Impact of Technology Driven Mental Health Task-shifting for Accredited Social Health Activists (ASHAs): Results from a Randomised Controlled Trial of Two Methods of Training.

Mental health task shifting is a potential way to address the burgeoning treatment gap for mental illness. Easily available and accessible digital technology can be utilised to continuously engage grassroot level health workers (for example, Accredited Social Health Activists (ASHAs). However, the impact of such a strategy is not yet systematically evaluated. In this randomised controlled trial, longitudinal hybrid training of ASHAs [1 day in-person classroom training and seven online sessions (ECHO model), aimed to screen and refer to commonly prevalent mental health issues in communities] was compared with traditional one-day in-person classroom training. ASHAs (n = 75) from six Primary Health Centres in Ramanagara district, Karnataka, India were randomized into study (SG-ASHAs) and control (CG-ASHAs) groups. After excluding drop-outs, 26 ASHAs in each group were included in the final analysis of the scores on their Knowledge, attitude, and practices (KAP) in mental health. Two house-to-house surveys were conducted by both groups to identify and refer possible cases. The number of screen positives (potential persons with mental illnesses) and the KAP scores formed the outcome measures. Online sessions for SG-ASHAs were completed over 18 months, the COVID-19 pandemic being the main disruptor. SG-ASHAs identified significantly higher number of persons with potential alcohol use disorders [n = 873 (83%); p ≤ 0.001] and common mental disorders [n = 96(4%); p = 0.018], while CG-ASHAs identified significantly higher number of those with potential severe mental disorders [n = 61(61.61%); p ≤ 0.001]. As regards KAP, after controlling for baseline scores, the time effect in RMANOVA favoured SG-ASHAs. Mean total KAP score increased from 16.76 to18.57 (p < 0·01) in SG-ASHAs and from 18.65 to 18.84 (p = 0.76) in CG-ASHAs. However, the Time-group interaction effect did not favour either (F = 0.105; p = 0.748). Compared to traditional training, mentoring ASHAs for extended periods is more impactful. Easily accessible digital technology makes the latter feasible. Scaling up such initiatives carry the potential to considerably improve treatment access for those in need.

Successful use of ketamine to treat severe depression with suicidality post-COVID-19 - A case report.

Every second patient who suffers from COVID-19 experiences is at risk for depression. The treatment of severe depression with suicidal risk is challenging in patients with COVID-19 given the restrictions in access to and safety concerns with the use of electroconvulsive therapy during the COVID pandemic. Although ketamine is effective in treating depression, especially in presence of acute suicidality, to date, there are no reports on ketamine use to treat severe depression in the context of COVID-19. In this case report, we describe the success of ketamine to treat a person with severe depression and suicidality following COVID-19 infection.

Ethical and legal issues concerning COVID 19 vaccinations in persons with mental illness in India.

Mental healthcare in India faces severe challenges amid the ongoing pandemic. India runs the largest vaccination drive globally, including booster doses to rapidly vaccinate its population of over a billion. As persons with mental illness are at greater risk of adverse outcomes from COVID 19, they need prioritized access and administration of these vaccines. This manuscript examines the current legislation and identifies how the legal and ethical frameworks can prioritize COVID 19 vaccinations for persons with mental illness in India through a review of the various legislations of India concerning persons with mental illness and judicial judgments concerning the pandemic and vaccination. Subsequently, we discuss ethical and legal challenges associated with vaccination in this vulnerable population and possible solutions. Based on the current review, the authors recommend the guidelines for capacity assessment for vaccination decisions and discuss existing legal frameworks relevant to the vaccination of persons with mental illness.

