Task-Shifting, Training Non-specialist Providers in Brief Mental Health Interventions: A Commentary on a JAMA Article
Singla, D. R., et al. (2021) Implementation and effectiveness of nonspecialist-delivered interventions for perinatal mental health in High-Income Countries: A systematic review and meta-analysis. JAMA Psychiatry, published online February 3rd, 2021. Download a pdf of this article HERE.
Context for this article:
Prior research in global mental health has supported the use of task-shifting in training non-specialist providers to administer mental health interventions to good effect. Non-specialist providers (NSP) are those who do not have formal education or training in the provision of mental health services and may include nurses, medical assistants, midwives, peers, and others. The article discussed here is a meta-analysis that looked at the use of non-specialists to provide mental health services to pregnant and postpartum women in high-income countries.
The demand for mental health services worldwide dramatically exceeds the supply of care provided by professional mental health specialists. Evidence suggests that even in high-income countries (HIC), most people in need of mental health care are not able to access it. There simply are not enough Clinical Social Workers, Licensed Mental Health Counselors, Clinical Psychologists, or Psychiatrists to meet current demand. Furthermore, training enough new specialists to meet global demand would be extremely costly and time-consuming.
The Singla, D. R., et al. study systematically reviewed Randomized Clinical Trials (RCTs) to determine whether: the study investigated providing mental health care to pregnant or postpartum women, whether that care was provided by non-specialist providers, and whether that care was provided in a HIC. Out of an initial pool of 1005 potentially relevant articles, the research team identified 44 studies (which together included more than 18,000 participants) to be included in the analysis.
Key Findings of the article:
Consistent with previous studies investigating the use of NSP's, this meta-analysis suggests that interventions delivered by NSP's are effective at preventing and treating depression anxiety for perinatal women in HICs.
The most common types of NSP's noted in these studies were midwives and nurses, but also included peers or community members, health visitors, and even family physicians. In many of the studies included in the analysis, professional mental health specialists served in a training or supervisory role without providing any direct care.
Most participants (67.4% ) were recruited from primary care settings. A variety of interventions were included in the analysis, including both supportive counseling and specific evidence-based treatments, including cognitive behavior therapy, behavioral activation, and interpersonal psychotherapy. Evidence-based treatments outperformed supportive counseling in this analysis.
Significance for integrated primary care providers:
While there exists a significant unmet need for mental health services throughout the populations of HIC's, this JAMA article focused on the needs of women during pregnancy and after childbirth. The United States Preventive Task Force (USPSTF) currently recommends counseling interventions for women at risk of perinatal depression and anxiety. The American College of Obstetricians and Gynecologists (ACOG) recommends screening women for depression during every trimester of pregnancy. Nevertheless, there are simply not enough professional mental health providers to be able to meet this demand.
Not every primary care practice that provides obstetric care has access to integrated behavioral health, but all (or nearly all) of these practices employ RNs or MAs who could be trained to provide effective mental health interventions. Training NSPs to do this work would shift the role of those highly trained and credentialed professionals who currently provide direct mental and behavioral healthcare (such as social workers, psychologists, and psychiatrists) from direct service provider to trainer and supervisor. This shift would allow them to act as “force multipliers”, effectively extending patient access to care without necessarily adding additional staff, and at minimal additional cost.
It seems evident that there is utility to building interventions by NSPs, such as the ones discussed in the JAMA article, into routine care that is given to pregnant women—and in other patient populations as well. Interestingly, the authors specifically note/designate family physicians as non-specialist behavioral health providers who can be trained to administer mental health interventions. Although this approach might be counterproductive from a task-shifting standpoint, adding behavioral health intervention training into residency training might yield a host of positive outcomes.
