Primary‐level worker interventions for the care of people living with mental disorders and distress in low‐ and middle‐income countries

Abstract

Background

Community‐based primary‐level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low‐ and middle‐income countries. 

Objectives

To evaluate the effectiveness of PW‐led treatments for persons with mental health symptoms in LMICs, compared to usual care. 

Search methods

MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).  

Selection criteria

Randomised trials of PW‐led or collaborative‐care interventions treating people with mental health symptoms or their carers in LMICs. 

PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non‐health professionals (CPs). 

Data collection and analysis

Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality‐of‐life (QOL), functioning, service use (SU), and adverse events (AEs). 

Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. 

For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. 

Analysis timepoints: T1 (<1 month), T2 (1‐6 months), T3 (>6 months) post‐intervention. 

Main results

Description of studies

95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). 

Risk of bias

Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. 

Intervention effects

*Unless indicated, comparisons were usual care at T2. 

“Probably”, “may”, or “uncertain” indicates "moderate", "low," or "very low" certainty evidence.  

Adults with common mental disorders (CMDs)

a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56);

b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96);

c. may reduce symptoms (4 trials, 798 participants; SMD ‐0.59, 95%CI ‐1.01 to ‐0.16);

d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69);

e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD ‐0.47, 95%CI ‐0.8 to ‐0.15);

f. may reduce AEs (risk of suicide ideation/attempts);

g. may have uncertain effects on SU.

a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43);

b. may reduce prevalence although the actual effect range indicates it may have little‐or‐no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01);

c. may slightly reduce symptoms (6 trials, 4419 participants; SMD ‐0.35, 95%CI ‐0.63 to ‐0.08);

d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53);

e. probably has little‐to‐no effect on functional impairment (5 trials, 4216 participants; SMD ‐0.13, 95%CI ‐0.28 to 0.03);

f. may reduce SU (referral to MH specialists); 

g. may have uncertain effects on AEs (death).

Women with perinatal depression (PND)

a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54);

b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD ‐0.26, 95%CI ‐0.37 to ‐0.14);

c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD ‐0.23, 95%CI ‐0.41 to ‐0.04);

d. may have little‐to‐no effect on AEs (death); 

e. may have uncertain effects on SU.

a. has uncertain effects on symptoms/QOL/SU/AEs.

Adults with post‐traumatic stress (PTS) or CMDs in humanitarian settings

a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD ‐0.36, 95%CI ‐0.56 to ‐0.15);

b. probably slightly improve QOL (4 trials, 1918 participants; SMD ‐0.27, 95%CI ‐0.39 to ‐0.15);

c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs.

a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08); 

b. may have uncertain effects on symptoms/functioning/SU/AEs.  

Adults with harmful/hazardous alcohol or substance use

a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little‐or‐no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74);

b. may have little‐to‐no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD ‐0.14, 95%CI ‐0.32 to 0.03);

c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD ‐0.22, 95%CI ‐0.32 to ‐0.11); 

d. may have uncertain effects on SU/AEs.

a. probably have little‐to‐no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI ‐0.10 to 0.10);

b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD ‐0.20, 95%CI ‐0.35 to ‐0.05; moderate‐certainty evidence);

c. may have uncertain effects on prevalence (cannabis use)/SU/AEs.

a. may have uncertain effects. 

Adults with severe mental disorders

*Comparisons were specialist‐led care at T1.

a. may have little‐to‐no effect on caregiver burden (1 trial, 253 participants; MD ‐0.04, 95%CI ‐0.18 to 0.11); 

b. may have uncertain effects on symptoms/functioning/SU/AEs. 

a. may reduce functional impairment (7 trials, 874 participants; SMD ‐1.13, 95%CI ‐1.78 to ‐0.47);

b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU. 

Adults with dementia and carers

a. may have little‐to‐no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD ‐0.26, 95%CI ‐0.60 to 0.08);

b. may reduce carers' mental distress (2 trials, 134 participants; SMD ‐0.47, 95%CI ‐0.82 to ‐0.13); 

c. may have uncertain effects on QOL/functioning/SU/AEs.