Are the Collaborative Video Consultations module in Diploma in Primary Care Psychiatry helpful

Introduction: The ‘Diploma in Primary Care Psychiatry’ (DPCP) is a 1-year, module-based, digitally-driven, hybrid format, distance education training program conducted by Tele-Medicine Centre, Department of Psychiatry at National Institute of Mental Health and Neurosciences, Bengaluru for in-service MBBS doctors [Primary Care Doctors (PCDs)] of various states. This course can catalyze India’s National Mental Health Program for the capacity building of PCDs. We discuss the outcome of “Collaborative Video Consultation” (CVC) modules that mimics real-time expert guidance for the DPCP course conducted for MBBS in-service doctors of Bihar, India. Methodology: In one year, we supervised 217 CVCs. We examined the diagnostic concurrence between PCDs and tele-psychiatrists, reviewed the CVCs, and generated learning themes. Results: Among the total sample (n=217), 64 (29.9%) patients had Severe Mental Disorders, 73(32.8%) had Common Mental Disorders, and 36(14.7%) had substance use disorders. The diagnostic concurrence was 83%, with a kappa agreement of 0.77 (p<0.001). Learning themes that emerged ranged from diagnostic clarification to enhancement of clinical skills. Discussion: It is the first study to evaluate the impact of the CVC module. The 83% diagnostic concordance reflects on the overall effectiveness of the training modules. The learning themes that emerged were quite diverse and involved various aspects of psychiatric care. Hence, this training model in a post-COVID world is a feasible and scalable option for training primary care doctors in India, leading to a reduced treatment gap and global burden of disease. Introduction: Primary healthcare provides universally accessible ‘essential healthcare’ to individuals and families in the community. In India, the prevalence of psychiatric disorders in the National Mental Health Survey from a representative adult population was 10.6%1, and the treatment gap is more than 70% for all psychiatric disorders. Psychiatric disorders are major contributors to the global health burden1. To address this, empowering Primary Care Doctors (PCDs) in identifying, assessing, and managing first-line psychiatric illness in a primary care setting is the feasible strategy given the country’s inadequate psychiatrist to patient ratio. The concept of comprehensive primary healthcare services has been highlighted by the Bhore committee2 and demonstrated to be feasible through the landmark Bellary model3. However, with a population of 1.4 billion, India needs more novel methods to implement and sustain community psychiatry services through District Mental Health Program (DMHP). After the Mental Health care Act (MHCA) 20174, mental health services delivery in the community and deinstitutionalization have become a legal mandate in India. Since 2015 there has been a paradigm shift in the district mental health program delivery in Bihar state5 through an innovative, collaborative model between NIMHANS, National Health Mission (NHM) state health society, Bihar. The DMHP program has successfully trained several health care providers from Bihar Doctors and nurses from Bihar over the last three years. In 2017-18, eleven district medical officers were trained to initiate DMHP services.6 Despite this, there was a need to better prepare the primary doctors in psychiatry to provide mental healthcare services, especially given the lack of formal Psychiatric training beyond two weeks in undergraduate in most medical colleges. PCD training in mental health care involves several logistic challenges such as inadequate undergraduate training in psychiatry, time constraints in learning due to their hectic clinical work, lack of adequate human resources, and failure of multiple capacity-building programs through traditional classroom training. To overcome these challenges, Diploma in Primary Psychiatry (DPCP), a 1-year modular-based digitally-driven hybrid training program, was conceptualized by the Telemedicine Centre, Department of Psychiatry at Nationa Institute of Mental Health and Neurosciences) (NIMHANS) Bengaluru for DMHP capacity building. This course can be the catalyst to further mobilize India’s National Mental Health Program for the capacity building of PCDs. DPCP program was designed to cater to PCDs training in psychiatry with minimal disruption to their clinical duties with the incentive of career enhancement through an additional diploma degree. This program was initiated first with PCDs of Uttarakhand in collaboration with the State Government. The Uttarakhand DPCP program was reasonably effective and paved the way to conceptualizing other telemedicine-based innovative approaches to mental health capacity enhancement7. This study discusses the outcome of one of the modules, the Collaborative Video Consultation