PREMIUM

PRogram for Effective Mental health Interventions in Under-resourced health systeMs

Objectives:

• To define the steps of a systematic methodology for the development of new psychological treatment for delivery by community or lay health workers (CLHW).
• To test this methodology in the development of treatment for Depressive Disorder (DD) and Alcohol Use Disorders (AUD).
• To evaluate the clinical benefit and cost effectiveness of the resulting treatments.
• To develop a framework for scaling up psychological treatment delivered by CLHW.

Background:

Depression and Alcohol Use Disorders are important public health problems worldwide with high prevalence rates, high levels of disability and potentially fatal consequences through suicide, road traffic accidents or health complications such as liver cirrhosis. Psychological treatments such as Cognitive Behavior Therapy for Depression and Motivational Interviewing for Alcohol Use Disorders have been shown to be effective in “western” settings. The vast majority of people who live in low and middle income countries (LAMIC) do not have access to these psychological treatments. The main reasons for this are the lack of skilled personnel for delivering treatments and concerns regarding the acceptability of treatments developed in ‘western’ cultural settings. PREMIUM will address these challenges by developing culturally appropriate psychological treatments for delivery by non-specialist health workers in primary health care settings.

Project Framework (Activities):

 
PREMIUM activities will comprise three overlapping phases, which will be followed for each disorder.  These are: A) Development of psychological treatments in a systematic process including reviewing the existing knowledge, consultation with experts and persons affected by the two disorder, and pilot studies in primary health care; B) Randomized controlled trials to evaluate the impact of the treatments on health and socio-economic outcomes; and C) Dissemination and planning for scale-up of the treatments through public health systems. 
 

PREMIUM has just completed its formative phase (October 2010-April 2012). Literature review was conducted to synthesize and update the existing international evidence for PTs. This was followed by a review of the regional literature for PTs and interviews with patients, families and health care providers in India. These were undertaken in order to identify the full range of specific components for treatment of the target disorders, including those that were likely to be contextually appropriate. Next, the identified treatment strategies were rated for their acceptability and feasibility, effectiveness and safety when delivered by counsellors by a group of mental health experts and counsellors in India. The short listed strategies were then presented to the Investigators Group at an Intervention Design Workshop held in London in September 2011in order to organise these treatment strategies into an organised PT package. The key outputs of this workshop were: (1) identification of core intervention packages for the two disorders: Motivational Interviewing (MI) for Alcohol Use Disorders (AUD) and Behaviour Activation (BA) for Depressive Disorders (DD); and (2) a number of other strategies were identified which may improve the acceptability and feasibility, and potentially the effectiveness, of these core packages in the Indian context.


 Four workshops were held with mental health experts (two at Chennai, one at the Schizophrenia Research Foundation (SCARF) and the other at TT Krishanammachari Deaddiction Institute; and two at the National Institute of Mental Health and Neurological Sciences (NIMHANS), Bangalore). The objectives of these workshops were to: refine the list of strategies identified for treating AUD and DD and organise them to form a coherent PT and phases of treatment delivery and to define desirable characteristics of counsellors and the competencies that would be needed by them to deliver the PT; explore training and supervision requirements to develop these competencies; and understand the likely barriers and challenges in counsellors delivering the PT and ways of overcoming these.  
Clinical case studies were undertaken simultaneously to explore the acceptability and feasibility of the PTs and to understand potential adaptations to the manuals that need to be made to enable their delivery in the study settings. The case studies were conducted by clinicians from both sites who have been trained in the PTs. Based on these activities, a preliminary treatment integrating these various adaptations has been developed which will now be tested for its acceptability and feasibility when delivered by counsellors to patients attending primary care clinics.
 

 The major outputs of PREMIUM will be:

1) New psychological treatments delivered by non-specialist health workers for Depression and Alcohol use Disorders 
2)  A systematic methodology for the development of psychological treatments for delivery by non-specialist health workers in routine care settings which integrates global and local knowledge

Read more in our brochure