Children with PTS or CMDs

a. may have little‐to‐no effect on PTS symptoms (3 trials, 1090 participants; MCD ‐1.34, 95%CI ‐2.83 to 0.14);

b. probably have little‐to‐no effect on depression symptoms (3 trials, 1092 participants; MCD ‐0.61, 95%CI ‐1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD ‐0.81, 95%CI ‐1.48 to ‐0.13); 

c. may have little‐or‐no effect on AEs.

a. may have little‐to‐no effect on depression symptoms (2 trials, 602 participants; SMD ‐0.19, 95%CI ‐0.57 to 0.19) or on AEs; 

b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

Authors' conclusions

PW‐led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Author(s)

Nadja vanGinneken, Weng Yee Chin, Yen Chian Lim, Amin Ussif, Rakesh Singh, Ujala Shahmalak, Marianna Purgato, Antonio Rojas-García, Eleonora Uphoff, Sarah McMullen, Hakan Safaralilo Foss, Ambika Thapa Pachya, Laleh Rashidian, Anna Borghesani, Nicholas Henschke, Lee-Yee Chong, Simon Lewin

Abstract

Plain language summary

The effects of primary‐level workers on people with mental disorders and distress in low‐ and middle‐income countries

This Cochrane Review update aims to assess the effects of engaging community‐based workers, such as primary‐care workers and teachers, to help people with mental disorders or distress. The review focused on studies from low‐ and middle‐income countries and found 95 studies for inclusion (including 23 from the previous review). 

Key messages

Primary health professionals, lay health workers, teachers, and other community workers may be able to help people with mental health issues if they are trained. However, more evidence is needed. 

What was studied in the review?

In low‐ and middle‐income countries, many people with mental illness do not receive the care they need because of stigma and difficulty accessing services. One solution is to offer services through ‘primary‐level workers’. These are people who are not mental health specialists but who receive some mental health training, including primary health professionals (e.g. doctors, nurses); lay health workers; community volunteers; and other community members (e.g. teachers, social workers). Primary‐level workers deliver these services alone or in collaboration with specialists.

What are the main results of the review?

95 relevant trials from 30 low‐ or middle‐income countries were found. 

The review authors searched for evidence about the effects of these strategies on the number of people who had mental health problems, the number who recovered, their symptom severity, quality of life, day‐to‐day functioning, use of health services, and negative effects of treatment. All results were measured one to six months after treatment completion, except in group 5, in which results were measured immediately after treatment completion. When results are not presented, this is because there was no evidence, or because the evidence was very uncertain. Evidence of the results below is of low to moderate certainty.

1. Adults with depression and anxiety

Treatments from lay health workers compared to usual care:

a. may increase recovery;

b. may reduce the number of people with depression/anxiety; 

c. may improve quality of life;

d. may slightly improve day‐to‐day functioning; and

e. may reduce risk of suicidal thoughts/attempts.

Treatments from primary‐level workers in collaboration with mental health specialists compared to usual care:

a. may increase recovery;

b. may reduce the number of people with depression/anxiety although the range for the actual effect indicates they may have little or no effect;

c. may slightly reduce symptoms;

d. may slightly improve quality of life;

e. probably have little to no effect on day‐to‐day functioning; and

f. may reduce referral to mental health specialists.

2. Women with depression related to pregnancy and childbirth

Treatments from lay health workers compared to usual care:

a. may increase recovery;

b. probably slightly reduce symptoms of depression;

c. may slightly improve day‐to‐day functioning; 

d. may have little to no effect on risk of death.

3. Adults in humanitarian settings with post‐traumatic stress or depression and anxiety

Treatments from lay health workers compared to usual care:

a. may slightly reduce depression symptoms; and

b. probably slightly improve quality of life.

Treatments from primary health professionals compared to usual care:

a. may reduce the number of adults with post‐traumatic stress and depression.

4. Adults with alcohol or substance use problems 

Treatments from lay health workers compared to usual care:

a. may increase recovery from harmful/hazardous alcohol use although the range for the actual effect indicates they may have little or no effect;

b. probably slightly reduce the risk of harmful/hazardous alcohol use;

c. may have little to no effect on day‐to‐day functioning; and

d. may have little to no effect on the number of people who use methamphetamine;

Treatments from primary health and community professionals compared to usual care:

a. probably have little to no effect on recovery from harmful/hazardous alcohol use;

b. probably slightly reduce risk of harmful/hazardous alcohol and substance use; and

c. probably have little to no effect on quality of life.

5. Adults with severe mental disorders (e.g. schizophrenia)

Treatments from lay health workers compared to mental specialists alone:

a. may have little to no effect on caregiver burden.

Treatments from primary health professionals alone or in collaboration with mental health specialists:

a. may improve day‐to‐day functioning.

6. Adults with dementia and their carers

Treatments from lay and professional health workers, compared to usual care:

a. may have little to no effect on the severity of behavioural symptoms in dementia patients; and

b. may reduce carers' mental distress.

7. Children in humanitarian settings with post‐traumatic stress or depression and anxiety

Treatments from lay health workers, compared to usual or no care:

a. may have little to no effect on post‐traumatic stress symptoms;

b. probably have little to no effect on depressive symptoms nor on day‐to‐day functioning; and

c. may make little or no difference in risk of adverse events.