Module (CVC) (on-the-job supervised training by a board-certified psychiatrist) of the DPCP program for in-service MBBS doctors from Bihar. To evaluate the outcome of this training program, this paper focuses on assessing PCD’s ability to diagnose psychiatric disorders and their perception of learnings from the CVC module. Methodology: This paper was based on findings from the DPCP program conducted for in-service MBBS doctors of Bihar from February 2020 to March 2021. The overview of the program has been explained in brief below. So far, Telemedicine Centre, NIMHANS, Bengaluru, awarded DPCP to 20 in-service MBBS doctors of Uttarakhand. It follows the hybrid model of training with initial brief (5 days) onsite training at a tertiary care psychiatry department (NIMHANS), which has classroom sessions, consultation-based training (real-time observations of psychiatric assessments of patients and management), and also visit a DMHP center to understand the working of DMHP. This brief onsite module followed by everything digital modules aiming for direct skill transfer using adult learning principles (andragogy)8. The details about different modules of DPCP are described elsewhere9(https://pubmed.ncbi.nlm.nih.gov/32361210/) (https://pubmed.ncbi.nlm.nih.gov/30166682/). In continuation with the collaboration and to enable the provision of DMHP services across all districts of Bihar, primary care doctors from 19 districts of Bihar and 3 Prisons were enrolled in a one-year DPCP program. The curriculum for DPCP is Clinical Schedules of Primary Care Psychiatry version 2.2(CSP), which has a validated screening procedure and a heuristic point of care manual designed for PCDs10. The 22 PCDs came to NIMHANS from 17th February 2020 to 22nd February 2020. In this module, PCDs were trained in psychiatric history-taking and mental state examination through clinical demonstration and onsite classes. In-Person consultation-based training in the outpatient clinic was conducted at First contact and follow-up outpatient services of the Department of Psychiatry, NIMHANS, Bengaluru. All PCDs underwent didactic teaching sessions in Common mental disorders (CMDs), teaching sessions on specialized topics such as Emergency psychiatry, Geriatric Psychiatry, Child and Adolescent Psychiatry, Forensic and legal aspects of psychiatry, along with a visit to DMHP services at Chikkaballapur district, about 70 km from Bangalore, Karnataka. They also received orientation on Tele- On-Consultation-Training sessions and made them familiarised with the digital modules of DPCP and the telemedicine platforms. On returning to their workplace- District hospital settings, Digital Modules were initiated. This paper focuses on findings from the collaborative video consultation (CVC) module conducted throughout the course, especially after Tele on-consultation training module. CVC module Format: In the CVC module, instant video consultation is sought by trainee PCDs from tele-psychiatrist, which is a real-time second opinion from a board-certified psychiatrist. The Tele-psychiatrist was available to the PCDs during working hours and occasionally for emergency cases, anytime for discussion/advice. PCDs choose to discuss their selected patients to decide the best treatment for them or any ifficulty in diagnosis. Some of these patients were also seen in follow-ups up to 6 months whenever these patients visit these doctors (one of the criteria of formative assessment of DPCP course). Soon after CVC, a tele-psychiatrist enters all clinical data in a specially designed proforma containing learning points and whether PCD felt skill enhancement or not from each CVC. Diagnosis of the patient population is made as per clinical schedules of primary care psychiatry. Whenever clinical presentation is not allowing CSP diagnoses, ICD-10 CDDG diagnosis is considered. PCDs discussed several cases ranging from children, adolescents with mental health issues to elderly individuals with psychiatric complaints. PCDs were also actively involved in providing care to psychiatry patients who could not follow up with their treating psychiatrists during the 1st wave of the COVID 19 pandemic and travel restrictions during the lockdown. They also discussed patients presenting to emergencies with psychiatric disorders. The PCDs were motivated and actively involved in helping patients who needed psychiatry care, including counseling patients in isolation centers. Diagnostic concurrence was evaluated from similarities/differences in PCD and tele-psychiatrist diagnosis. The authors screened all the data entered in the CVC, and pre-defined learning themes were generated. The learning themes were finalized after agreement by all the authors. Data were analyzed using SPSS version 27.011. Results: In the past year, 217 CVCs were conducted for 15 PCDs as a part of the CVC module. The socio-demographic of these 217 cases are as follows (Table 2)Table 1 CVC module case discussion sheetDateTimeVerbal consent of patient/CaregiversCase descriptionPCD DiagnosisTele-psychiatrist diagnosisCMD/SMD SUDAdvisedLearning pointsDuration ofSessionTable 2 Socio-demographic profile of the CVC sample (n=217)SociodemographicMean (SD)/n (%)Age34.84 (15.75)Gender Male147 (67.7)Gender Female68 (31.3) The mean age of the clinical sample was 34 years (S. D – 15.75). The gender distribution of the sample has shown that males were more than females. Table 3 shows the psychiatric diagnosis made by the psychiatrist of the total sample. 