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Prasrimahabhodi Psychiatric Hospital, Department of Mental Health
Thailand

The Problem

Depressive disorders are not just feelings of sadness or unhappiness, but are diseases resulting from defects in neurotransmission system, and silently constitute one of the world’s most serious health problems. Patients tend to present with severe depressed mood most of the day with markedly diminished interest or pleasure during most of the same 2 weeks. If not timely detected and treated, patients can be at greater suicidal risks, approximately 20 times those of general population. Collaterally, families would also loss time and money; countries would also be affected by having to subsidize a large amount of budget to counter their consequences.

According to a joint study by World Health Organization(WHO), Harvard School of Public Health and the World Bank, depressive disorder is predicted to become the second disease with the highest Disability Adjusted Life Years calculating with burden of disease from mortality and morbidity by 2020. The Thai Working Group on Burden of Disease and Injuries in 2004 similarly ranked it fourth and tenth, in term of burden of diseases, in Thai women and men respectively and the government has had to allot 2,250 million baht per year to fight it. An epidemiology survey of Thailand in 2008 found approximately 1.5 million people aged 15 and over to experience with depressive disorders, most were being unrecognized and untreated within the community, a situation that was found to be in need of redressing.
These problems were analyzed as followed:
1. Depressed patients had limited access to health services. According to statistics, only 4 percent of the patients had access to care mainly of three major causes, firstly, they did not understand that they were sick or that their depressive mood is the result of a sickness. Secondly, the stigma of mental illness which depressive disorders have been judged as part of psychotic diseases affects access to care. Lastly, they did not know that what they were experiencing could be treated and if brought to a full remission, they could lead normal lives again.
2. There were no standard and quality cares for depressive disorders in the country’s health services then. The Thai study cited, also found health professionals in primary and secondary care-settings to be lacking in the knowledge and skills to manage these patients, not least because general practitioners themselves were less than confident in diagnosing and treating the disease. Thus, what the system needed was an easily employed instrument that not only response to the context of various levels of users to help assessed signs and symptoms but also help in initiating an effective treatment plan. This tool should help guide them in initial assessment, treatments to choose from, how to consider associated psychosocial issues of each patient, more importantly, the ways to further monitor and prevention of relapsing symptoms.

Toward this goal, Department of Mental Health- tasked to tackle the country’s mental health issues, together with specialists from all major universities, established a surveillance system of depressive disorders at provincial level in order to address these problems.

Solution and Key Benefits

 What is the initiative about? (the solution)
Surveillance system of depressive disorders at provincial level (SDDP) has been initially developed since 2006. The objectives are to increase access to care for depressed patients and to improve quality of health services for the disease, an innovation in mental health care to connect all three levels of the country’s care setting for depressive disorders.

Overall, the system is revolved around the circle of five activities. Firstly, initial screening for depressive symptoms in high-risk groups within general population by having health volunteers in communities and health professionals in primary health services assess people in their community with a 2-questions questionnaire (2Q). Those answers positively are then given brief psycho-education to help enhance self-awareness and prevention of depressive disorders. Secondly, those that are possible of having depression are further stratified by their severity using 9-questions questionnaire (9Q) and are also assessed for suicidal risks by 8-questions questionnaire (8Q). Thirdly, the diagnosis is then confirmed by trained physicians using the standard DSM-IV-TR’s diagnosis criteria for depressive disorders. Fourthly, patients are then treated according to their severities in following instructions and guidelines developed. And lastly, they are then monitored for the result and efficacy of treatments provide by monthly reassessment with 9Q and 8Q until achieving full remission, indicate by a score of less than 7 on the 9Q continuously for at least six months. After the cessation of antidepressant medications following successful treatment, they would still be followed to prevent relapse for another year, also using 9Q and 8Q. Patients without relapsing are the discharged from the system, those that are, are reassessed and referred to secondary care settings to resume treating process.

