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

Autoři: Sabrina Gabrielle Anjara aff001;  Chiara Bonetto aff002;  Poushali Ganguli aff003;  Diana Setiyawati aff004;  Yodi Mahendradhata aff005;  Bambang Hastha Yoga aff005;  Laksono Trisnantoro aff005;  Carol Brayne aff001;  Tine Van Bortel aff001
Působiště autorů: Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom aff001;  Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy aff002;  Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, England, United Kingdom aff003;  Centre for Public Mental Health, Faculty of Psychology, Universitas Gadjah Mada, Yogyakarta, Indonesia aff004;  Centre for Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia aff005
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224724



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.


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.


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.


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 NCT02700490

Klíčová slova:

Cost-effectiveness analysis – Indonesia – Mental health and psychiatry – Nurses – Primary care – Psychological and psychosocial issues – Psychologists – Quality of life


1. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bulletin of the World Health Organization. 2004;82(11):858–66. Epub 2005/01/11.15640922.

2. WHO-SEARO. Developing Country Specific Community-Based Strategies for Reduction of Treatment Gap in Common Neuropsychiatric Conditions. New Delhi, India: World Health Organization, 2004 18–20 November 2004. Report No.

3. Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science and Medicine. 2014;118:33–42. Epub 2014/08/05. doi: 10.1016/j.socscimed.2014.07.057 25089962.

4. Dummer TJ. Health geography: supporting public health policy and planning. CMAJ. 2008;178(9):1177–80. doi: 10.1503/cmaj.071783 18427094.

5. Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Harimurti P, et al. The Republic of Indonesia health system review. Health Systems in Transition India: World Health Organization. 2017.

6. Kessler R, Stafford D. Primary care is the de facto mental health system. Collaborative medicine case studies: Springer; 2008. p. 9–21.

7. Allen C. Peers and partners: a stakeholder evaluation of preceptorship in mental health nursing. Nurse Researcher (through 2013). 2002;9(3):68.

8. Coyne JC, Thompson R, Palmer SC, Kagee A, Maunsell E. Should we screen for depression? Caveats and potential pitfalls. Applied and Preventive Psychology. 2000;9(2):101–21.

9. Sorel E, Everett A. Psychiatry and primary care integration: Challenges and opportunities. International Review of Psychiatry. 2011;23(1):28–30. doi: 10.3109/09540261.2010.549117 21338295

10. Callahan EJ, Bertakis KD, Azari R, Robbins JA, Helms LJ, Leigh JP. Association of higher costs with symptoms and diagnosis of depression. Journal of family practice. 2002;51(6):540–5. 12100778

11. Katon W. Collaborative care: Patient satisfaction, outcomes, and medical cost-offset. Family Systems Medicine. 1995;13(3–4):351.

12. Bao Y, Casalino LP, Pincus HA. Behavioral health and health care reform models: patient-centered medical home, health home, and accountable care organization. The journal of behavioral health services & research. 2013;40(1):121–32.

13. Katon W, Russo J, Von Korff M, Lin E, Simon G, Bush T, et al. Long‐term Effects of a Collaborative Care Intervention in Persistently Depressed Primary Care Patients. Journal of general internal medicine. 2002;17(10):741–8. doi: 10.1046/j.1525-1497.2002.11051.x

14. Caulfield A, Vatansever D, Lambert G, Van Bortel T. World Health Organization Guidance on Mental Health Training: A systematic review of the progress for non-specialist health workers. BMJ Open. 2018;(in press).

15. van Ginneken N, Tharyan P, Lewin S, Rao GN, Romeo R, Patel V. Non-specialist health worker interventions for mental health care in low- and middle- income countries. The Cochrane database of systematic reviews. 2011;2011(5). Epub 2011/05/11. doi: 10.1002/14651858.CD009149 24143128.

16. Dua T, Barbui C, Patel AA, Tablante EC, Thornicroft G, Saxena S, et al. Discussion of the updated WHO recommendations for mental, neurological, and substance use disorders. Lancet Psychiatry. 2016;3(11):1008–12. doi: 10.1016/S2215-0366(16)30184-5 27794363.

