Non-specialist Providers

Question 1

What roles would be considered NSPs?

Answer 1

1 - community health workers
2 - peers or others recruited through community
3 - nurses
4 - midwives
5 - teachers

6 - those who receive training for specific task/intervention (though training varies greatly, 3hr - 2 mo, Singla et al 2017)

- frequent contact w/target pop
- sustainable resource (eg employed in local healthcare system)

Question 2

What are the main arguments that NSPs should provide psychological services?

Answer 2

1 - there is a treatment need
2 - there is a treatment gap
3 - there are benefits
4 - NSPs are effective

Question 3

What are the main points supporting the argument that there is a treatment need?

Answer 3

1 - prevalence of mental disorders is high and growing according to the National Comorbidity Survey (‘90-‘92) and its replication (‘01 - ‘03) in USA

30% of people over one year met criteria for mental disorder
50% of population over the lifespan met criteria for mental disorder

Question 4

What are the main points for the argument that there is a treatment gap?

Answer 4

1 - empirically-supported treatments not accessible for most populations in most countries
2 - larger gap in low and middle income countries (up to 93%)
3 - about 1/2 of Canadians receive potentially adequate care (Patten et al 2016)
4 - 1/3 of Canadians aged 15+ report not having a mental health care need fully met in the past year (Sunderland & Findlay 2013)
5 - about 75% of children with mental disorders do not access specialized treatment services (Waddell et al 2005)

Question 5

What are the main points to the argument that there are benefits to NSPs?

Answer 5

1 - NSPs can capitalize on therapeutic elements that are common across effective treatments
2 - these treatments are often based on transdiagnostic treatment guides (requires less resources and training than models where each disorder requires a distinct treatment)
3 - lower upfront cost
4 - increased accessibility
5 - capitalizes on local resources
6 - better fit with local culture

Question 6

What are the main points for the argument that NSP is effective?

Answer 6

1 - Singla et al (2017) Meta-analysis synthesized results for depression and PTSD in low/middle income countries where specialists oversaw training, quality/safety assurance, and outcome evaluation (NSPs were peers/community members, nurses, midwives)
2- medium effect size

Question 7

What are the main arguments that NSPs should not provide psychological services?

Answer 7

1 - because even psychotherapy has problems
2 - professional competence is important
3 - limitations of training methods for NSPs
4 - level of therapist training affects outcomes
5 - the evidence for NSPs has been criticized

Question 8

What are the main points for the argument that even evidence-based psychotherapy is not always effective?

Answer 8

1 - 1 in 20 people report long-lasting negative effects of treatment (5.2%, Crawford et al 2016)
2 - those more likely to report negative effects are over 65, ethnic minorities, non-heterosexual, and those w/o sufficient information prior to therapy

Question 9

What are the main points of the argument that professional competence is important (and that NSPs may not have it)?

Answer 9

1 - Professional competence includes accurate assessment, provision of adequate information, appropriate treatment recommendation, therapeutic alliances, successful treatment
2 - these skills vary depending on the professional’s knowledge and continuing competency (Blease et al 2016)
3 - APA requires training in evidence based practice to fully understand evidence (and strengths/limits) of treatments, socio-cultural context, ethics, and autonomy of patient (consent)

Question 10

What are the main points for the argument that there are limitations of NSP training methods?

Answer 10

1 - reliance on face-to-face training and supervision by experts is a barrier to scaling up the provision of services
2 - even with solid training, there are no clear procedures to trailer interventions to individual patients

Question 11

What are the main points for the argument that therapist training impacts outcomes (Stein & Lambert, 1995)?

Answer 11

1 - lower dropout rates (23%) for psychiatrists/psychologists/MA social worker vs. Nurses/teachers/BA-level therapists/other(64%)
2 - better outcomes (small to moderate effect sizes when measured)
3 - strongest reported satisfaction
4 - true across community and university settings

Question 12

What are the main points of the argument for criticisms of evidence for NSPs?

Answer 12

1 - gender gap in evidence represents a lack of psychological treatments for men
2 - meta-analysis by Singla et al (2017) did not capture the extent to which therapeutic elements were truly applied

Question 13

Under what conditions would it be acceptable for NSPs to provide psychological services (Mendenhall et al 2014)?

Answer 13

1 - increased numbers of Human Resources and better access to medications
2 - ongoing structured supportive supervision at community and primary care levels
3 - adequate training and compensation for health workers involved in task-sharing