Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine.

INTRODUCTION: Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months. METHODS: A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months. PRELIMINARY RESULTS: For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months. CONCLUSION: This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.

Rettigheter og tvang i kommunale hjelpetilbud til personer med alvorlige samtidige rus- og psykiske lidelser: erfaringer med regelverket, i lys av menneskerettigheter.

Rights and coercion in municipal services for persons with co-occurring severe mental illness and substance use disorders - experiences with legal framework, in light of human rights. Aims: Persons with co-occurring severe mental illness and substance use disorders can have a considerable need for municipal health and care services but can be difficult to reach with such services. In Norway, there are known perceived ambiguities and obscurities in the legal framework for such services. This study aims to further examine these legal issues in a Norwegian context, by examining what challenges service providers experience in the practice of the current legal framework in this field. Design: The data consists of 13 qualitative interviews with strategically selected service providers from Norwegian municipalities and county governors' offices. The interviews were analyzed through systematic text condensation. Results: The participants reflections resulted in three especially salient perceived challenges in the practice of the current legal framework in this field: 'being dependent upon extra efforts that exceed the legal minimum requirements', 'lacking a legal basis and tools' and 'a complex and composite legal framework'. Conclusions: When seen in light of human rights, the three identified challenges in legal framework should be considered more closely both from a research perspective and from a policy making perspective. It should be investigated further whether human rights oblige the state beyond setting forth minimum requirements, how different human rights impact one another, especially with a view to service providers' rights v. service recipients' rights, and lastly if it is feasible to simplify or clarify the current legal framework to ensure adherence to the law and to promote equal practice among service providers.