17. Keynejad RC, Dua T, Barbui C, Thornicroft G. WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries. Evid Based Ment Health. 2018;21(1):30–4. doi: 10.1136/eb-2017-102750 28903977.

18. Bluestein D, Cubic BA. Psychologists and primary care physicians: A training model for creating collaborative relationships. Journal of Clinical Psychology in Medical Settings. 2009;16(1):101–12. doi: 10.1007/s10880-009-9156-9 19259793

19. Liu C-F, Hedrick SC, Chaney EF, Heagerty P, Felker B, Hasenberg N, et al. Cost-effectiveness of collaborative care for depression in a primary care veteran population. Psychiatric Services. 2003;54(5):698–704. doi: 10.1176/ 12719501

20. Areán PA, Alvidrez J, Barrera A, Robinson GS, Hicks S. Would older medical patients use psychological services? The Gerontologist. 2002;42(3):392–8. doi: 10.1093/geront/42.3.392 12040142

21. Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, et al. Effectiveness of collaborative care depression treatment in Veterans’ Affairs primary care. Journal of General Internal Medicine. 2003;18(1):9–16. doi: 10.1046/j.1525-1497.2003.11109.x 12534758

22. Psikolog PUSKESMAS: Kebutuhan dan Tantangan bagi Profesi Psikologi Klinis Indonesia (Clinical Psychologist in Indonesian Primary Health Care: Opportunities and Challenges) [Internet]. Yogyakarta: Universitas Gadjah Mada; 2011 [cited 22 June 2013].

23. Hass L, deGruy F, Haas L. Primary care, psychology, and primary care psychology. Handbook of primary care psychology. 2004:5–19.

24. Haas LJ. Handbook of primary care psychology: Oxford University Press; 2004.

25. Derksen J. Primary care psychologists in the Netherlands: 30 years of experience. Professional Psychology: Research and Practice. 2009;40(5):493.

26. Elder MQ, Silvers SA. The integration of psychology into primary care: Personal perspectives and lessons learned. Psychological Services. 2009;6(1):68.

27. Setiyawati D, Blashki G, Wraith R, Colucci E, Minas H. Australian experts’ perspectives on a curriculum for psychologists working in primary health care: implication for Indonesia. Health psychology and behavioral medicine. 2014;2(1):970–82. doi: 10.1080/21642850.2014.951937 25750829.

28. Ford I, Norrie J. Pragmatic Trials. N Engl J Med. 2016;375(5):454–63. Epub 2016/08/16. doi: 10.1056/NEJMra1510059 27518663.

29. Gupta SK. Intention-to-treat concept: a review. Perspectives in clinical research. 2011;2(3):109. doi: 10.4103/2229-3485.83221 21897887

30. Priyono JD. Analisis Ketimpangan Pengeluaran Penduduk (Indeks GINI) Daerah Istimewa Yogyakarta 2014–2016. Provinsi Daerah Istimewa Yogyakarta: Badan Pusat Statistik, 2017.

31. Hohmann AA, Shear MK. Community-based intervention research: Coping with the “noise” of real life in study design. American Journal of Psychiatry. 2002;159(2):201–7. doi: 10.1176/appi.ajp.159.2.201

32. Raupach T, Brown J, Anders S, Hasenfuss G, Harendza S. Summative assessments are more powerful drivers of student learning than resource intensive teaching formats. Bmc Medicine. 2013;11. Artn 61. doi: 10.1186/1741-7015-11-61 23497243

33. Goldberg D, Williams P. General health questionnaire (GHQ). Swindon, Wiltshire, UK: nferNelson. 2000.

34. Loudon K, Treweek S, Sullivan F, Donnan P, Thorpe KE, Zwarenstein M. The PRECIS-2 tool: designing trials that are fit for purpose. BMJ. 2015;350:h2147. Epub 2015/05/10. doi: 10.1136/bmj.h2147 25956159.

