Integrating a Stepped Care Model of Screening and Treatment for Depression into Malawi's National HIV Care Delivery Platform

将抑郁症筛查和治疗的阶梯式护理模式纳入马拉维国家艾滋病毒护理服务平台

• 批准号: 10426113
• 负责人: Ryan K McBain
• 金额: $ 59.56万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-07-01 至 2025-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10426113
• 关键词: Accounting; Address; Adherence; Adult; Affect; Africa South of the Sahara; Aftercare; Antidepressive Agents; Blood Pressure; Caring; Chronic Care; Clinic; Cluster randomized trial; Collaborations; Cost Effectiveness Analysis; Country; Diabetes Mellitus; Effectiveness; Emotional; Enrollment; Epidemic; Evaluation; Financial Support; Funding; Gold; HIV; Health; Health care facility; Household; Human Resources; Hypertension; Incidence; Individual; Infrastructure; Institutes; Institution; International; Intervention; Interview; Investments; Lead; Major Depressive Disorder; Malaria; Malawi; Maps; Measures; Mental Depression; Mental Health; Mental disorders; Mentorship; Methods; Modeling; Outcome; Output; Participant; Patient Care; Patients; Perception; Phase; Prevalence; Protocols documentation; Provider; Randomized; Research; Screening procedure; Services; Time; Training; Uganda; Universities; Viral; Viral Load result; Work; World Health Organization Disability Assessment Schedule; base; burden of illness; care burden; care delivery; care systems; comorbidity; cost; cost effective; cost effectiveness; cost estimate; depression model; depressive symptoms; design; diagnostic tool; disability; economic impact; effectiveness evaluation; effectiveness measure; evidence base; experience; feasibility research; follow-up; functional disability; human capital; improved; infectious disease treatment; informant; low and middle-income countries; member; physical conditioning; post intervention; primary outcome; problem solving therapy; programs; response; scale up; screening; secondary outcome; service delivery; success; symposium; systolic hypertension; tool; treatment effect

PROJECT SUMMARY This proposal brings together leading experts on mental health and HIV service delivery from top US and Malawian institutions, including the Malawian Ministry of Health (MOH), to evaluate the effectiveness and cost-effectiveness of an evidence-based stepped model of depression care integrated into Malawi's national HIV platform. Malawi has the 9th highest HIV prevalence in the world, and the 2nd lowest GDP per capita. Additionally, depression is a leading cause of disability but remains untreated in over 90% of cases. Lack of cost-effective, scalable solutions is a fundamental barrier. Against this backdrop, one major success has been the scale-up of a network of 709 HIV clinics, with over half a million patients enrolled in ART. As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care, and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. Members of the research team have already successfully piloted this model in a neighboring district, demonstrating feasibility, acceptability and preliminary efficacy. Moreover, the team has already integrated treatment for other non-communicable diseases such as hypertension and diabetes into the HIV care system of Neno District, Malawi. Additionally, team members have successfully integrated depression care into HIV services in similar settings (Uganda) and instituted depression care models such as Problem Solving Therapy (PST) in settings throughout sub-Saharan Africa, in addition to conducting formative work on depression prevalence, screening and diagnostic tools in Malawi. Building from this, we will evaluate a gold standard stepped model of depression care that combines group-based PST with antidepressant therapy (ADT) in n=420 patients with moderate/severe depression (PHQ-9>10), following a stepped wedge cluster randomized design in which 14 facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g. HIV: viral load, ART adherence; diabetes: A1C levels; hypertension: systolic blood pressure) will be measured every three months, inclusive of baseline, pre-treatment, post-treatment (3 months), 6- and 12 months follow-up. We will also evaluate the model's suitability for national scale-up from three perspectives: cost-effectiveness, feasibility and research capacity. Cost-effectiveness will examine direct treatment effects on depressive symptoms, as well as indirect benefits on (a) comorbid conditions, and (b) burden of care among household members of participants. Feasibility will be assessed through key informant interviews with n=20 study participants and n=10 providers. Research capacity will be supported through (i) a university course and field placement instituted in Years 3-5, (ii) a local research mentorship program, and (iii) a training protocol on the depression care package, inclusive of evaluation tools, for national dissemination launched in Year 5.

项目概要 该提案汇集了来自美国和美国顶尖心理健康和艾滋病毒服务提供方面的领先专家。 马拉维机构，包括马拉维卫生部 (MOH)，评估有效性和 将基于证据的抑郁症护理阶梯模型纳入马拉维的成本效益 国家艾滋病毒平台。马拉维的艾滋病毒感染率在世界上排名第九，人均国内生产总值排名第二低 资本。此外，抑郁症是导致残疾的主要原因，但 90% 以上的病例仍未得到治疗。 缺乏具有成本效益、可扩展的解决方案是一个根本障碍。在此背景下，取得了重大成功 扩大了由 709 个 HIV 诊所组成的网络，超过 50 万患者参加了 ART。作为一个 慢性病护理系统拥有专门的人力资源和基础设施，这为慢性病护理系统提供了一个战略平台 整合抑郁症护理，并对概述双向性的强有力的证据基础做出反应 抑郁症和艾滋病毒结果。研究团队的成员已经成功地在 邻近地区，论证了可行性、可接受性和初步成效。此外，团队还拥有 已经将高血压、糖尿病等其他非传染性疾病的治疗纳入 马拉维尼诺区的艾滋病毒护理系统。此外，团队成员已成功整合抑郁症 在类似的环境中（乌干达）将护理纳入艾滋病毒服务，并建立了抑郁症护理模式，例如问题 除了开展以下方面的形成性工作外，还在撒哈拉以南非洲地区开展解决疗法（PST）： 马拉维的抑郁症患病率、筛查和诊断工具。以此为基础，我们将评估黄金 抑郁症护理的标准阶梯模型，将基于团体的 PST 与抗抑郁治疗相结合 (ADT) 在 n=420 名中度/重度抑郁症患者 (PHQ-9>10) 中进行，遵循阶梯式楔形簇 随机设计，其中 14 个设施被随机分配，在 15 个月内分五个步骤实施该模型 时期。主要结局（抑郁症状、功能障碍和整体健康状况）和次要结局 结果（例如 HIV：病毒载量、ART 依从性；糖尿病：A1C 水平；高血压：收缩压） 每三个月测量一次，包括基线、治疗前、治疗后（3 个月）、6-和 12个月随访。我们还将从三个角度评估该模型在全国范围内的适用性： 成本效益、可行性和研究能力。成本效益将检查直接治疗效果 抑郁症状，以及对 (a) 共存疾病和 (b) 护理负担的间接益处 参与者的家庭成员。将通过关键知情人访谈（n=20）来评估可行性 研究参与者和 n=10 名提供者。研究能力将通过（i）大学课程和 第 3-5 年设立的实地实习，(ii) 当地研究指导计划，以及 (iii) 培训协议 第 5 年推出的抑郁症护理包，包括评估工具，用于全国传播。