This surveillance system could deal with two main issues of depressive disorders by:
1. Increasing access to care for depressive patients. All depressed patients are given health education that help change their attitude and increased self-awareness of the disease during assessment, treatment and monitoring process. Consequently, they would better understand the disease and help them adhere to treatment plan showing result in an increasing rate of access to health services.
2. Improving quality of health services in recognizing and treating depressed patients. First of all, health professionals at all levels are trained to equip with the knowledge and skills to care for these patients. The instruments (2Q, 9Q and 8Q) developed are easily employed, take little time but have a high rate of sensitivity, validity and reliability. The clinical practice guidelines for depressive disorders is simultaneously implemented into primary and secondary settings all over the country with accompanying ‘Guidebook of depressive disorders surveillance and care at provincial level’ to increase understanding of the scheme. Finally, information system links at provincial level were established to help keep track of depressive patients in the system to monitor and improve the quality of health services for all new patients and old ones who are at risk of relapsing.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Prasrimahabhodi Psychiatric Hospital, under the aegis of the Department of Mental Health, began the process of reviewing available knowledge to develop surveillance system of depressive disorders at the provincial level in 2006. This was followed by six years of vigorous participations of national mental health, health system and local experts, who continually helped contribute towards the creation, implementation and revision of the surveillance systems. The key stakeholders are:

1.Director of Prasrimahabhodi Psychiatric Hospital, the principle investigator and the key person who introduced the idea of innovative context-based project. He is still actively involved with the project and is still one of the main trainers for the guidelines.
2.The project staff, whose members tirelessly worked to develop the proposals, helped in determining the conceptual framework, reviewing relevant literature, devising the surveillance system, and developing the tools and reporting system. Furthermore, they are also involved in monitoring and evaluating the project, helped in training of health care professionals, and have coaching of areas that need extra assistance in implementing the system.
3.Mental health experts from departments of psychiatry and nursing from four major regional universities, namely Mahidol, Chiangmai, Prince of Songkla and Khon Kaen Universities, who offered their expertise in analyzing the service systems for depressive disorders and in developing the pattern of the context-based surveillance system at local areas. They are instrumental in the development of the resulting tools and management guidelines.
4.Provincial chief medical officers, medical practitioners, nurses, public health technical officers and public health officers who supported and make recommendation to this particular pattern of the context-based surveillance. Yasothon, a province in northeastern Thailand was selected as the first pilot area for the testing of this surveillance system, and then the system was further tested in four other provinces at different parts of the country then to twenty five other as the third step before being put in place nationally.
5.Village health volunteers, general populations and depressed patients all contributed to all the steps of the system, in the development of tools and process, in the adjustment of tools to each locality, in giving feedbacks to help improve the system and in actively participating in the surveillance system.
6.The director general and the deputy director generals of the Department of Mental Health have continuously supported the project both financially and strategically, providing encouragement and help throughout the implementation and sustenance of the surveillance system.
7.Thailand’s National Health Security Office (NHSO), the provider of the budget needed for the surveillance system during the fiscal year of 2011-2012.
8.The permanent undersecretary of public health, whose concern for the depressive patients, burden of the disease and values of economic losses from depressive disorders, endlessly supports the system with financial and relevant resources.

In conclusion, the surveillance system of depressive disorders at provincial level was implemented effectively because of the participation of Department of Mental Health’s personals, investigators, experts, monetary supporters, community leaders, village health volunteers, general populations and depressed patients.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
There were 4 strategies used to achieve the goals:
1. Establishing and promoting awareness, knowledge, and perception of depressive disorders for general populations through the media
Knowledge of depressive disorders was disseminated to the public via broadcasting media both at national and local levels, while the administrators also provide information to printing media, for example, information about depressive disorders was delivered to Thairath, the newspaper with the highest circulation in Thailand. Moreover, mental health organizations introduce campaigns to promote higher awareness during the National Mental Health Week, November 1-7 of every year and publicize the events through community radios nationwide.
2. Developing innovations and the system based on context of users
Suitable knowledge of depressive disorders was developed differently for each age group before being distributed. Comics for teenagers, folk songs in local dialect for people in the northeast, short movies for people in rural and urban area are just a few examples. Moreover, 2Q was developed with the ease of use in mind, thus, can be administered by community leaders, village health volunteers and health care professionals to screen, in a short amount of time, for high-risk individuals from general population. Subsequently, 9Q was developed to help physicians and registered nurses in assessment for depressive disorders to arrive at a correct diagnosis and treatment regimen according to the severity of the disease. Finally, the clinical practice guideline of depressive disorder was developed for general practitioners in primary and secondary care settings to enable them to diagnose and treat depressed patients with confidence. As a result of all steps taken, the access to care of depressed patients is continuously increasing. Lastly, 8Q questionnaire to assess suicidal risks was also made so that registered nurses would be able to classify severity of suicide risk and could then prevent or offer adequate support to depressed patients.
3. Pushing the system into policy-making
The depressive surveillance system working group has constantly made known of the problem of access to care of depressed patients at national conferences and appropriate meetings of administrators at provincial level, health service areas, departments, and Ministry of Public Health until the access rate of health service in depressed patients becomes one of the key indicators of success of health services for Department of Mental Health and ultimately, assigned as a measure of performance of all health services of the Ministry of Public Health.
4. Connecting and extending the system into health networks of Thailand
Director of Prasrimahabhodi Psychiatric Hospital, in his role as the manager of the project cooperated with National Health Security Office to secure the budget to support the policy implementation and expansion of the system. Consequently, there are now 159,444 physicians, nurses, and health professionals who are trained to utilize the system to help depressed patients. Now almost all primary health services are able to screen and initiate care for depressed patients, and also integrated the surveillance into the Bangkok metropolitan administration’s bureau of health’s service system within its high-risk groups’ care routines.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The system is divided chronologically into seven phases as followed:

