Research spotlight: Testing a model for depression care in Malawi using existing medical infrastructure

How would you summarize your study for a lay audience?

We tested a model of depression care in Malawi, a low-income country in sub-Saharan Africa, that builds off the infrastructure of the country’s HIV delivery system. The intervention involved clinical officers who delivered medications for depression, and it involved lay personnel, people living in the community, to deliver psychotherapy. Unlike past research, we did not limit our evaluation to improvements in depression; we also looked at improvements in other chronic health conditions that participants had, and we measured effects on household members.

What knowledge gap does your study help to fill?

Prior studies have examined the benefits and costs of mental health interventions in low-resource settings—but these are often standalone interventions that examine a narrow set of benefits among the recipients. As a result, oftentimes mental health interventions do not look particularly cost-effective. We assessed a mental health intervention that was integrated into an existing model of chronic care and examined a broader set of health benefits among recipients and members of their household.

What methods or approach did you use?

We conducted a stepped-wedge cluster randomized controlled trial. This means that the rollout of the mental health intervention was staggered across 14 health facilities throughout a rural district in Malawi, each randomized to start at different time periods. Ultimately, we enrolled 487 adults with major depressive disorder.

We found that the intervention improved depressive symptoms, reduced the prevalence of major depressive disorder, improved overall functioning, and it also reduced systolic blood pressure among those with hypertension.  We also found that the intervention also corresponded to improvements in depressive symptoms among household members. Once these benefits were fully incorporated, we found that the mental health intervention was highly cost-effective.

What did you find?

Participants had sizable improvements in their depression symptoms, and those who had hypertension also showed improvements in their blood pressure. Household members also experienced improvements in depression symptoms and their overall functioning. In terms of cost-effectiveness, the intervention translated to $329 per disability-adjusted life year averted once we accounted for the household benefits.

What are the implications?

Over 75% of people with mental health conditions in low-income countries fail to receive any treatment—in part because governments tend to think mental healthcare is not a cost-effective investment. We showed that interventions are cheap if they (1) build off existing infrastructure, (2) involve lay personnel, and (3) deliver therapy in a group format. We also show that the benefits of these interventions are often underestimated: because treating depression has knock-on benefits for participants’ physical health and household members’ wellbeing.

What are the next steps?

Our next goal is to integrate additional screening, diagnosis, and treatment protocols for mental health conditions into the chronic care platform in Neno District, Malawi—for example, for generalized anxiety disorder. Partners In Health, the implementation partner, also plans to decentralize the chronic care model so that it is operational at all facilities throughout the district, rather than limited to a mobile team that travels from facility to facility. We hope to present the final investment case to stakeholders, including the Ministry of Health, as they consider ways to scale up treatment for non-communicable diseases.

Authorship: Ryan K McBain, Owen Mwale, Kondwani Mpinga, Myrrah Kamwiyo, Waste Kayira, Todd Ruderman, Emilia Connolly, Samuel I. Watson, Emily B. Wroe, Fabien Munyaneza, Luckson Dullie, Giuseppe Raviola, Stephanie L. Smith, Kazione Kulisewa, Michael Udedi, Vikram Patel, Glenn J Wagner.

Paper cited: McBain, RK et al. “Effectiveness, cost-effectiveness, and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi: a stepped-wedge cluster-randomised trial” The Lancet DOI: 10.1016/S0140-6736(24)02149-4

Funding: The study was funded by the National Institute of Mental Health (NIMH: R01 MH117760). NIMH had no role in study design, study implementation, data analysis, writing the manuscript, or the decision to submit the manuscript for peer review.

Disclosures: The authors declare no competing interests.