World Psychiatry ( IF 73.3 ) Pub Date : 2023-09-15 , DOI: 10.1002/wps.21114 Mark van Ommeren 1 , Sian Lewis 1 , Edith Van't Hof 1 , Kenneth Carswell 1
Task-sharing – in which specialists train, supervise and support non-specialist health care providers – is proven to be acceptable, feasible and effective in scaling up mental health care for depressive and anxiety disorders1. In this perspective, we focus on reasons for and barriers to task-sharing of psychological interventions in primary health care. We also cover what the World Health Organization (WHO) does to address these barriers.
Task-sharing in primary health care is vital to increase treatment coverage for people in need, but it rarely includes providing evidence-based psychological interventions. Yet research shows that cognitive-behavioral therapy (CBT), on its own or combined with antidepressants, is the first-line treatment for adult depressive disorders2. CBT is also first-line treatment for other conditions, including anxiety disorders. Several other psychological therapies – such as interpersonal, problem solving and behavioral activation therapies – are likely equally effective3.
Many evidence-based psychological interventions are well suited to task-sharing. They can be designed to be safely delivered by supervised non-specialists. They can be adjusted to be briefer and less resource-intensive than conventional psychotherapy, without being less effective1. And they can be adapted for remote or group delivery or provided through guided or unguided self-help manuals, websites and applications. WHO's Problem Management Plus, for example, comprises just five weekly sessions, can be delivered to individuals or groups, and is suitable for many contexts, types of adversity and types of helpers4.
Despite their potential, psychological interventions are rarely provided at scale5. Yet scale up is possible. The National Mental Health Programme in Lebanon is showing that implementing a nationwide self-help intervention for depression is feasible, even amid multiple crises1, 6.
- Lack of political support. Despite the evidence, decision-makers in many countries remain unaware of the effectiveness of psychological interventions and so exclude them from universal health coverage packages of essential services and financial protection schemes.
- Resistance to change. Still some psychologists today – including some national psychological associations – are against sharing responsibility for delivering psychological treatments with non-specialists. The reality though is that no society, however rich, will ever have enough specialists to offer more than a fraction of the volume of care required to help the large numbers of people who need mental health interventions.
- Little commercial incentive. Despite their cost-effectiveness, there is little commercial incentive to make psychological interventions widely available. By comparison, pharmacological interventions are heavily promoted by pharmaceutical companies, which may influence decision-makers and medical staff to focus on drug treatments6.
- Lack of human resources. Task-sharing for psychological interventions in primary health care typically means recruiting and retaining additional (non-specialist, community-based) staff to deliver those interventions. This is needed since medical staff in primary health care typically have heavy workloads and, while they can refer people for psychological interventions, they rarely have time to deliver lengthy therapeutic sessions themselves.
- Lack of financial resources. Funding a national workforce of providers, trainers and supervisors demands larger mental health budgets than are currently available. This means that more funds must be allocated within health budgets or, importantly, from the state treasury.
- Lack of access to relevant tools. Too few proven psychological intervention manuals for non-specialists are freely available (open access)7.
- Lack of operational guidance. Apart from the Design, Implementation, Monitoring and Evaluation (DIME) manuals8, there is little international guidance on how to integrate psychological interventions in primary health care. Even if service planners want to add those interventions to their services, they may not know what steps, service models and resources they need.
Building on the work of many others, the WHO is addressing a range of these barriers. We recommend psychological interventions and promote task-sharing through our Comprehensive Mental Health Action Plan 2013-2030, our mhGAP programme, our Universal Health Coverage (UHC) compendium and our World Mental Health Report1. We develop, test and publish open access diverse psychological interventions that are scalable and suit different delivery models. And we support training and supervision tools to help assure a competent non-specialist workforce through our Ensuring Quality in Psychological Support (EQUIP) initiative9.
We are also finalizing a new, operational guide – a Psychological Interventions Implementation Manual – to help service planners and programmers add psychological interventions to their services. Written for managers and others responsible for planning and implementing services, this manual provides practical guidance on how to plan, prepare and provide psychological interventions within existing services, such as health, social or education services.
This new WHO manual advises service planners on how to: a) choose and adapt psychological interventions to be relevant for their specific settings; b) decide a setting and system for delivery, including linking to associated services; c) develop a competent workforce by selecting, training, assessing and supervising providers; d) identify potential service users, assess their support needs and ensure people get the care they need; and e) use monitoring and evaluation to evaluate and improve the service provided.
The manual marks the latest addition to our toolbox for psychological interventions. After publication, it will be field-tested and refined.
Service planners can now freely access all the resources they need to implement psychological interventions: intervention manuals, tools to support competence, and operational guidance for implementation. The next big step is to get these resources into use. Ultimately, this work is intended to help improve the quality and local availability of evidence-based mental health care, so that millions more people with depression and anxiety will be effectively helped.