Phase I developing instruments and technological innovations
The system began from a proposed research by the director of Prasrimahabhodi Psychiatric Hospital, also the principle investigator. The technological innovations of depressive disorders were developed with context-based local users and different age groups in mind. Comic books, radio plays and spots, local music, short documentaries and movies are engaged in promoting and preventing depressive disorders. Instruments that were produced from the process to assist in better caring for depressed patients are 2Q, 9Q and 8Q questionnaires.

Phase II developing the system
Situation analysis of health system for depressive disorders such as information of access to care, competency of health professionals, health resources was done during this phase. The results enabled the incorporation of the system into general health services particularly, referral system from communities to primary, secondary, and tertiary care settings. There are five activities as mentioned above.

Phase III testing the system with pilot areas
Yasothon, in northeastern Thailand was the first province selected for testing the system that was then expanded to four other provinces the next year. Those provinces’ chief medical officers implemented the system as part of their provincial health policies. Health professionals were trained to recognize depressive disorders and how to manage the system. Village health volunteers were taught to screen high-risk groups for depressive symptoms. The surveillance team closely supervised the implementation of the system during this period.

Phase IV evaluating and redeveloping the system
One year after phase III, the results and problems of the pilot study and the four provinces expansion scheme were analyzed to summarize the success and obstacles. All issues were studied to revise and improve the surveillance system. It was found that, even at the pilot stage, the access rate of health services in depressed patients dramatically increased from 1.42 percent to 6.05 percent and 3.7 percent to 6.31 percent in Yasothon and the four provinces respectively. The instructions and training courses of the system were revised using data based on these results.

Phase V extending the system into 25 provinces

Phase VI the second of redeveloping the system and technological innovations
Clinical practice guideline for general practitioners in primary and secondary care settings was developed to address the problems of GPs not confidently able to diagnose and treat depressed patients. The system instructions were redeveloped for better ease of use in clear directions for all levels of health services. The reporting system was also improved to enable easy recording through web application.
Phase VII extending the system into health services around the country
Access to care of depressed patients has been assigned as a key policy since 2009 and had been indicated as one of the key performance indicators for all health services by the Ministry of Public Health. All health professionals have been trained in the knowledge and management of depressive disorders. All high-risk groups of depressive disorders have been screened and offered care.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The main obstacles encountered during the different phases of the system’s implementations were:

Phase I developing instruments and technological innovations
The instruments were initially difficult to develop as the aim was to tailor the questionnaires for the ease and accuracy of use in all areas of the country. At the start they were only available in the central and northeastern dialects making it difficult for people from other parts of the country to understand and use, showing in low usage in those areas. The problem was resolved by developing the questionnaires in the native southern Thai and Malaya dialects resulting in higher access in the south. The northern dialect questionnaires were also in development to be implemented in the future.