Treatments from community professionals (teachers and social workers) compared to no care:

a. may have little to no effect on depressive symptoms; and

b. may make little or no difference in adverse events.

How up‐to‐date is this review?

Originally published in November 2013, this update includes studies published up to 20 June 2019.

Author(s)

Nadja vanGinneken, Weng Yee Chin, Yen Chian Lim, Amin Ussif, Rakesh Singh, Ujala Shahmalak, Marianna Purgato, Antonio Rojas-García, Eleonora Uphoff, Sarah McMullen, Hakan Safaralilo Foss, Ambika Thapa Pachya, Laleh Rashidian, Anna Borghesani, Nicholas Henschke, Lee-Yee Chong, Simon Lewin

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

Most results from the 95 randomised trials suggest that primary‐level workers (PWs) delivering interventions for the care of individuals with mental disorders and distress have some impact on patient outcomes, although most evidence is of low certainty. Given the multitude of settings, disorders, interventions, and health worker expertise covered in this review, studies within each category are still too few to allow conclusions on specific intervention characteristics (such as type of health worker, duration of intervention, levels of training and supervision, etc.) that may impact effectiveness.

Evidence does show important results across studies, in particular, the impact of lay health workers (LHWs) and primary health professionals (PHPs) on clinical symptoms and improvement in functioning and quality of life for patients, as mentioned above.

1. Adults with depression and anxiety

Treatments from LHWs compared to usual care may increase recovery, may reduce the number of people with depression/anxiety, may improve quality of life, may slightly improve day‐to‐day functioning, and may reduce risk of suicidal thoughts or attempts.

Treatments from primary‐level workers in collaboration with mental health specialists compared to usual care may increase recovery; may reduce the number of people with depression/anxiety, although the range for the actual effect indicates they may have little or no effect; may slightly reduce symptoms; may slightly improve quality of life; probably have little to no effect on day‐to‐day functioning; and may reduce referral to mental health specialists.

2. Women with depression related to pregnancy and childbirth

Treatments from LHWs compared to usual care may increase recovery; probably slightly reduce symptoms of depression; may slightly improve day‐to‐day functioning; and may have little to no effect on risk of death.

3. Adults in humanitarian settings with post‐traumatic stress or depression and anxiety

Treatments from LHWs compared to usual care may slightly reduce symptoms of depression; probably slightly improving quality of life.

Treatments from primary health professionals compared to usual care may reduce the numbers of adults with post‐traumatic stress and depression.

4. Adults with alcohol or substance use problems 

Treatments from LHWs compared to usual care may increase recovery from harmful/hazardous alcohol use, although the range for the actual effect indicates they may have little to no effect; probably slightly reduce the risk of harmful or hazardous drinking; may have little to no effect on day‐to‐day functioning; and may have little to no effect on the number of people who use methamphetamine.

Treatments from primary health and community professionals compared to usual care probably have little to no effect on recovery from harmful/hazardous alcohol use; probably slightly reduce risk of harmful/hazardous alcohol and substance use; and probably have little to no effect on quality of life.

5. Adults with severe mental disorders such as schizophrenia

Treatments from primary health professionals alone or in collaboration with mental health specialists compared to mental health specialists alone may improve day‐to‐day functioning.

6. Adults with dementia and their carers

Treatments from lay and professional health workers may have little to no effect on the severity of behavioural symptoms in dementia patients and may reduce carers' mental distress.

7. Children in humanitarian settings with post‐traumatic stress or depression and anxiety

Treatments from LHWs may have little to no effect on post‐traumatic stress symptoms; probably have little to no effect on depressive symptoms or on day‐to‐day functioning; and make little to no difference in adverse events.

Treatments from community professionals (teachers and social workers) may have little to no effect on depressive symptoms; and make little to no difference in adverse events.

Very few studies measured unintended consequences of PW‐led care. We divided adverse events (as per description in the methods) into clinical indicators, service delivery indicators, and social indicators. How we defined and categorised adverse events was arbitrary, reflecting lack of reporting for this important outcome. Health service utilisation was thus included within adverse events to reflect that increased utilisation is linked to worsening symptoms. Few studies reported adverse effects (although these studies seemed to describe a few of these). Of the adverse events reported, most were clinical indicators (such as suicide rates and worsening of mental health) and health service delivery indicators (hospital re‐admissions, increased use of outpatient or alternative mental healthcare services). There were no social indicators (such as measuring impact on social exclusion/integration), nor were there indirect effects on other parts of the primary health service delivery (e.g. diversion of resources leading to neglect of other aspects of care) or on carers. Such effects could impact the appropriateness and quality of care. 

