Adaptation of problem-solving therapy for primary care to prevent late-life depression in Goa, India: the 'DIL' intervention

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Primary mental healthcare for older people in India: between stigmatization and community orientation

BACKGROUND

Questions of equitable access to primary mental healthcare (PMHC) for older persons in India have been examined mostly in terms of the coverage of services, although perceptions of mental health and old age and social norms at the community level should be considered in the shaping of PMHC approaches. The present qualitative study, therefore, examined how social perceptions and norms of mental health in old age are and should be considered in the design and implementation of primary healthcare approaches in India.

METHODS

A secondary thematic analysis of semi-structured interviews with key stakeholders (n = 14) of PMHC in India was conducted.

RESULTS

Four key themes emerged from the analysis, in which social perceptions and norms were discussed: (1) family participation and low threshold access to mental healthcare, (2) the position of community health workers as an important pillar of old age and mental health-sensitive community-based care, (3) the role of social cohesion and traditional values in fostering a positive and supportive community environment for old age mental health, and (4) the empowerment of communities, families and older persons through mental health education.

CONCLUSIONS

PMHC, with its focus on mental health promotion, could be an important anchor for combatting negative attitudes about mental health and old age. The findings presented in this study can inform age-sensitive policies and programmes for mental health in India and could inform future research on the subject.

Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis

We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.

Problem Solving as an Active Ingredient in Indicated Prevention and Treatment of Youth Depression and Anxiety: An Integrative Review

Problem solving is a common focus of psychological interventions for young people. However, existing evidence syntheses are relatively limited in their scope and conclusions. Taking a transdiagnostic approach and incorporating diverse sources of evidence, we examined the role of problem solving as an active ingredient for the indicated prevention and treatment of depression and anxiety in 14-24-year-olds. Three information sources were integrated using framework synthesis: (1) a systematic review of randomized controlled trials of problem solving; (2) a metasynthesis of qualitative evidence on the therapeutic experience of problem solving; and (3) consultations with a Youth Advisory Group. Intervention protocols that included problem solving and no more than one other specific component appeared to be effective for depression but not anxiety. Larger multicomponent interventions with a problem-solving element achieved moderate effect sizes for both conditions. There was no clear evidence that effectiveness varied by population characteristics, intervention formats, or contextual factors. Qualitative evidence and youth consultations highlighted positive views about the practicality, simplicity, and flexibility of problem solving. Converging sources also suggested changes in problem orientation as a key transdiagnostic process contributing to positive outcomes. Problem solving is a widely applicable therapeutic approach that can help young people with emotional problems to resolve specific stressors and lead to a more hopeful mindset about managing future challenges. Implications for practice are discussed.

Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC.

METHODS

Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers.

RESULTS

From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish.

CONCLUSIONS

Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO [CRD42021271404].

Adapting an intervention of brief problem-solving therapy to improve the health of women with antenatal depressive symptoms in primary healthcare in rural Ethiopia

BACKGROUND

Evidence-based brief psychological interventions are safe and effective for the treatment of antenatal depressive symptoms. However, the adaptation of such interventions for low- and middle-income countries has not been prioritised. This study aimed to select and adapt a brief psychological intervention for women with antenatal depressive symptoms attending primary healthcare (PHC) in rural Ethiopia.

METHODS

We employed the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. Alongside this, we used the ADAPT-ITT model of process adaptation and the ecological validity model (EVM) to guide content adaptation. We conducted formative work, comprising a qualitative study, a series of three participatory theories of change workshops and an expert adaptation workshop to assess the needs of the target population and to select an intervention for adaptation. The adaptation process followed a series of steps: (1) training Ethiopian mental health experts in the original South African problem-solving therapy (PST version 0.0) and an initial adaptation workshop leading to PST Version 1.0. (2) Version 1.0 was presented to perinatal women and healthcare professionals in the form of a 'theatre test', leading to further adaptations (version 2.0). (3) Local and international stakeholders reviewed version 2.0, leading to version 3.0, which was used to train 12 PHC staff using clinical cases. (4) Finally, feedback about PST version 3.0 and its delivery was obtained from PHC staff.

RESULTS

In the first step, we modified case examples and terminology from the South African model, introduced an in-session pictorial flipchart for this low literacy setting, and added strategies to facilitate women's engagement before translating into Amharic. In the second step, adaptations included renaming of the types of problems and inclusion of more exercises to demonstrate proposed coping strategies. In the third step, the components of motivational interviewing were dropped due to cultural incongruence. In the final step, refresher training was delivered as well as additional training on supporting control of women's emotions to address PHC staff training needs, leading to the final version (version 4.0).

CONCLUSION

Using a series of steps, we have adapted the content and delivery of brief PST to fit the cultural context of this setting. The next step will be to assess the feasibility and acceptability of the intervention and its delivery in antenatal care settings.

The architecture of the primary mental healthcare system for older people in India: what public policies tell us

Background

Old age mental healthcare is an issue that cuts across old age, general health, and mental healthcare policies. While strengthening the primary mental healthcare system in India is a common strategy across policy fields to improve the mental health of older persons, very little is known about the system’s planned architecture. This study explores public policy strategies for and approaches to the mental health of older persons, focusing on the primary healthcare (PHC) level and the role of the family.

Methods

A document analysis of 39 key public national policy documents (2007 – 2019) from three thematically grouped policy fields (mental health, old age, and general health) was conducted.

Results

Comprehensive community-based primary mental healthcare – focusing on vulnerable population groups including older persons – has been strengthened significantly since 2007. The promulgated approaches and strategies build on traditional community-based approaches to mental healthcare in India. They focus on (a) integrating community health workers into primary mental healthcare, (b) empowering the community to participate in healthcare planning, implementation, and monitoring, (c) supporting the family through a family-led approach to mental healthcare, and (d) integrating traditional Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy (AYUSH) services into primary mental healthcare.

Conclusions

While all policy fields address mental PHC, they do so in different ways, and approaches and strategies that promote an integrated perspective across policy fields are lacking. To realize the policies vision, strengthening PHC will be essential. Further research should evaluate strategies and approaches in light of social developments, such as eroding family norms and the poor state of the public health system in India, in order to assess their opportunities, challenges, and overall feasibility, with the benefits older people would experience taking centre stage in these inquiries.

Primary mental health care for older persons in India: how age-inclusive are public policies?

The need to improve the primary mental healthcare system in India has gained increasing public health attention. Concomitantly, efforts to frame and develop appropriate public mental health care through legislation and related strategies and programmes have been undertaken. Because older people in India are particularly prone to mental health problems, this study explores the inclusiveness of Indian public policies in addressing the primary mental health care needs of older people from a cross-policy perspective. The basis of this thematic document analysis is 41 key national strategic documents (1999-2018) from different thematically grouped policy fields. In the context of population ageing, socio-economic challenges for older people and changing family norms, the policies delineate a pronounced interest in old-age-inclusive primary mental health care, whereas international policies are regarded as important reference points. While some of the policies address older persons as a vulnerable group in general, others delineate a more differentiated picture of the older population. Moreover, as new rights with implications for old-age mental health care, including community-based access to mental health care, have emerged, an integrated old-age mental healthcare policy spanning across sectors remains absent. Although old-age-inclusive primary mental health care is an emerging trend in India, its development as a cross-cutting policy issue remains in its infancy. Accordingly, unambiguous integrated policy approaches are needed to address the complex mental healthcare needs of older persons, and further research should be undertaken to focus on mental healthcare strategies and approaches at the primary care level.