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基层工作者干预措施在中低收入国家对精神障碍和痛苦患者的护理。

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries.

机构信息

Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.

Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong.

出版信息

Cochrane Database Syst Rev. 2021 Aug 5;8(8):CD009149. doi: 10.1002/14651858.CD009149.pub3.

DOI:10.1002/14651858.CD009149.pub3
PMID:34352116
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8406740/
Abstract

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS: PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

摘要

背景

在中低收入国家，以社区为基础的初级保健工作者（PW）是解决精神卫生服务提供差距的重要策略。

目的

评估在中低收入国家，PW 主导的治疗与常规护理相比，对有精神卫生症状的人治疗的有效性。

检索方法

MEDLINE、Embase、CENTRAL、ClinicalTrials.gov、ICTRP 和参考列表（截至 2019 年 6 月 20 日）。

选择标准

随机试验，PW 主导或协作护理干预，治疗有精神卫生症状或其照顾者的人，PW 包括：初级卫生专业人员（PHPs）、初级保健工作者（LHWs）、社区非卫生专业人员（CPs）。

数据分析

事先确定了 7 种情况，并按障碍和 PW 分析了恢复、患病率、症状变化、生活质量（QOL）、功能、服务使用（SU）和不良事件（AEs）。比值比（RRs）用于二分类结局；均数差（MDs）、标准化均数差（SMDs）或平均变化差（MCDs）用于连续结局。对于 SMD，0.20 至 0.49 表示小、0.50 至 0.79 表示中、≥0.80 表示大临床效果。分析时间点：T1（<1 个月）、T2（1-6 个月）、T3（>6 个月）干预后。

主要结果

描述了来自 30 个中低收入国家（25 个来自 13 个低中等收入国家）的 95 项试验（2013 年以来新增 72 项）。

偏倚风险

最常见的偏倚：检测偏倚、随访偏倚（疗效）、保护措施不足防止污染。

干预效果

除非另有说明，T2 时的比较是常规护理。“可能”、“可能”或“不确定”表示“中度”、“低度”或“非常低度”确定性证据。

成年人患有常见精神障碍（CMDs）：LHW 主导的干预措施 a. 可能增加恢复（2 项试验，308 名参与者；RR 1.29，95%CI 1.06 至 1.56）；b. 可能降低患病率（2 项试验，479 名参与者；RR 0.42，95%CI 0.18 至 0.96）；c. 可能减少症状（4 项试验，798 名参与者；SMD-0.59，95%CI-1.01 至-0.16）；d. 可能改善生活质量（1 项试验，521 名参与者；SMD 0.51，95%CI 0.34 至 0.69）；e. 可能轻度降低功能障碍（3 项试验，1399 名参与者；SMD-0.47，95%CI-0.8 至-0.15）；f. 可能减少不良事件（自杀意念/企图的风险）；g. 对服务使用的影响不确定。协作护理：a. 可能增加恢复（5 项试验，804 名参与者；RR 2.26，95%CI 1.50 至 3.43）；b. 尽管实际效应范围表明它可能几乎没有或没有效果，但可能降低患病率（2 项试验，2820 名参与者；RR 0.57，95%CI 0.32 至 1.01）；c. 可能轻微减少症状（6 项试验，4419 名参与者；SMD-0.35，95%CI-0.63 至-0.08）；d. 可能轻度改善生活质量（6 项试验，2199 名参与者；SMD 0.34，95%CI 0.16 至 0.53）；e. 可能对功能障碍几乎没有或没有影响（5 项试验，4216 名参与者；SMD-0.13，95%CI-0.28 至 0.03）；f. 可能减少服务使用（转介给心理健康专家）；g. 对不良事件的影响不确定（死亡）。

围产期抑郁（PND）妇女：LHW 主导的干预措施 a. 可能增加恢复（4 项试验，1243 名参与者；RR 1.29，95%CI 1.08 至 1.54）；b. 可能轻度减少症状（5 项试验，1989 名参与者；SMD-0.26，95%CI-0.37 至-0.14）；c. 可能轻度减少功能障碍（4 项试验，1856 名参与者；SMD-0.23，95%CI-0.41 至-0.04）；d. 可能对不良事件（死亡）的影响不确定；e. 对服务使用的影响不确定。协作护理：对症状/生活质量/服务使用/不良事件的影响不确定。

成年人患有创伤后应激障碍（PTS）或 CMD 处于人道主义环境中：LHW 主导的干预措施 a. 可能轻度减少抑郁症状（5 项试验，1986 名参与者；SMD-0.36，95%CI-0.56 至-0.15）；b. 可能轻度改善生活质量（4 项试验，1918 名参与者；SMD-0.27，95%CI-0.39 至-0.15）；c. 对症状（PTS）/功能/服务使用/不良事件的影响不确定。PHP 主导的干预措施：a. 可能降低 PTS 症状患病率（1 项试验，313 名参与者；RR 5.50，95%CI 2.50 至 12.10）和抑郁患病率（1 项试验，313 名参与者；RR 4.60，95%CI 2.10 至 10.08）；b. 对症状/功能/服务使用/不良事件的影响不确定。