64 (29.9%) of the patients had SMD (Severe Mental Disorders), 73 (32.8%) had CMD (Common Mental Disorders), and 36 (14.7%) had substance use disorders.Table 3 Psychiatric diagnosis of the total sample (n=217) by Tele-psychiatristPsychiatric Diagnosisn%Adapted primary care psychiatric diagnoses as per CSP manual Depressive disorder209.2 Generalized anxiety disorder2511.5 Panic disorder115.06 Somatization disorder73.2 Psychosis5726.3 Alcohol disorders73.2 Tobacco addiction20.9 Mixed anxiety and Depressive disorder136Non-CSP diagnosis (ICD-10 CDDG) Mental & behavioral disorders due to use of cannabinoids (F12)62.8 Mental & behavioral disorders due to use of opioids (F11)83.7 Mental & behavioral disorders due to use of sedatives or hypnotics (F13)52.3 Mental & behavioral disorders due to multiple drugs and use of other psychoactive substances (F19)83.7 Bipolar affective disorder current episode mania with psychotic symptoms (F31.2)62.8 Bipolar affective disorder current episode severe depression with psychotic symptoms (F31.5)10.5 Obsessive-compulsive disorder (F42)41.8 Dissociative disorders (F44)31.4 Personality disorders (F60)31.4 Intellectual Developmental Disorders (F70)41.8 Sleep Disorders83.7 Headache20.9 Organic mental disorders41.8 Not Yet Diagnosed136Table 4 Diagnostic concurrence between PCDs and tele-psychiatristDiagnosisnPercentagekappaPConcordance180/217840.78<0.001CSP-Concordance123/151870.83<0.001Non-CSP Concordance57/66750.71<0.001 Table 5 shows the diagnostic concurrence between PCD doctors and Tele-psychiatrists on the psychiatric diagnosis. Among diagnostic discordance, the distribution of psychiatric diagnosis was analyzed and presented below.Table 5 Distribution of psychiatric diagnosis among discordant diagnosisTele-psychiatrist diagnosisnPCD diagnosisDepressive d sorder1Anxiety disorder3Sleep disordersAnxiety disorders2Major Depressive disorder1Psychosis1Sleep disordersSomatization1Not yet diagnosedAlcohol dependence & related disorders1Psychosis1Not yet diagnosedPsychosis4Depressive disorder1Anxiety disorder2Mixed anxiety depression1Not yet diagnosedPersonality disorders2Anxiety disorders1Depressive disorderBipolar affective disorder2Depressive disorder1Psychosis1Alcohol dependence & relatedCannabis dependence & related disorders1PsychosisIntellectual Development Disorders (IDD)2PsychosisSleep disorder1Depressive disorderNot yet diagnosed1Psychosis3Anxiety disorderHeadache (Table 6) shows the descriptive analysis of the pre-defined learning themes obtained from PCD doctors at the end of each discussion.Table 6 Learning themes in PCDs after CVC discussionLearning ThemesFrequencyPercentageScreening for Psychiatric Disorders 31.4Symptomatology 2210.1Diagnostic clarification146.5Pharmacology - In drug dose/duration/side-effects/compliance2712.4Non-pharm management e.g., motivational interviewing104.6Identification of referral red flags136Handling difficult cases156.9Atypical presentations62.8Special population - Adolescent, pregnancy, elderly167.4Learning areas of error146.5Enhancement of clinical skills7735.5Table 7 Type of treatment received by clinical sample (n=17)Type of treatmentnPercentagePharmacotherapy + Counselling19087.6Antidepressants12238Antipsychotics6234.6Mood stabilizers63.7Only Counselling2712.4 Discussion: The study results demonstrate that PCDs could accurately diagnose psychiatric disorders with statistically significant (kappa value: 0.78) diagnostic concordance between PCDs diagnosis and tele-psychiatrist diagnoses. The learning acquired during CVCs demonstrated by the learning themes ranged from understanding psychopathology, arriving at a diagnosis, and planning treatment. The maximum number of CVCs who conducted the learning theme was the enhancement of their advanced clinical skills. Of the 217 CVCs, the PCDs prescribed both pharmacological and also non-pharmacological management (counseling) in a maximum number of patients (n=190, 87.6%) Assessing the effectiveness of a training program is essential;effectiveness is measured in several parameters such as knowledge attitude and practices of the trainee health workers through structured questionnaires, assessing patient outcomes, and evaluating the skill acquired12 . Collaborative Video Consultations (CVC) module is an instant video