries

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial.

BACKGROUND The optimum way to improve the recognition and treatment of postnatal depression in developing countries is uncertain. We compared the effectiveness of a multicomponent intervention with usual care to treat postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile. METHODS 230 mothers with major depression attending postnatal clinics were randomly allocated to either a multicomponent intervention (n=114) or usual care (n=116). The multicomponent intervention involved a psychoeducational group, treatment adherence support, and pharmacotherapy if needed. Usual care included all services normally available in the clinics, including antidepressant drugs, brief psychotherapeutic interventions, medical consultations, or external referral for specialty treatment. The primary outcome measure was the Edinburgh postnatal depression scale (EPDS) score at 3 and 6 months after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00518830. FINDINGS 208 (90%) of women randomly assigned to treatment groups completed assessments. The crude mean EPDS score was lower for the multicomponent intervention group than for the usual care group at 3 months (8.5 [95% CI 7.2-9.7] vs 12.8 [11.3-14.1]). Although these differences between groups decreased by 6 months, EPDS score remained better in multicomponent intervention group than in usual care group (10.9 [9.6-12.2] vs 12.5 [11.1-13.8]). The adjusted difference in mean EPDS between the two groups at 3 months was -4.5 (95% CI -6.3 to -2.7; p<0.0001). The decrease in the number of women taking antidepressants after 3 months was greater in the intervention group than in the usual care group (multicomponent intervention from 60/101 [59%; 95% CI 49-69%] to 38/106 [36%; 27-46%]; usual care from 18/108 [17%; 10-25%] to 11/102 [11%; 6-19%]). INTERPRETATION Our findings suggest that low-income mothers with depression and who have newly born children could be effectively helped, even in low-income settings, through multicomponent interventions. Further refinements to this intervention are needed to ensure treatment compliance after the acute phase.

Education and income: which is more important for mental health?

Study objective: To assess which indicators of socioeconomic status are associated with an increased prevalence of common mental disorders. Design: Cross sectional household survey. Setting: Santiago, Chile. Participants: Random sample of adults aged 16–65 residing in private households. Main results: Less education (odds ratio 2.44, 95% confidence intervals 1.50 to 3.97), a recent income decrease (odds ratio 2.14, 1.70 to 2.70), and poor housing (odds ratio 1.53, 1.05 to 2.23), were the only socioeconomic status variables that remained significantly associated with an increased prevalence of common mental disorders after adjustments. The prevalence of common mental disorders was also higher among people with manual unskilled occupations, overcrowded housing, and lower per capita income but these associations disappeared after adjustment for other explanatory and confounding variables. Conclusions: There is a strong, inverse, and independent association between education and common mental disorders. However, income was not associated with the prevalence of common mental disorders, after adjusting for other socioeconomic variables. Similar results have been found in other Latin American studies but British studies tend to find the opposite, that income but not education is associated with common mental disorders. Understanding the impact of socioeconomic factors on mental health requires research in poor as well as rich countries.

Inequities in mental health care after health care system reform in Chile

OBJECTIVES We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. METHODS We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. RESULTS Among individuals with mental disorders, only 20% (95% confidence interval [CI]=16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity of symptoms, private insurance coverage (odds ratio [OR]=2.72; 95% CI=1.6, 4.6) and higher disability level (OR=1.27, 95% CI=1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. CONCLUSIONS The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision.

School Intervention to Improve Mental Health of Students in Santiago, Chile A Randomized Clinical Trial

IMPORTANCE Depression can have devastating effects unless prevented or treated early and effectively. Schools offer an excellent opportunity to intervene with adolescents presenting emotional problems. There are very few universal school-based depression interventions conducted in low- and middle-income countries. OBJECTIVE To assess the effectiveness of a school-based, universal psychological intervention to reduce depressive symptoms among adolescents from low-income families. DESIGN, SETTING, AND PARTICIPANTS A 2-arm, parallel, cluster, randomized clinical trial was conducted in secondary schools in deprived socioeconomic areas of Santiago, Chile. Almost all students registered in the selected schools consented to take part in the study. A total of 2512 secondary school students from 22 schools and 66 classes participated. INTERVENTIONS Students in the intervention arm attended 11 one-hour weekly and 2 booster classroom sessions of an intervention based on cognitive-behavioral models. The intervention was delivered by trained nonspecialists. Schools in the control arm received the standard school curriculum. MAIN OUTCOMES AND MEASURES Scores on the self-administered Beck Depression Inventory-II at 3 months (primary) and 12 months (secondary) after completing the intervention. RESULTS There were 1291 participants in the control arm and 1221 in the intervention arm. Primary outcome data were available for 82.1% of the participants. There was no evidence of any clinically important difference in mean depression scores between the groups (adjusted difference in mean, -0.19; 95% CI, -1.22 to 0.84) or for any of the other outcomes 3 months after completion of the intervention. No significant differences were found in any of the outcomes at 12 months. CONCLUSIONS AND RELEVANCE A well-designed and implemented school-based intervention did not reduce depressive symptoms among socioeconomically deprived adolescents in Santiago, Chile. There is growing evidence that universal school interventions may not be sufficiently effective to reduce or prevent depressive symptoms. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN19466209.

El Programa Nacional para el diagnóstico y tratamiento de depresión en Atención Primaria: una evaluación necesaria.