35. van den Brink AM, Gerritsen DL, Voshaar RCO, Koopmans RT. Residents with mental–physical multimorbidity living in long-term care facilities: prevalence and characteristics. A systematic review. International psychogeriatrics. 2013;25(4):531–48. doi: 10.1017/S1041610212002025

36. Lyketsos CG, Dunn G, Kaminsky MJ, Breakey WR. Medical comorbidity in psychiatric inpatients: relation to clinical outcomes and hospital length of stay. Psychosomatics. 2002;43(1):24–30. doi: 10.1176/appi.psy.43.1.24 11927754

37. WHO. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: World Health Organization; 2010.

38. WHO. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings 2016.

39. Beecham J, Knapp M. Costing psychiatric interventions: Gaskell London; 2001.

40. Wing J, Curtis R, Beevor A. HoNOS: Health of the nation outcome scales. Report on Research and Development London: Royal College of Psychiatrists. 1996.

41. Lewis G, Pelosi A. Manual of the revised clinical interview schedule (CIS-R). Institute of Psychiatry, London. 1990.

42. Sousa RM, Dewey ME, Acosta D, Jotheeswaran AT, Castro-Costa E, Ferri CP, et al. Measuring disability across cultures—the psychometric properties of the WHODAS II in older people from seven low- and middle-income countries. The 10/66 Dementia Research Group population-based survey. Int J Methods Psychiatr Res. 2010;19(1):1–17. doi: 10.1002/mpr.299

43. Oppe M, Devlin NJ, SZENDE A. EQ-5D value sets: inventory, comparative review and user guide: Springer; 2007.

44. Audin K, Margison FR, Clark JM, Barkham M. Value of HoNOS in assessing patient change in NHS psychotherapy and psychological treatment services. The British journal of psychiatry: the journal of mental science. 2001;178:561–6. doi: 10.1192/bjp.178.6.561 11388975.

45. Guittet L, Ravaud P, Giraudeau B. Planning a cluster randomized trial with unequal cluster sizes: practical issues involving continuous outcomes. BMC Med Res Methodol. 2006;6:17. doi: 10.1186/1471-2288-6-17 16611355.

46. Campbell MK, Fayers PM, Grimshaw JM. Determinants of the intracluster correlation coefficient in cluster randomized trials: the case of implementation research. Clin Trials. 2005;2(2):99–107. doi: 10.1191/1740774505cn071oa 16279131.


48. Statista. Indonesia: Inflation rate from 2012 to 2022 (compared to the previous year) 2018 [cited 2018 14 March 2018].

49. Widodo S. Pengukuran Efisiensi Pada Puskesmas di Daerah Istimewa Yogyakarta. Yogyakarta: Universitas Gadjah Mada; 2016.

50. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial‐based cost‐effectiveness analysis: the importance of controlling for baseline utility. Health economics. 2005;14(5):487–96. doi: 10.1002/hec.944

51. Fenwick E, Claxton K, Sculpher M. Representing uncertainty: the role of cost-effectiveness acceptability curves. Health Econ. 2001;10(8):779–87. Epub 2001/12/18. 11747057.

52. Rachapelle S, Legood R, Alavi Y, Lindfield R, Sharma T, Kuper H, et al. The Cost-Utility of Telemedicine to Screen for Diabetic Retinopathy in India. Ophthalmology. 2013;120(3):566–73. doi: 10.1016/j.ophtha.2012.09.002 23211635

53. Eichler HG, Kong SX, Gerth WC, Mavros P, Jonsson B. Use of cost-effectiveness analysis in health-care resource allocation decision-making: How are cost-effectiveness thresholds expected to emerge? Value in Health. 2004;7(5):518–28. doi: 10.1111/j.1524-4733.2004.75003.x 15367247

54. Woods B, Revill P, Sculpher M, Claxton K. Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research. Value Health. 2016;19(8):929–35. Epub 2016/12/19. doi: 10.1016/j.jval.2016.02.017 27987642.


56. Jiang Y. Cluster Randomised Controlled Trials. Stats 773: Design and Analysis of Clinical Trials2012.

57. Hemming K, Girling AJ, Sitch AJ, Marsh J, Lilford RJ. Sample size calculations for cluster randomised controlled trials with a fixed number of clusters. BMC Med Res Methodol. 2011;11:102. doi: 10.1186/1471-2288-11-102 21718530.

58. Rees A, Richards A, Shapiro DA. Utility of the HoNOS in measuring change in a community mental health care population. Journal of Mental Health. 2004;13(3):295–304.