consultations module with trainer tele-psychiatrist on selected general patients, wherein, Tele-OCT module focused on imbibing basic clinical skills for identification and management of commonly presenting psychiatric illness in a PCD among consecutive general practice patients. At the same time, CVCs (which can be equated to second opinion through video consultations) are PCD-driven modules that focus on enhancing their skills obtained in the Tele-OCT module 13. In CVC, the initial screening of the patient is done by PCDs and reaches out to tele-psychiatrist in case of any clarification/difficulty for these selected patients. It is the first study to evaluate the impact of the CVC module. Since PCDs would have completed a minimum of one session of Tele-OCT before CVCs, it is expected that PCDs have been trained already in rapid screening and management of psychiatric disorders. Of the total CVC consultations, 83% had diagnostic concordance with kappa agreement of 0.78 which means to say that PCDs were able to diagnose most of the cases which reflect on the overall effectiveness of the DPCP program, in particular, the Tele-OCT module pointing towards achieving adequate competency to provide mental health care which is essential for assessing the impact of any medical training program14. The CVC module helped PCDs to sustain confidence secondary to real time positive feedback experience. This has also been proved in an earlier study on the impact of the overall effectiveness of training programs for PCDs in Bihar15. Gask L et al. (1998), in the pre-digital era, had discu sed the application of video feedback (playing of recorded videos of patient consultations) of training in mental health skills to address areas requiring improvement16, CVC which can be considered as an innovative digital module enables to provide real-time confidence maintaining feedback to the PCDs;thus the discordance of 17% also can be taken on a positive note as PCDs were able to identify their areas of error/doubts and bring it to discussion with tele-psychiatrist. On assessing the descriptive of learning themes, it has been shown that PCDs perceive skill enhancement in 35.5% of case discussions. This is in line with the objectives of CVCs, as basic training would have been done in previous modules, and CVCs essentially result in skill enhancement in the assessment, diagnosis, and management of psychiatric cases. CVCs allowed the Tele psychiatrists to observe and help the PCDs to refine and help PCDs gain new skills, the importance of knowledge transfer and case-based reader acceptance, which has been demonstrated in a study by Fleury, MJ et al. 2012 wherein they studied qualitative aspects of training of general practitioner in psychiatry17. Learning themes also reflected 7.4% of learning happened in special population management. PCDs need to be aware of psychiatric issues in special populations such as the elderly and pregnant women to facilitate appropriate and timely referrals and emergency management. Other learning themes such as handling complex cases, referral red flags, and atypical case presentations will likely help PCDs identify patients requiring specialist management. Some learning themes such as screening for psychiatric illness, diagnosis, and pharmacological management also reflect building upon their learned skills through Tele-OCT and getting practiced at CVC discussions. The documenting of the learning points enabled the tele-psychiatrist to assess the areas wherein PCD would require more handholding. The traditional classroom training focuses on knowledge transfer, whereas the CVC focuses on skill transfer using a bottom-up approach, in line with the adult learning principles. Though the training aimed to provide essential DMHP services, additional skills were also imbibed, as demonstrated by the various learning themes discussed in our study results. The CVC module also enabled the PCDs to collaboratively engage with the tele-psychiatrist, which would, in turn, will allow them to provide collaborative care under DMHP and be team leaders. In the absence of psychiatrists and difficulty to access the limited specialty psychiatric services, training of PCDs in psychiatry is vital;the CVC module is probably preliminary evidence that without such training, many individuals with mental health issues would remain undiagnosed and untreated and continue to be in the “functional treatment gap” among primary care attendees3. The learning and the training would serve the purpose of task sharing and task shifting in mental health, which is an effective strategy to address the treatment gap under the current scenario. Strengths & Limitations: This study is the first study to evaluate the effectiveness of the CVC module of the DPCP program by assessing the diagnostic concurrence. This study also involves a qualitative component of assessing