Integrating an evidence-based mental health intervention into non-communicable disease care

Principal Investigators: Dr. Wongsa Laohasiriwong, Khon Kaen University and Dr Judy Bass, Johns Hopkins University.

What did the study set out to achieve?

Non-communicable diseases (NCDs) are the leading cause of mortality worldwide. There is an increasing burden of NCDs within humanitarian contexts, but a lack of evidence of effective NCD interventions in humanitarian settings outside the Middle East. Mental disorders and major NCDs often share risk factors such as sedentary life style and alcohol misuse, and can coexist, leading to high care costs care and premature mortality. Mental health conditions significantly impact NCD risk factors and treatment compliance. This study integrates the evidence-based intervention Common Elements Treatment Approach (CETA) , into existing care models for people with hypertension, diabetes and epilepsy. Its objectives are to assess factors influencing treatment compliance, determine improvement in health outcomes, and evaluate potential cost savings.

This study aimed to (1) assess the impact of the intervention on mental health outcomes including wellbeing, mental and physical health status, (2) assess the differences between intervention and control group behavioral risk factors. The research aimed to inform the role of mental health care as part of comprehensive NCD care in humanitarian settings.

What were the key findings?

• Medication Adherence: People receiving CETA reported statistically significantly better adherence to their medication compared to the control group; similar trends were found for pill count, but these results were not statistically significant. On average, both groups showed improved medication adherence over the study period.
• Mental Health: Among study participants who had elevated mental health symptoms at baseline (~40% of all study participants), those receiving CETA reported a significantly greater drop in mental health symptoms compared to those who were in the control group
• ‍Physical Health: No significant impacts were found on clinical outcomes (blood pressure, HbA1C and fasting blood sugar levels) and BMI, however small sample sizes for those with each of these outcomes at baseline limits interpretation of these findings.‍
• Costs: Excluding start-up costs, ongoing implementation for routine chronic disease care cost about US $549 per patient per year. Adding the CETA intervention costs an additional 29% ($157 per patient per year), for a total of $706 per patient per year.

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What does this mean for policymakers and practitioners?

The high rate (~40%) of mental health problems among the NCD patients with poor treatment adherence demonstrates the value of planning and integrating mental health care into broader NCD care. Additionally, mental health interventions have the potential to be beneficial even for people without mental health problems. CETA had a significant impact on self-reported medication adherence – a primary outcome - and on mental health symptoms among those with elevated symptoms.

While the results are promising, the costs per patient are not insignificant. There is value in exploring whether alternative, less costly evidence based mental health interventions may have a comparable impact. Targeted interventions for improving medication adherence could be a focus for future innovation.

Key programmatic recommendations:

• Individuals with poor adherence to medication, even in the absence of mental health problems, may benefit from an evidence-based mental health intervention.
• Patients living with chronic diseases experiencing poor medication adherence should be screened for mental health problems and receive evidence-based services if they are identified with mental health conditions.
• Addressing structural factors related to poor medication adherence and increased risks for NCDs, such as poor access to necessary medications, and limited access to healthy foods and space for physical activity.

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