Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda.
Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda.
Lancet Glob Health. 2020 Mar;8(3):e387-e398. doi: 10.1016/S2214-109X(19)30548-0. Epub 2020 Feb 5.
WHO recommends the use of psychological interventions as first-line treatment for depression in low-income and middle-income countries. However, evaluations of the effectiveness and cost-effectiveness of such interventions among people with HIV are scarce. Our aim was to establish the effectiveness of group support psychotherapy (GSP) delivered by lay health workers for depression treatment among people living with HIV in a rural area of Uganda on a large scale.
In this cluster-randomised trial, we included 30 health centres offering HIV care. These were randomly assigned to deliver either GSP or group HIV education (GHE). Randomisation, in a ratio of 1:1, was achieved by health centre managers separately picking a paper containing the intervention allocation from a basket. Participants were people living with HIV, aged 19 years and older, with mild to moderate major depression assessed with the Mini International Neuropsychiatric Interview depression module, taking antiretroviral therapy, and antidepressant-naive. Group sessions were led by trained lay health workers once a week for 8 weeks. The primary outcomes were the proportion of participants with major depression and function scores at 6 months post-treatment, analysed by intention to treat by means of multilevel random effect regression analyses adjusting for clustering in health centres. This trial is registered with the Pan African Clinical Trials Registry, PACTR201608001738234.
Between Sept 13 and Dec 15, 2016, we assessed 1473 individuals, of whom 1140 were recruited from health centres offering GSP (n=578 [51%]) or GHE (n=562 [49%]). Two (<1%) participants in the GSP group were diagnosed with major depression 6 months post-treatment compared with 160 (28%) in the GHE group (adjusted odds ratio=0·01, 95% CI 0·003-0·012, p<0·0001). The mean function scores 6 months post-treatment were 9·85 (SD 0·76) in the GSP group and 6·83 (2·85) in the GHE group (β=4·12; 95% CI 3·75-4·49, p<0·0001). 36 individuals had 63 serious adverse events, which included 25 suicide attempts and 22 hospital admissions for medical complications. The outcomes of these serious adverse events included 16 deaths, 4 of which were completed suicides (GSP=2; GHE=2), and 12 of which were HIV-related medical complications (GSP=8; GHE=4). Cost-effectiveness estimates showed an incremental cost-effectiveness ratio of US$13·0 per disability-adjusted life-year averted, which can be considered very cost-effective in Uganda.
Integration of cost-effective psychological treatments such as group support psychotherapy into existing HIV interventions might improve the mental health of people living with HIV.
MQ Transforming Mental Health and Grand Challenges Canada.
世界卫生组织建议在中低收入国家将心理干预作为治疗抑郁症的一线治疗方法。然而，针对艾滋病毒感染者的此类干预措施的有效性和成本效益评价却很少。我们的目的是评估在乌干达农村地区，由非专业卫生工作者提供的团体支持心理疗法（GSP）对艾滋病毒感染者的抑郁症治疗的有效性。
在这项整群随机试验中，我们纳入了 30 个提供艾滋病毒护理的卫生中心。这些中心被随机分配接受团体支持心理疗法（GSP）或团体艾滋病毒教育（GHE）。通过卫生中心管理者分别从篮子中抽取包含干预分配的纸张来实现 1:1 的随机分组。参与者为年龄在 19 岁及以上、接受抗逆转录病毒治疗、且正在服用抗抑郁药的轻度至中度重度抑郁症患者，使用 Mini International Neuropsychiatric Interview 抑郁模块进行评估。每周一次进行 8 周的团体治疗，由经过培训的非专业卫生工作者进行。主要结局为 6 个月治疗后患有重度抑郁症的参与者比例和功能评分，通过意向治疗分析，采用多水平随机效应回归分析，根据卫生中心的聚类进行调整。该试验在泛非临床试验注册中心（PACTRO201608001738234）进行注册。
2016 年 9 月 13 日至 12 月 15 日，我们评估了 1473 名参与者，其中 1140 名从提供 GSP（n=578 [51%]）或 GHE（n=562 [49%]）的卫生中心招募。GSP 组中有 2 名（<1%）参与者在治疗后 6 个月被诊断患有重度抑郁症，而 GHE 组中有 160 名（28%）参与者患有重度抑郁症（调整后的优势比=0.01，95%CI 0.003-0.012，p<0.0001）。治疗后 6 个月时，GSP 组的平均功能评分为 9.85（SD 0.76），GHE 组为 6.83（2.85）（β=4.12；95%CI 3.75-4.49，p<0.0001）。有 36 名参与者发生 63 例严重不良事件，其中包括 25 例自杀企图和 22 例因医疗并发症住院。这些严重不良事件的结局包括 16 人死亡，其中 4 人是自杀（GSP=2；GHE=2），12 人是艾滋病毒相关的医疗并发症（GSP=8；GHE=4）。成本效益估计表明，每避免一个残疾调整生命年的增量成本效益比为 13.0 美元，这在乌干达可以被认为是非常具有成本效益的。
将经济有效的心理治疗方法（如团体支持心理疗法）纳入现有的艾滋病毒干预措施中，可能会改善艾滋病毒感染者的心理健康。
MQ 转化心理健康和大挑战加拿大。