learning themes, through which it assesses PCD’s perception about CVC discussions. This study also shows the feasibility of providing instant video consultations to all PCDs amidst the Covid pandemic. Follow-up data were not available, which is an essential limitation of this study. The authors are planning to incorporate it in future studies. Conclusion: In this study, we have discussed the implication of CVC on the training of PCDs and their skills. The study demonstrates the positive impact of the CVC on the training of PCDs in primary care psychiatry. Capacity-building training programs should employ training modules such as the CVC for effective training and better patient care. Such modules may be used not just to PCDs but to other cadres of the he lth care workforce. The symptomatic and functional outcomes of CVC-treated patients have to be studied in the future. The cost-effectiveness and impact on service provision need to be studied in the future. Further, there is also a need to assess and compare the various training formats in primary care psychiatry and its impact. Funding: The Training Program was funded by the State Health Society,Government of Bihar Acknowledgements: The researchers would like to thank the Doctors, Nurses who took up the training and were selflessly strived for ensuring best patient care. The Authors thank patients and families for their cooperation. We thank the NIMHANS Administration for their support in conducting the training program. We would like to express our gratitude to the Government of Bihar Administrators without whose efforts and collaboration this program would not have been possible. References: (Endnotes) 1. Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, Dua T, Ganguli A, Varghese M, Chakma JK, Kumar GA. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020 Feb 1;7(2):148-61. 2. Duggal R. Bhore Committee (1946) and its relevance today. 3. Van Ginneken N, Jain S, Patel V, Berridge V. The development of mental health services within primary care in India: learning from oral history. International journal of mental health systems. 2014 Dec;8(1):1-4. 4. Mental Health Care act 2017. 5. Mantri G. Many Indian states have less than 10 psychiatrists: These govt figures tell a shocking story. The News Minute. 6. Malathesh BC, Bairy BK, Kumar CN, Nirisha PL, Gajera GV, Pandey P, Manjunatha N, Ganesh A, Mehrotra K, Bhaskarapillai B, Gunasekaran DM. Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India. Psychiatric Quarterly. 2021 Sep 12:1-2 7. Pahuja E, Kumar TS, Uzzafar F, Manjunatha N, Kumar CN, Gupta R, Math SB. An impact of a digitally driven primary care psychiatry program on the integration of psychiatric care in the general practice of primary care doctors. Indian Journal of Psychiatry. 2020 Nov;62(6):690. 8. Knowles M. Andragogy: An emerging technology for adult learning. London, UK. 1996. 9. Pahuja E, Santosh KT, Harshitha N, Manjunatha N, Gupta R, Kumar CN, Math SB, Chandra PS. Diploma in primary care psychiatry: An innovative digitally driven course for primary care doctors to integrate psychiatry in their general practice. Asian journal of psychiatry. 2020 Apr 23;52:102129-. 10. Kulkarni K, Adarsha AM, Parthasarathy R, Philip M, Shashidhara HN, Vinay B, Manjunatha N, Kumar CN, Math SB, Thirthalli J. Concurrent validity and interrater reliability of the “clinical schedules for primary care psychiatry”. Journal of neurosciences in rural practice. 2019 Jul;10(03):483-8. 11. Nie NH, Bent DH, Hull CH. SPSS: Statistical package for the social sciences. New York: McGraw-Hill;1975. 12. Caulfield A, Vatansever D, Lambert G, et al WHO guidance on mental health training: a systematic review of the progress for nonspecialist health workers BMJ Open 2019;9:e024059. doi: 10.1136/ bmjopen-2018-024059 13. Pahuja E, Kumar S, Kumar A, Uzzafar F, Sarkar S, Manjunatha N, Balhara YP, Kumar CN, Math SB. Collaborative video consultations from tertiary care based telepsychiatrist to a remote primary care doctor to manage opioid substitution therapy clinic. Journal of Neurosciences in Rural Practice. 2020 Jul;11(03):498- 501. 14. Andrzej Wojtczak (2002) Glossary of medical education terms: Part 1, Medical Teacher, 24:2, 216- 219, DOI: 10.1080/01421590220120722 15. Malathesh BC, Bairy BK, Kumar CN, Nirisha PL, Gajera GV, Pandey P, Manjunatha N, Ganesh A, Mehrotra K, Bhaskarapillai B, Gunasekaran DM. Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India. Psychiatric Quarterly. 2021 Sep 12:1-2. 16. Linda Gask and Richard Morriss (1999). Training general practitioners in mental health skills. Epidemiologia ePsichiatria Sociale, 8, pp 79-84 doi:10.1017/S1121 89X00007570 17. Fleury, MJ., Imboua, A., Aubé, D. et al. General practitioners' management of mental disorders: A rewarding practice with considerable obstacles. BMC Fam Pract 13, 19 (2012). https://doi. org/10.1186/1471-2296-13-19