59. Parabiaghi A, Barbato A, D’avanzo B, Erlicher A, Lora A. Assessing reliable and clinically significant change on Health of the Nation Outcome Scales: method for displaying longitudinal data. Australian & New Zealand Journal of Psychiatry. 2005;39(8):719–24.

60. Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological medicine. 2015;45(1):11–27. doi: 10.1017/S0033291714000129 24569086.

61. Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367(9509):528–9. doi: 10.1016/S0140-6736(06)68184-1 16473129.

62. Schulze B, Angermeyer MC. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Social science & medicine (1982). 2003;56(2):299–312. doi: 10.1016/s0277-9536(02)00028-x 12473315.

63. Ayano G, Assefa D, Haile K, Chaka A, Haile K, Solomon M, et al. Mental health training for primary health care workers and implication for success of integration of mental health into primary care: evaluation of effect on knowledge, attitude and practices (KAP). International journal of mental health systems. 2017;11(1).

64. Hanlon C, Alem A, Medhin G, Shibre T, Ejigu DA, Negussie H, et al. Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial. Trials. 2016;17:76. doi: 10.1186/s13063-016-1191-x 26865254.

65. Grelotti DJ, Lee AC, Fils-Aime JR, Jean JS, Therosme T, Petit-Homme H, et al. A Pilot Initiative to Deliver Community-based Psychiatric Services in Rural Haiti After the 2010 Earthquake. Ann Glob Health. 2015;81(5):718–24. doi: 10.1016/j.aogh.2015.08.028 27036731.

66. Jordans MJ, Luitel NP, Pokhrel P, Patel V. Development and pilot testing of a mental healthcare plan in Nepal. The British journal of psychiatry: the journal of mental science. 2016;208 Suppl 56:s21–8. doi: 10.1192/bjp.bp.114.153718 26447173.

67. Khoja S, Scott R, Husyin N, Durrani H, Arif M, Faqiri F, et al. Impact of simple conventional and Telehealth solutions on improving mental health in Afghanistan. J Telemed Telecare. 2016;22(8):495–8. doi: 10.1177/1357633X16674631 27799454.

68. Musyimi CW, Mutiso V, Ndetei DM, Henderson DC, Bunders J. Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya. Culture, medicine and psychiatry. 2017;41(3):453–65. doi: 10.1007/s11013-017-9527-x 28251478.

69. Musyimi CW, Mutiso VN, Haji ZR, Nandoya ES, Ndetei DM. Mobile Based mhGAP-IG Depression Screening in Kenya. Community Ment Health J. 2018;54(1):84–91. doi: 10.1007/s10597-016-0072-9 27900652.

70. Musyimi CW, Mutiso VN, Ndetei DM, Unanue I, Desai D, Patel SG, et al. Mental health treatment in Kenya: task-sharing challenges and opportunities among informal health providers. International journal of mental health systems. 2017;11:45. doi: 10.1186/s13033-017-0152-4 28775764.

71. Sheikh WA, Paul R, Banda H, Agath K, Luty J. Impact of brief relapse prevention intervention in patients with alcohol dependence in Zambia. Journal of Substance Use. 2017;22(1):113–7.

72. Miller BF, Petterson S, Burke BT, Phillips RL Jr, Green LA. Proximity of providers: colocating behavioral health and primary care and the prospects for an integrated workforce. American Psychologist. 2014;69(4):443. doi: 10.1037/a0036093 24820692

73. Kwan BM, Nease DE. The state of the evidence for integrated behavioral health in primary care. Integrated behavioral health in primary care: Springer; 2013. p. 65–98.

74. Ward E, King M, Lloyd M, Bower P, Sibbald B, Farrelly S, et al. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: clinical effectiveness. BMJ. 2000;321(7273):1383–8. doi: 10.1136/bmj.321.7273.1383 11099284.

75. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet. 2007;370(9593):1164–74. doi: 10.1016/S0140-6736(07)61263-X 17804061.

76. Allison TA, Sudore RL. Disregard of patients’ preferences is a medical error: comment on "Failure to engage hospitalized elderly patients and their families in advance care planning". JAMA Intern Med. 2013;173(9):787. doi: 10.1001/jamainternmed.2013.203 23545699.

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