Phase II developing the system
During the first phase of development, stakeholders were having negative attitude and understanding of depressive disorders. Therefore, they were quite indifferent to the efforts to the changing of the health service system. The problems were addressed by repetitively showing current situation and burden of depression, and the possibility of reducing the harm done in recognizing and treating depression via meetings and conferences until the negative attitudes were modified and the significance of the system was accepted. Having acquired awareness and understanding of depression, they became the force that helped propelled the surveillance system to its success.

Phase III testing the system with pilot areas
All general practitioners in primary and secondary care settings were unable to fully attend the training because of their heavy workload, this problem was overcome by the team delivering onsite training to their hospitals and preparing studies materials of all instruments so that they could directly understand the system via the internet and DVD.

Phase IV evaluating and redeveloping the system
The problem of collecting data at the beginning was the main obstacle because each health service had different way of collecting information and some health service was even out of data coverage’s area and was unable to report the result. The obstacle was resolved by normalizing the surveillance’s reporting system with each area’s usual data gathering process in order to raised cooperation with local health professionals in reporting the data.

Phase V-VII extending the system into 25 provinces, the second of redeveloping the system and technological innovations, and extending the system into health services around the country
Resistance of health care providers who saw the system as complex and cumbersome, an added task to an already heavy workload was the main obstacle. The process was also viewed as comprising of too many steps from screening to evaluating, treating and referring. The web-reporting was seen as complicate especially in areas where there were no internet connections or no IT personnel. Most importantly, depressive disorders were perceived to be a lesser problem than other diseases, especially medical ones. These obstacles were addressed by on-hand supervision and by encouraging them to be a part of the system. All instruments and documents were readily made available to help them in the implementation process.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The resources and key benefits used in the system are as followed:

Phase I-II developing instruments and technological innovation, and developing the system during 2006-2007
Initially there were twenty people within the core group who were tasked with setting the system up. These include project administrators, researchers and experts from the academia. Feedbacks were then collected from 31 medical physicians and nurses and 90 community leaders and village health volunteers from the pilot provinces. The fund used during these phases was from the government, totaling Bt. 6,195,300, which was used for the reviews, research, conferences and meetings for the development of the tools used in the system, resulting in 3 tools, 2 models, 1 program, and 5 activities of the surveillance.

Phase III-IV testing the system with pilot areas, and evaluating and redeveloping the system in 2008
180 health professionals and 300 village health volunteers were trained in the second stage of the system development in 25 provinces by phase I personals using Bt. 7,267,300 from the central government with some help from regional mental health offices in footing the bills for their area of operation to all aspects of the pilot testing including the production of manuals, tools and models and multiple training sessions.

Phase V-VII extending into 25 provinces, the second of redeveloping the system and technological innovations, and extending the system into health services around the country during 2009-2011
All in all, 11,345 public health services had been implemented with the system, where at least one personal from these centers had been trained to become acquainted with its operation. At the outset, 496 health professionals and 24,930 village health volunteers were trained to become local coachers who were able to further coach another 23,054 health professionals and 112,110 village health volunteers. Moreover, participants of evaluation process were a total of 2,209 health professionals, village health volunteers, depressed patients and general populations who were interviewed to find out information about the system. These phases were funded by the government to the sum of Bt. 48,453,600 in order to produce manuals, tools and models, re-evaluating, training human resources, and maintenance the system. The National Health Security Office also supported budget of medical mechanism for older people who were experiencing chronic diseases for health care settings to operate the system. There were totally 164,992 elderly who had been treated and cared resulting from the system which used to financial resources approximately Bt. 49,497,600 and Bt. 14,340,000 for administrative the system.

Overall, these resources had been utilized in development and organization of the system resulting in the care of more than 9 million people who had been screen for depressive disorders. The access of care this system brought have also help to reduced the unit cost for care of depressed patients seven-folds from Bt. 14,381 to Bt. 930 baht per person, or more than Bt. 20 billion saved for the country, with the estimates of 1.5 million depressed patients.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The surveillance system of depressive disorders at provincial level is the first mental health innovation system in Thailand, a the result of the co-operation between department of mental health’s research team, mental health experts, local health professionals, village health volunteers, general populations, and depressed patients within communities.