Economic evaluation techniques are useful for conducting cost‐effectiveness analyses of different interventions to inform policy. Results from this review show that, in general, task‐shifting for the care of mental disorders and distress in LMICs could be cost‐effective, particularly for child and adolescent PTSD, perinatal depression, and alcohol and drug use, for which findings were consistent. This approach may be cost‐effective or cost‐saving for common mental disorders and severe mental disorders, though these findings were less consistent (see details in ). We found no data on adult PTSD or dementia. Although several studies that showed cost‐effectiveness in their settings have recommended implementing the intervention in LMIC settings, the numbers of studies identified were small. However, these results could start to inform and influence policy making regarding allocation of resources at a national level.

Implications for research 

Although this review has identified a large number of studies conducted in low‐ and middle‐income countries (LMICs), a number of important research questions remain. Research recommendations have been subdivided into those for trialists, those for systematic reviewers, and those for other researchers. 

Trialists 

Trialists need to: 

  • describe trial interventions better, for example, in terms of training, supervision, and incentives for primary‐level workers (PWs). This will allow systematic reviewers to identify and compare characteristics that may help to better explain the effects of PW interventions; 
  • conduct trials comparing interventions with different characteristics/types of PWs, modes of delivery, and types of training and supervision or intensity of intervention, to enhance understanding of the effects of these variations. This is particularly applicable to collaborative care and other complex interventions for which there may be several types of specialists and PWs and several types of interventions on offer (such as stepped care); 
  • conduct trials of different high‐risk populations (people living with HIV, people who are victims of domestic violence, veterans, etc.), as different populations may respond differently to these therapies and may have different outcomes of interest;
  • compare PWs versus specialists to assess the potential for task‐shifting/(substitution of roles); 
  • consistently consider whether and how to include adverse effects or unintended consequences of PWs related to safety. We noticed about half of trials did not report safety data. This could have affected confidence intervals around point estimates. Not all trials of health systems interventions (such as task‐shifting) will explicitly collect safety data, as it is often the case that main concerns do not reflect safety in the clinical sense but unintended adverse effects (e.g. negative changes in quality of care; fewer appropriate referrals). This points to the need for more trials to assess the most relevant adverse outcomes, whether for the patient or the service, and other adverse impact; 
  • include better data on service utilisation, which are important for understanding costs and cost‐effectiveness, but also for understanding (as mentioned above) the indirect consequences of an intervention for broader services provided and utilised;
  • improve the conduct of trials including more rigorous allocation concealment, randomisation, outcome assessment, and reporting; local validation of instruments; and agreement on standard instruments for specific outcomes and disorders to facilitate pooling and comparing of data;
  • use core outcome sets when available. This would be useful for developing core outcome sets when these are not yet available;
  • focus on clinical issues that have been poorly addressed to date, including severe mental disorders, alcohol/substance dependence, and child mental disorders; 
  • include process evaluations alongside trials, to (1) better understand intervention fidelity and the pathways through which interventions impact outcomes; (2) assess the indirect impact of delivering mental health care (when this is added to existing roles and tasks) on other elements of PW health care or other roles (e.g. is it taking time away from other job roles); and (3) assess the impact on well‐being of PWs (stress/burnout); and
  • consistently include economic data in their trials, as costs and cost‐effectiveness are important for health planning across all mental disorders and distress;

Low‐ to moderate‐certainty clinical evidence is available for common mental disorders (CMDs), adult post‐traumatic stress (PTS), and perinatal depression, but additional studies are needed to examine severe mental disorders, alcohol and drug use, dementia, child PTS, and other child mental disorders, which were not meta‐analysed.

Systematic reviewers 

Further systematic reviews drawing on a range of study designs (such as reviews on processes of care, but also economic evaluations and qualitative work) are needed, particularly to evaluate these trials through the implementation science lens and to provide broader certainty about whether they are feasible, acceptable, effective, and sustainable in their various settings. In particular, mixed qualitative and quantitative reviews should focus on: 

  • factors affecting the sustainability of PW interventions when scaled up; 
  • effectiveness of different approaches to ensure programme sustainability, including use of different types of incentives and payment systems for PWs; 
  • mechanisms for integrating LHW programmes into the formal health system; 
  • equity impact of these programmes and factors of accessibility and acceptability;
  • fidelity and quality of these programmes; and
  • cost‐effectiveness, coverage, and scalability of these programmes.

Other researchers 

Given the very broad range of PWs with considerable variation in their characteristics (e.g. training, supervision), settings, interventions, and delivery mechanisms in mental health care, there is a need to develop a comprehensive typology for PWs (and how they are selected, trained, and supported/supervised), as well as for the interventions they provide, which would help health planners and future researchers to develop more standardised and comparable interventions and situations. 

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