RESUMEN
BACKGROUND: There is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health. METHODS: A systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised. RESULTS: Few (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes. CONCLUSION: Evidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.
RESUMEN
OBJECTIVE: To synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors. DESIGN: Systematic review of studies evaluating the involvement of families in tripartite communication between health professionals, 'families' (or other unpaid carers) and adult patients, in a single-family context. A theoretical thematic analysis approach and thematic synthesis were used. DATA SOURCES: A systematic electronic search was carried out in seven databases, using database-specific search strategies and controlled vocabulary. A secondary manual search of grey literature was performed as well as using forwards and backwards snowballing techniques. RESULTS: A total of 43 studies were included. The majority featured qualitative data (n=42), focused solely on staff perspectives (n=32) and were carried out in the UK (n=23). Facilitating the training and ongoing supervision needs of staff are necessary but not sufficient conditions for a consistent involvement of families. Organisational cultures and paradigms can work to limit family involvement, and effective implementation appears to operate via a whole team coordinated effort at every level of the organisation, supported by strong leadership. Reservations about family involvement regarding power relations, fear of negative outcomes and the need for an exclusive patient-professional relationship may be explored and addressed through mutually trusting relationships. CONCLUSIONS: Implementing family involvement carries additional challenges beyond those generally associated with translating research to practice. Implementation may require a cultural and organisational shift towards working with families. Family work can only be implemented if this is considered a shared goal of all members of a clinical team and/or mental health service, including the leaders of the organisation. This may imply a change in the ethos and practices of clinical teams, as well as the establishment of working routines that facilitate family involvement approaches.