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Table 2 Primary care recommendations for an adapted mhGAP-IG.v2

From: Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study

DOMAIN Primary Care Recommendations for an Adapted mhGAP-IG.v2
Rank ordered by mean score Based on all items receiving consensus after two waves of Delphi survey
(Wave 1: 75 CHC doctors; Wave 2: 59 CHC doctors)
Developing a patient-centered guide 1.1 Not just patient-centred but person-centred
 Ensure patient privacy
 Sensitive to events in patients life (i.e. grief)
 Accommodate for patient diversity
1.2 Provide a personalised patient management plan (PMP)
 developed in partnership with the patient
 flexible to evolve over time to suit patient needs
 outlines several strategies to elicit positive behaviour change
1.3 PMP to incorporate doctor, patient and administrative outcomes:-
 Doctor review of treatment progress (e.g. drug side effects, treatment changes)
 patient’s treatment evaluation (e.g. treatment experience and engagement with therapy)
 administrative tracker (e.g. consultation appointments and potential referral options)
1.4 Doctor with mental health certification to develop PMP template
1.5Address contextual differences
 Consider suicide risk as a priority
 Highlight family involvement in every stage of care
 Provide specific examples of patient success stories from Shenzhen
Depressive episodes in bipolar disorder 2.1 Differentiate between treatment practice for (uncomplicated) depression and depressive episode in bipolar disorder
 mood stabilizer required as an adjunct to antidepressant treatment
2.2 Check for symptoms of mania with the patient or with family members
Communicating depression to patients and the community 3.1 Doctors to play a role in improving community awareness and health literacy
3.2 Stronger emphasis of the role of family in patient support
3.3 Include strategies for CHC to monitor patients at risk of suicide
3.4 Expand content of patient psychoeducation
 include approaches to develop patient trust (e.g. listening with empathy)
 address any misconceptions about the disease
 provide treatment success stories
 prepare patients for community stigma
 discuss the importance of treatment adherence
 provide advice on engagement with activities
 encourage attendance of follow-up appointments with CHC/specialists
 agree to a management/healthcare plan
 provide advice on self-care
 Consider implementing an appointment system
Healthcare interconnectivity 4.1 Highlight community involvement with monitoring patients at risk of suicide
4.2 Clarify referral pathways and the division of professional responsibilities
4.3 Highlight opportunities for medical and non-medical intersectorial care*
4.4 Reference involvement of family as a component of intersectorial care
4.5 Include a reminder to keep the patient central to all discussions
Access/usage to depression questionnaires 5.1 Recommend questionnaire usage during management and/or/both follow-up
5.2 Questionnaires conducted in a private consultation room
5.3 Doctors & nurses can administer questionnaire (assuming training provided)
5.4 Clarify scope for tools (i.e. multiple times? non-clinic settings?)
Managing patient information 6.1 Review a patient’s history before consultation and update patient records
6.2 Supplement information from patient management system if necessary
6.3 Validate patients’ treatment with specialists, other treating doctors, family members or by sighting medication
6.4 Hold regular in-clinic meetings to discuss difficult cases with other doctors
Considering pharmacological interventions for depression 7.1 Address Dr’s role with regards to monitoring and changing drug dose
7.2 Include indication and side effect profiles for each drug group
7.3 Include drug availability & reimbursement status for each drug group
7.4 Include adherence advice for each drug group
7.5 Provide details of latest generation of drugs
7.6 Provide Chinese brand names
7.7 Add information for Benzodiazepines
Symptom presentation of depression 8.1 Guide should “reflect a real-life consultation”
 consider whether a patient had had a previous episode of depression
 ascertain details of relationship problems (including grief)
 assess patient’s risk of suicide early in consultation
 consider physical symptoms first
8.2 Include triggers and risk factors for depression
8.3 Diagnosis based on “a symptom spectrum rather than core symptoms alone”
 merge both the core and additional symptoms into one listing
 include loss of libido in symptom listing
 order the list by good predictors of depression/commonly seen symptoms
 provide additional details of symptom profile changes over time
8.4 Structural clarity to differentiate between physical and mental symptoms
8.5 Additional symptom information required for children
8.6 Careful quantifications/translations required for
 “sleeping too much”
 “talking and moving more slowly than usual”
Overall structure 9.1 Some or major restructuring needed to better reflect the context of use
9.2 Emphasise intersectorial involvement including family/community network
9.3 Highlight differences between depression and a depressive episode in bipolar disorder
9.4 Integrate follow-up and management into one continuous section
9.5 Commence assessment with consideration of patients at high risk of suicide
9.6 Place the patient at the centre of the guide
Follow-up 10.1 Define follow-up and explain why it is necessary
 to determine a patient’s treatment status
 to establish previous therapy/treatments received
 to monitor current treatment side effects & assess for improvement
10.2 Explain how to assess for improvement:- i.e. itemise signs of improvement
10.3 Highlight key CHC outcomes to be achieved from follow-up consultation
 options for basic psychotherapy at CHC level
 referral options for either psychological interventions/drug treatment
10.4 Itemise modes of follow-up contact (face-to-face, telephone, electronic)
10.5 Recommend preferred mode of consultation contact
 ideally, face-to-face follow-up for all patients
 at least, face-to-face for all those with serious conditions
 patient’s preference for non-emergency cases
10.6 Frequency and duration of contact determined by depression severity, risk of self harm and treatment compliance
  1. *schools; police; social services; work-place support groups; voluntary sector; other mental health support services; disabled persons federation