成年人有危险/有害酒精或物质使用：LHW 主导的干预措施 a. 可能增加有害/危险酒精使用的恢复率，尽管实际效果范围表明它可能几乎没有或没有效果（4 项试验，872 名参与者；RR 1.28，95%CI 0.94 至 1.74）；b. 对甲基苯丙胺使用的患病率（1 项试验，882 名参与者；RR 1.01，95%CI 0.91 至 1.13）和功能障碍（2 项试验，498 名参与者；SMD-0.14，95%CI-0.32 至 0.03）的影响可能较小；c. 可能轻度降低危险/有害酒精使用的风险（3 项试验，667 名参与者；SMD-0.22，95%CI-0.32 至-0.11）；d. 对服务使用/不良事件的影响不确定。

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Implement Sci Commun. 2025 May 7;6(1):55. doi: 10.1186/s43058-025-00744-7.
10
Transdiagnostic Psychological Interventions for Symptoms of Common Mental Disorders Delivered by Non-Specialist Providers in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.低收入和中等收入国家非专科医疗服务提供者提供的针对常见精神障碍症状的跨诊断心理干预：一项系统评价和荟萃分析
Depress Anxiety. 2024 Jul 10;2024:5037662. doi: 10.1155/2024/5037662. eCollection 2024.
Correction: Nurse-Delivered Cognitive Behavioral Therapy for Adherence and Depression Among People Living With HIV (the Ziphamandla Study): Protocol for a Randomized Controlled Trial.
更正：护士提供的针对艾滋病毒感染者依从性和抑郁症的认知行为疗法（Ziphamandla研究）：一项随机对照试验的方案。
JMIR Res Protoc. 2020 Sep 28;9(9):e24074. doi: 10.2196/24074.
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Effectiveness of a peer-led adolescent mental health intervention on HIV virological suppression and mental health in Zimbabwe: protocol of a cluster-randomised trial.同伴主导的青少年心理健康干预对津巴布韦艾滋病毒病毒学抑制和心理健康的有效性：一项整群随机试验方案
Glob Ment Health (Camb). 2020 Aug 28;7:e23. doi: 10.1017/gmh.2020.14. eCollection 2020.
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Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial.尼日利亚和加纳传统与信仰治疗师和初级卫生保健工作者合作照料对精神病结局的影响（COSIMPO）：一项集群随机对照试验。
Lancet. 2020 Aug 29;396(10251):612-622. doi: 10.1016/S0140-6736(20)30634-6.
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Effectiveness of a peer-delivered, psychosocial intervention on maternal depression and child development at 3 years postnatal: a cluster randomised trial in Pakistan.同伴提供的心理社会干预对产后3年母亲抑郁和儿童发育的有效性：巴基斯坦的一项整群随机试验
Lancet Psychiatry. 2020 Sep;7(9):775-787. doi: 10.1016/S2215-0366(20)30258-3.
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Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial.印度一项针对伴发抑郁和糖尿病患者的随机临床试验（INDEPENDENT）表明，协同护理模式可改善抑郁症状及糖化血红蛋白、血压和血清胆固醇水平。
JAMA. 2020 Aug 18;324(7):651-662. doi: 10.1001/jama.2020.11747.
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Effectiveness of life skills education and psychoeducation on emotional and behavioral problems among adolescents in institutional care in Kenya: a longitudinal study.生活技能教育和心理教育对肯尼亚机构照料中青少年情绪和行为问题的有效性：一项纵向研究。
Child Adolesc Ment Health. 2018 Nov;23(4):351-358. doi: 10.1111/camh.12232. Epub 2017 Jul 25.
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Cost and effects of integrated care: a systematic literature review and meta-analysis.整合照护的成本与效果：系统文献回顾与荟萃分析。
Eur J Health Econ. 2020 Nov;21(8):1211-1221. doi: 10.1007/s10198-020-01217-5. Epub 2020 Jul 6.
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Supervised treatment in outpatients for schizophrenia plus (STOPS+): protocol for a cluster randomised trial of a community-based intervention to improve treatment adherence and reduce the treatment gap for schizophrenia in Pakistan.门诊精神分裂症患者的监督治疗（STOPS+）：一项基于社区的干预措施改善治疗依从性和减少巴基斯坦精神分裂症治疗差距的群组随机试验方案。
BMJ Open. 2020 Jun 30;10(6):e034709. doi: 10.1136/bmjopen-2019-034709.