What are the changes in knowledge and skills on identification, treatment/management and referrals of mental disorders among primary care practitioners who have been trained to use a locally adapted version of the WHO mhGAPprogramme compared to existing standard of care?

Study settings: 25 primary care facilities across all 5 districts of the Northern Province, Sri Lanka

Method of allocation: Multi-centre stepped wedge cluster randomised trial

Intervention

Primary care practitioners: Primary Care Practitioners (PCP) at randomly selected facilities will be monitored for 1 month prior to commencement of training. They will receive 3 days training, 6 hours a day, 1-on-1 training using locally adapted WHO mhGAP intervention guide. Once training is completed, PCPs will use the mhGAP guide to diagnose, treat and refer primary care patients with possible mental health problems.

Public health professionals (PHPs): 2 days training in groups of 3, 6 hours a day using locally adapted educational material on mental health awareness and stigma reduction. Once training is completed, PHPs will engage in specific activities outlined during their training with the patient population attending their respective facilities.

Community representatives (CRs): 1 day training in groups of 2 or more, 6 hours total, using locally adapted educational material on mental health awareness and stigma reduction. Community Representatives (CR) will not be randomized. CR within the catchment area of each randomly selected primary care facility will be identified and approached for inclusion. Once training is completed, CRs will engage in specific activities outlined in their training within their respective communities such as creating awareness, finding local resources and organizing mental health promotional activities.

Patients attending primary care facilities who are identified by mhGAP trained primary care practitioners will be asked to answer a brief socio-demographic questionnaire at point of recruitment along with the Hopkins Symptoms Checklist (for depression and anxiety) at point of recruitment and at 3 and 6 months follow up. They will also be re-examined by a psychiatrist to confirm the primary care practitioner diagnosis.

All training interventions will be based on the World Health Organization mhGAP 2.0 training module. Key modules informed by previous work on depression, stress related disorders, medically unexplained symptoms, alcohol/drug use disorder, and others will be used. All materials have been locally translated and adapted.

After training is completed PCPs, PCPs and CRs will be monitored for a period of 1 month.

Pre- and post-knowledge tests and refresher courses will be carried out at 3 and 6 months after initial training.

PCPs, PHPs, CRs who haven’t yet received training, and their patients will act as controls and will continue treatment as usual.

Primary Care Practitioners (PCP)
1. Full registration with the Sri Lankan Medical Council
2. At least 6 months or more until their next transfer rotation (this applies only for PCP working in government facilities) or 6 months to retirement

Public Health Personnel (PHP)
1. Nurse, attendant or health service assistant within each facility
2. At least 6 months left on their transfer rotation (this applies only for PHP working in government facilities) or 6 months to retirement

Community Representatives (CR)
1. Located within the catchment area of each selected facility

Patients
1. Aged 18 years or older
2. Attend selected facilities
3. Belong to IDP or post-conflict populations

Primary care practitioners, public health professionals and community representatives will be excluded if they have secondary mental health training. Patients will be excluded if they are under 18 years or diagnosed with mental disorders other than depression and/or anxiety.