Can General Practitioners manage mental disorders in primary care? A partially randomised, pragmatic, cluster trial.

Publisher: Public Library of Science Country of Publication: United States NLM ID: 101285081 Publication Model: eCollection Cited Medium: Internet ISSN: 1932-6203 (Electronic) Linking ISSN: 19326203 NLM ISO Abbreviation: PLoS One Subsets: MEDLINE

Original Publication: San Francisco, CA : Public Library of Science

General Practitioners* ; Primary Health Care*; Mental Disorders/*therapy; Adult ; Female ; Humans ; Male ; Mental Disorders/diagnosis ; Patient Dropouts ; Regression Analysis ; Treatment Outcome

Background: For a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care.
Methods: In this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment. All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ-5D-3L, and resource use and costs evaluated from a health services perspective, at six months.
Results: 153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY.
Conclusion: General Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap.
Trial Registration: ClinicalTrials.gov NCT02700490.
Competing Interests: DS is the Director of the Centre for Public Mental Health (CPMH), Universitas Gadjah Mada. CPMH wholly or partially administered the salary of clinical psychologists co-located in the primary care clinics before 2016. CPMH still provides continuing professional developments for clinical psychologists in the province. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Lancet Psychiatry. 2016 Nov;3(11):1008-1012. (PMID: 27794363)
Soc Sci Med. 2014 Oct;118:33-42. (PMID: 25089962)
BMC Med Res Methodol. 2006 Apr 12;6:17. (PMID: 16611355)
Bull World Health Organ. 2004 Nov;82(11):858-66. (PMID: 15640922)
Perspect Clin Res. 2011 Jul;2(3):109-12. (PMID: 21897887)
Value Health. 2004 Sep-Oct;7(5):518-28. (PMID: 15367247)
Psychol Med. 2015 Jan;45(1):11-27. (PMID: 24569086)
J Gen Intern Med. 2003 Jan;18(1):9-16. (PMID: 12534758)
Lancet. 2007 Sep 29;370(9593):1164-74. (PMID: 17804061)
Int Psychogeriatr. 2013 Apr;25(4):531-48. (PMID: 23206307)
J Clin Psychol Med Settings. 2009 Mar;16(1):101-12. (PMID: 19259793)
Am Psychol. 2014 May-Jun;69(4):443-51. (PMID: 24820692)
BMJ. 2000 Dec 2;321(7273):1383-8. (PMID: 11099284)
Gerontologist. 2002 Jun;42(3):392-8. (PMID: 12040142)
JAMA Intern Med. 2013 May 13;173(9):787. (PMID: 23545699)
Br J Psychiatry. 2001 Jun;178:561-6. (PMID: 11388975)
Lancet. 2006 Feb 11;367(9509):528-9. (PMID: 16473129)
Aust N Z J Psychiatry. 2005 Aug;39(8):719-25. (PMID: 16050926)
Int J Methods Psychiatr Res. 2010 Mar;19(1):1-17. (PMID: 20104493)
Trials. 2016 Feb 11;17:76. (PMID: 26865254)
Br J Psychiatry. 2016 Jan;208 Suppl 56:s21-8. (PMID: 26447173)
Int Rev Psychiatry. 2011;23(1):28-30. (PMID: 21338295)
BMC Med. 2013 Mar 05;11:61. (PMID: 23497243)
J Gen Intern Med. 2002 Oct;17(10):741-8. (PMID: 12390549)
Psychiatr Serv. 2003 May;54(5):698-704. (PMID: 12719501)
Health Econ. 2005 May;14(5):487-96. (PMID: 15497198)
J Telemed Telecare. 2016 Dec;22(8):495-498. (PMID: 27799454)
Value Health. 2016 Dec;19(8):929-935. (PMID: 27987642)
CMAJ. 2008 Apr 22;178(9):1177-80. (PMID: 18427094)
Am J Psychiatry. 2002 Feb;159(2):201-7. (PMID: 11823259)
Int J Ment Health Syst. 2017 Aug 1;11:45. (PMID: 28775764)
Cult Med Psychiatry. 2017 Sep;41(3):453-465. (PMID: 28251478)
Soc Sci Med. 2003 Jan;56(2):299-312. (PMID: 12473315)
Health Psychol Behav Med. 2014 Jan 1;2(1):970-982. (PMID: 25750829)
Evid Based Ment Health. 2018 Feb;21(1):30-34. (PMID: 28903977)
Cochrane Database Syst Rev. 2011 May 11;2011(5):. (PMID: 24143128)
Nurse Res. 2002;9(3):68-84. (PMID: 11985149)
Community Ment Health J. 2018 Jan;54(1):84-91. (PMID: 27900652)
Int J Ment Health Syst. 2017 Oct 12;11:63. (PMID: 29046715)
Psychosomatics. 2002 Jan-Feb;43(1):24-30. (PMID: 11927754)
J Behav Health Serv Res. 2013 Jan;40(1):121-32. (PMID: 23188486)
Health Econ. 2001 Dec;10(8):779-87. (PMID: 11747057)
Clin Trials. 2005;2(2):99-107. (PMID: 16279131)
Ophthalmology. 2013 Mar;120(3):566-573. (PMID: 23211635)
J Fam Pract. 2002 Jun;51(6):540-4. (PMID: 12100778)
Ann Glob Health. 2015 Sep-Oct;81(5):718-24. (PMID: 27036731)
BMC Med Res Methodol. 2011 Jun 30;11:102. (PMID: 21718530)
N Engl J Med. 2016 Aug 4;375(5):454-63. (PMID: 27518663)
BMJ. 2015 May 08;350:h2147. (PMID: 25956159)

ClinicalTrials.gov NCT02700490

Date Created: 20191108 Date Completed: 20200318 Latest Revision: 20200318

20240105

PMC6837310

10.1371/journal.pone.0224724

31697724