The system was developed during 2006 to 2009, first as a pilot study of one province, whose outcomes showed a greater access rate to care of depressed patients and an improvement in quality of health services. The department, thus, recognize that the replication of the project to other areas could obtain similar increase in access rate of health services for depressed patients. Moreover, the National Health Security Office of Thailand had used the data of depressed patients gathered in allocating the budget for health care services and medical supplies for caring the patients. Consequently, the system has ever since been continuously improved to enhance the efficacy of treatment and caring for the patients and in doing so helped reduce approximately seven times the unit costs for treating depressed patients. Additionally, qualities of life of the patients and caregivers have also increased as they are able to work and earn. Most importantly, the country can hugely trim down the budgets needed to address this problem and diverted the fund for other pressing health issues.

Thus, the Ministry of Public Health and the Department of Mental Health had continuously used the access rate to care of depressed patients as one of the indicators to gauge the quality of all level of health services for the period of 2012-2020, with the expectation of at least 70 percent coverage by 2020. The system is now being integrated into routine health services. All villages’ health volunteers at villages can now screen high-risk groups for depressive disorders with 2Q and give basic health education for promoting and preventing the disease. Moreover, assessment of depressive symptoms with 9Q and of suicide with 8Q had become a part of history interviews for all of those who receive health services. The monitoring system for preventing relapse of depressive disorders and suicide risk has also been applied to follow the patients at their home and communities. This system is able to be employed by other health services’ system as evident by the application by the Royal Thai Army and Navy for their personnel. Khon Kaen University had also used 2Q and 9Q in their Royal project of depressive disorders surveillance in women, supported by the WHO.

Last but not least, Department of Mental Health, the manager of the system has made available resources such as guidelines, instruments, and training regulation for any interesting organizations on their website www.thaidepression.com that is also used to share knowledge and experience in utilization of the system.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The impacts of the system can be divided into three levels as followed:

Individual level: Approximately 9,333,264 Thai had been provided with better knowledge of depression and were treated medically if found to have the symptoms. The satisfaction rate of the system’s health services was found to be as high as 96.5%, a patient had expressed that, “without the SDDP, I do not know what would happen to me, I might have succumbed to the disease, and I cannot thank you all enough.” Not only they are able to return to work and having a quality life but more importantly, all stakeholders became aware and understood the importance of depressive disorders and the need to tackle them.

National level: Access to care of depressed patients is continuously increasing from 3.7% in 2006 to 29.32% in 2012 after the implementation of the system, or 8 times higher. Suicide rate from depressive disorders is also markedly decreasing. Moreover, results from the system have improved health care services to further the quality and efficiency in caring for depressed patients. Local health professionals are also better adept in managing the surveillance of depressive disorders at provincial level (SDDP). Most importantly, the SDDP is able to assist the country by reducing the tolls of medical care from the disease nearly 7 times, more Bt. 20 billon over the years.

Global level: the SDDP is a health service model which covers all aspects of care for general populations and depressed patients. It also includes tools, caring and management instructions, the report system which is able to directly use or apply by other diseases. Furthermore, it had been discussed at various international conferences like Spain, Austria, Portugal, and China with much interested from the attendees. And if successfully implement, would also help other countries to reduce the Disability Adjusted Life Years (DARYs) of their depressive patients too.

The most important lesson of the SDDP implementation lies in its ability to develop the awareness and understanding of all stakeholders to the magnitude and effect of depressive disorders and the need to resolve them, not least from the number of preventable suicides, severity and burden of the disease, and also the 1.5 million more Thais who are still in dire need of care from their bouts with depressive disorders. Increasing awareness through other media, providing tools, training and information of the system to all stakeholders, with timely revisions and updates, help better understanding and acceptance of the system into all levels of Thai healthcare, as can be seen from the number of patients treated and the budget supported. Finally, these lessons and strategies are welcome to emulation by any interested parties in the application to other diseases, with possibly similar positive results.

Contact Information

Institution Name:   Prasrimahabhodi Psychiatric Hospital, Department of Mental Health
Institution Type:   Government Agency  
Contact Person:   Thoranin Kongsuk
Title:   Director  
Telephone/ Fax:   +(66)45352599/+(66)45352598
Institution's / Project's Website:   www.thaidepression.com
E-mail:   virgojinny12@gmail.com  
Address:   212 Jangsanit Road
Postal Code:   34000
City:   Muang District
State/Province:   Ubonratchathani
Country:   Thailand

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