Depression care in low-income nations can improve overall health

Treating people in low-income countries for major depressive disorder can also help improve their physical health and household members’ wellbeing, demonstrating that mental health treatments can be cost effective, according to a new RAND study.

Researchers examined a program in the sub-Saharan nation of Malawi that builds off the infrastructure of the country’s HIV care system and trains local people in rural communities to help treat people who suffer from depression.

The study found participants had significant improvements in their depression symptoms, and those who had hypertension also showed improvements in their blood pressure. In addition, household members of those treated experienced improvements in their own depression symptoms and their overall functioning.

The findings are published in the journal The Lancet.

“More than 75% of people with mental health conditions in low-income countries fail to receive any treatment, in part because governments tend to think mental health care is not a cost-effective investment,” said Ryan McBain, the study’s lead author and a senior policy researcher at RAND, a nonprofit research organization. “We showed that a strategy focused on integrated care and task-shifting can save money, and that the care has benefits that are usually underestimated because positive externalities are left unmeasured.”

In low- and middle-income countries, common mental disorders, including major depressive disorder, account for more years lived in disability than HIV and malaria combined. Nevertheless, the vast majority of affected individuals receive no treatment.

The funding landscape contributes to this disparity. For example, development assistance for HIV totaled $9.9 billion in 2021, compared to $217 million for common mental disorders -- a 45-fold difference.

At root is the perception that, relative to treatments for infectious diseases like HIV, treatments of common mental disorders are time-intensive and less cost-effective. The perception has been challenged, in part, by growing evidence that task-shifting from mental health professionals to lay health workers can maintain efficacy while reducing costs.

Researchers from RAND and partner organizations implemented a randomized trial in a network of 14 health facilities in a remote region of Malawi. The health facilities operated integrated chronic care clinics, a model in which HIV clinics are reconfigured to offer screening, diagnosis and treatment for a broad array of chronic health conditions such as hypertension, diabetes and asthma.

Adults were eligible for the study if they were newly diagnosed with major depressive disorder and were actively enrolled in an integrated chronic care clinic for treatment of one or more health conditions. Researchers enrolled 487 in the study.

The treatment for depression included group therapy sessions -- led by clinic staff and trained local community members -- that focused on managing stress, managing problems, behavioral activation, strengthening social support and maintenance routines. Some patients also received medication. All participants were followed for one year from the point that the facility they were attending started offering treatment.

The intervention resulted in 38% lower prevalence of depression, as well as significant improvements in depression and overall functioning among those attending facilities that had begun offering treatment, compared to those that had not begun offering treatment. In addition, six months following participants’ treatment initiation, household members reported fewer depressive symptoms, improved functioning, and sizable reductions in their perceived burden of care, relative to baseline.

“Interventions can be relatively cheap if they build off existing infrastructure, involve task-shifting to local community members, and deliver therapy in a group format,” McBain said. “We also show that the benefits extend to participants’ physical health and household members’ wellbeing.”

Support for the study was provided by the National Institute of Mental Health.

Other authors of the study are Owen Mwale, Kondwani Mpinga, Myrrah Kamwiyo, Waste Kayira, Todd Ruderman, Emilia Connolly, Fabien Munyaneza and Luckson Dullie, all of Partners In Health; Samuel I. Watson of the University of Birmingham; Emily B. Wroe, Giuseppe Raviola, Stephanie L. Smith and Vikram Patel, all of the Harvard Medical School;    Kazione Kulisewa of Kamuzu University; Michael Udedi of the Ministry of Health, Lilongwe, Malawi; and Glenn J. Wagner of RAND.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.