中文翻译：
将心理干预放在初级卫生保健的首位
事实证明，任务共享——专家对非专业医疗保健提供者进行培训、监督和支持——在扩大抑郁症和焦虑症的心理保健方面是可接受的、可行的和有效的1。从这个角度来看，我们重点关注初级卫生保健中心理干预任务分担的原因和障碍。我们还介绍了世界卫生组织 (WHO) 为解决这些障碍所做的工作。
初级卫生保健中的任务分担对于增加有需要的人的治疗覆盖率至关重要，但它很少包括提供基于证据的心理干预措施。然而研究表明，认知行为疗法 (CBT)，无论是单独使用还是与抗抑郁药物联合使用，都是成人抑郁症的一线治疗方法2。CBT 也是治疗其他疾病（包括焦虑症）的一线治疗方法。其他几种心理疗法——例如人际关系疗法、问题解决疗法和行为激活疗法——可能同样有效3。
许多基于证据的心理干预措施非常适合任务分担。它们可以设计为由受监督的非专业人员安全地交付。与传统心理治疗相比，它们可以调整得更简短、资源占用更少，但效果却不会降低1。它们可以适应远程或团体交付，或者通过引导或非引导的自助手册、网站和应用程序提供。例如，世卫组织的问题管理加强版仅包括每周五次会议，可以向个人或团体提供，并且适合多种情况、逆境类型和帮助者类型4。
尽管心理干预具有潜力，但很少提供大规模的5。但扩大规模是可能的。黎巴嫩国家心理健康计划表明，即使在多重危机中，在全国范围内实施抑郁症自助干预措施也是可行的1, 6。
- 缺乏政治支持。尽管有证据，许多国家的决策者仍然没有意识到心理干预措施的有效性，因此将其排除在全民健康覆盖基本服务和财务保护计划之外。
- 抵制变革。今天仍然有一些心理学家——包括一些国家心理学协会——反对与非专业人士分担提供心理治疗的责任。但现实是，无论社会多么富有，都无法拥有足够的专家来提供超过所需护理量的一小部分来帮助大量需要心理健康干预的人。
- 商业激励很少。尽管心理干预具有成本效益，但几乎没有商业动机来广泛应用心理干预。相比之下，制药公司大力提倡药物干预，这可能会影响决策者和医务人员专注于药物治疗6。
- 缺乏人力资源。初级卫生保健中心理干预的任务分担通常意味着招募和保留额外的（非专业、社区）工作人员来提供这些干预措施。这是必要的，因为初级卫生保健的医务人员通常工作量很大，虽然他们可以转介人们进行心理干预，但他们很少有时间自己提供冗长的治疗课程。
- 缺乏财力。为全国的提供者、培训师和监督人员队伍提供资金需要比目前更多的心理健康预算。这意味着必须在卫生预算中分配更多资金，或者更重要的是从国库中分配更多资金。
- 无法访问相关工具。可供非专业人士免费使用（开放获取）的行之有效的心理干预手册太少7。
- 缺乏操作指导。除了设计、实施、监测和评估（DIME）手册8之外，关于如何将心理干预纳入初级卫生保健的国际指导很少。即使服务规划者想要将这些干预措施添加到他们的服务中，他们也可能不知道他们需要哪些步骤、服务模型和资源。
世界卫生组织在许多其他人的工作的基础上，正在解决一系列这些障碍。我们通过《2013-2030 年综合心理健康行动计划》、我们的 mhGAP 计划、我们的全民健康覆盖 (UHC) 纲要和世界心理健康报告1推荐心理干预措施并促进任务分担。我们开发、测试和发布开放获取的多样化心理干预措施，这些干预措施可扩展并适合不同的交付模式。我们还支持培训和监督工具，通过我们的“确保心理支持质量”(EQUIP) 计划9来帮助确保拥有一支有能力的非专业劳动力队伍。
我们还正在敲定一份新的操作指南——心理干预实施手册——以帮助服务规划者和程序员在他们的服务中添加心理干预。本手册为负责规划和实施服务的管理者和其他人员编写，提供了如何在现有服务（例如健康、社会或教育服务）中规划、准备和提供心理干预的实用指导。
这份新的世卫组织手册就如何以下方面向服务规划者提供建议： a) 选择和调整心理干预措施，使其适合其具体环境；b) 决定交付的设置和系统，包括链接到相关服务；c) 通过选择、培训、评估和监督提供者来培养一支有能力的员工队伍；d) 识别潜在的服务使用者，评估他们的支持需求并确保人们得到他们需要的护理；e) 使用监控和评估来评估和改进所提供的服务。
该手册标志着我们心理干预工具箱的最新补充。发布后，将进行实地测试和完善。
服务规划者现在可以自由地获取实施心理干预所需的所有资源：干预手册、支持能力的工具以及实施的操作指南。下一个重要步骤是让这些资源投入使用。最终，这项工作旨在帮助提高循证精神卫生保健的质量和当地的可及性，从而使数以百万计的抑郁症和焦虑症患者得到有效的帮助。
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