Background: Depression is highly prevalent among Chilean adults, therefore a primary care treatment program was devised. Aim: To evaluate the Program for detection, diagnosis and integral treatment of depression, implemented in Chilean Primary Health Care Centers. Material and Methods: A three and six months follow-up study was conducted among women admitted to the program at seven primary health care centers in two regions of Chile. Socio-demographic data, treatments provided and compliance with the program were assessed. A clinical standardized interview (with ICD-10) was carried out and the intensity of depressive symptoms was evaluated using Beck Depression Inventory (BDI). Results: The initial sample was composed by 201 women aged 25 to 65 years. At 6 months, 35% were lost from follow up. Depression was mild, moderate or severe in 12, 63 and 25% of women, respectively. The severity of depression was underestimated by primary care teams. Among women with regular and irregular attendance to medical appointments and those that abandoned treatment, BDIscore decreased by 35,37and 13%, respectively. Conclusions: This primary care program for depression was effective to reduce BDI scores. Diagnostic precision of primary care teams must be improved.

Lessons from scaling up a depression treatment program in primary care in Chile

In Chile, the National Depression Detection and Treatment Program (Programa Nacional de Diagnóstico y Tratamiento de la Depresión, PNDTD) in primary care is a rare example of an evidence-based mental health program that was scaled up to the national level in a low- or middle-income country. This retrospective qualitative study aimed to better understand how policymakers made the decision to scale up mental health services to the national level, and to explore the elements, contexts, and processes that facilitated the decision to implement and sustain PNDTD. In-depth semistructured interviews with six key informants selected through intentional sampling were conducted in August-December 2008. Interviewees were senior officers at the Ministry of Health who were directly involved in the decision to scale up the program. Results yielded four elements pivotal to the decisionmaking process: scientific evidence, teamwork and leadership, strategic alliances, and program institutionalization. Each element contributed to building consensus, securing funding, attracting resources, and gaining lasting support from policymakers. Additionally, a review of available documentation led the authors to consider sociopolitical context and use of the media to be important factors. While research evidence for the effectiveness of mental health services in the primary care setting continues to accumulate, low- and middle-income countries should get started on the lengthy process of scaling up by incorporating the elements that led to decisionmaking and implementation of the PNDTD in Chile.

School-based intervention to improve the mental health of low-income, secondary school students in Santiago, Chile (YPSA): study protocol for a randomized controlled trial.

BackgroundDepression is common and can have devastating effects on the life of adolescents. Psychological interventions are the first-line for treating or preventing depression among adolescents. This proposal aims to evaluate a school-based, universal psychological intervention to reduce depressive symptoms among students aged 13-14 attending municipal state secondary schools in Santiago, Chile.Study designThis is a cluster randomised controlled trial with schools as the main clusters. We compared this intervention with a control group in a study involving 22 schools, 66 classes and approximately 2,600 students. Students in the active schools attended 11 weekly and 3 booster sessions of an intervention based on cognitive-behavioural models. The control schools received their usual but enhanced counselling sessions currently included in their curriculum. Mean depression scores and indicators of levels of functioning were assessed at 3 and 12 months after the completion of the intervention in order to assess the effectiveness of the intervention. Direct and indirect costs were measured in both groups to assess the cost-effectiveness of this intervention.DiscussionAs far as we are aware this is the first cluster randomised controlled trial of a school intervention for depression among adolescents outside the Western world.Trial RegistrationISRCTN19466209

Smoking and common mental disorders : a population-based survey in Santiago, Chile

BackgroundSmoking and common mental disorders (CMD), anxiety and depression, tend to co-exist and are important public health challenges for countries at all levels of development. We aimed to study the association between smoking and common mental disorders after adjusting for alcohol, illicit drug use and other confounders.MethodsCross-sectional household survey. CMD were assessed with a detailed psychiatric interview and smoking, alcohol, and illicit drug use with self-reported questionnaires.ResultsAbout 3,870 randomly selected adults were interviewed of whom 12.9% (95% CI 12–15) met criteria for ICD-10 CMD diagnoses. 38% (36–40) of the respondents were current smokers and 11% (10–13) ex-smokers. There was a robust association between heavier smoking and the presence and severity of CMD. However there were no major differences between non-smokers, ex-smokers and light smokers. In the fully adjusted models those individuals with ICD-10 CMD were significantly more likely to be current smokers [OR 1.6 (1.1–2.2)]. Smoking was also strongly associated with drinking heavily [OR 5.4 (4.0–7.3)] and illicit drug use [(OR 2.1 (1.1–4.1)] but there were no significant interactions.ConclusionsSmoking is highly prevalent and associated with CMD and other addictive behaviours in Chile. These are major public health problems in need of urgent action.

[A randomized trial of pharmacotherapy with telephone monitoring to improve treatment of depression in primary care in Santiago, Chile].

BACKGROUND Depression is a public health problem, due to its high prevalence and its associated disability. AIM To compare a pharmacological intervention for depression controlled by phone from a central level (TM) and the usual treatment (TH) in a randomized clinical trial. MATERIAL AND METHODS Three hundred and forty five women, aged 22 to 59 years were studied. They were randomly assigned to receive the usual therapy or a pharmacological intervention with periodical telephone contacts with medical collaboration personnel, to reinforce compliance with treatment and educate about the disease. Women were blindly evaluated at 3 and 6 months with the Hamilton depression rating score (HDRS) and the SF-36 to assess depressive symptoms and quality of life, respectively. RESULTS In both evaluations, improvement was significantly greater in the TM group than the TH group. At 3 months, improvement was higher in the TM group in the subscales of physical function, pain, general health, energy, emotional role, mental health and standardized physical and psychic scales of SF-36. At 6 months, this significant difference in favour of TM was maintained for energy, mental health and the standardized psychic scale. CONCLUSIONS A telephone reinforcement improves the outcomes of treatments for depression.