The global burden of disease attributable to depression rose 37% from 1990 to 2010. The future projected rise is greatest in low- and middle-income countries (LMIC). However, there is a gap of 1.2 million health workers needed to provide mental health services in LMIC. Task-sharing, the involvement of non-specialist health workers to deliver mental health services, is an essential aspect of reducing this gap. Randomized controlled trials (RCTs) of task-sharing interventions including psychotherapy have demonstrated depression symptom reduction in numerous LMIC. Barriers to scaling up RCTs include negative attitudes and discriminatory behaviors among non-specialist health workers against persons with mental illness. The goal of this K01 Mentored Research Career Development Award is to broaden the candidate s expertise in complex intervention trials of task-sharing initiatives with a focus on reducing negative attitudes and discriminatory behaviors among health workers assuming new responsibilities in mental health care delivery. Through research, coursework, and structured mentorship activities, the candidate will develop new competencies in complex intervention research including (1) conceptual knowledge of complex interventions and theory of change; (2) methodological techniques for design, implementation and analysis of cluster-RCTs in health systems; (3) ethical conduct of health systems intervention research in LMIC and collaboration with mental healthcare consumers; and (4) professional development to become an independent NIMH-funded investigator. Drs. Kathleen Sikkema, Vikram Patel, Crick Lund, and Bernice Pescosolido will mentor the candidate in these four objectives. The research will be conducted in Nepal through infrastructure of the NIMH U19 South Asia Hub for Advocacy, Research, and Education for Mental Health (SHARE) and the task-sharing initiative Programme for Improving Mental Health Care (PRIME). The candidate will evaluate the feasibility and acceptability of a supplemental training module to improve attitudes toward and social engagement with persons with mental illness, with the goal of moving past traditional concepts of stigma and stigma-reduction interventions. This module will be added to a mental health Gap Action Programme (mhGAP) training to of improve provider competence in evidence based practices (EBP), and reduce patient depression severity. A pilot cluster-RCT of social engagement training for primary care workers will be conducted to assess feasibility and acceptability of content, procedures, adverse event monitoring, and analytic approaches.
The aims of this pilot cluster-RCT include adaptation and pre-piloting a social engagement training module, piloting a cluster-RCT, and performing quantitative descriptive analysis to prepare for an appropriately powered R01, which would evaluate the impact of reducing negative attitudes and discriminatory behaviors among primary care workers on EBP quality and patient outcomes. In Nepal, this research will contribute to scalable training models that promote quality clinical services and minimize barriers to implementation stemming from biases and discrimination perpetuated by providers. The study addresses Grand Challenges in Global Mental Health Goal C to foster integration of mental health into primary care, Goal D to advance methods to reduce stigma, and Goal E to develop sustainable training models to deliver EBP. These goals advance NIMH Strategic Aim 4 by expanding the knowledge base to promote EBP among diverse provider groups and contribute to the mission of the NIMH Road Ahead through collaboration with persons living with mental illness to improve dissemination and implementation of EBP.

Public Health Relevance

training proposal and research addresses NIMH Strategic Aim 4 through strategy 4.1 expanding the knowledge base to promote evidence based practices among diverse provider groups through enhancing trainings across cultural groups. The NIMH Road Ahead is addressed through partnership with people living with mental illness to innovative strategies for dissemination and implementation. The activities address Grand Challenges in Global Mental Health, goals C, D, and E.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Scientist Development Award - Research & Training (K01)
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Special Emphasis Panel (ZMH1)
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Amarreh, Ishmael G
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Duke University
Schools of Medicine
United States
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