Approaches to deliver depression care and understanding barriers and facilitators to implementation in people with tuberculosis in LMICs: a systematic review
Authors: Nava-Ruelas Rocio , Todowede Olamide , Siddiqi Najma , Elsey Helen 
Published: February 2024

Background
Depression is a common comorbidity in people with tuberculosis. Various approaches to delivering depression care for people with tuberculosis have been implemented in low- and middle-income countries. To date, there are no comprehensive reviews that summarise and explore the implementation of these approaches to delivering depression care for people with tuberculosis.

Objectives
To identify the various interventions and approaches to delivering depression care as part of routine tuberculosis care in low- and middle-income countries, and to summarise the barriers and facilitators to their implementation.

Review methods
We conducted a systematic review to identify the relevant evidence. We conducted searches in June and July 2020 in the following databases, from inception: MEDLINE, Scopus, PsycINFO, Web of Science, PubMed, EMBASE, Cochrane Library, SciELO and LILACS, Health Management Information Consortium. We also hand-searched the reference lists of the included studies. Two reviewers independently screened the titles and abstracts of all records. Two reviewers independently screened the full texts. We used the Mixed Methods Appraisal Tool for quality appraisal. We coded and synthesised the findings using the constructs of the Consolidated Framework for Implementation Research as an a priori guide to analyse the barriers and facilitators.

Results
The search retrieved 10,982 records, 39 studies were selected for full-text screening and 10 studies were included in the analysis. We categorised the interventions as psychological, combined (pharmacological and psychological), combined with socioeconomic support and screening-only approaches. The most commonly implemented types of intervention were psychological interventions, on their own or combined with pharmacological interventions or socioeconomic support. The most common barrier to implementation was the costs associated with the intervention and its implementation. There were multiple facilitators for implementation for all types of interventions in different Consolidated Framework for Implementation Research domains. Facilitators were related to the characteristics of the intervention (relative advantage), the inner setting (compatibility of the intervention with existing workflows) and the process of implementation (the positive attitudes of innovation participants).

Limitations
This study relied on published information; thus, it is possible that important barriers and facilitators were not reported in the published studies and were, therefore, absent from this evidence synthesis.

Conclusion
We identified psychological interventions as the most commonly implemented approach to the delivery of depression care for people with tuberculosis, alone or in combination with other approaches. We identified the increase in costs as a barrier experienced for all intervention types. We identified the relative advantage of the intervention, its compatibility and the beliefs and attitudes of people with tuberculosis, their families and communities as facilitators that were reported in all intervention types. The integration of depression care for people with tuberculosis in existing tuberculosis services is possible but will require the barrier of the costs associated with delivery and implementation to be addressed. This review was carried out during the COVID-19 pandemic, when the effects of the pandemic on tuberculosis and mental health services were yet to be seen. Future research should focus on the impact of the pandemic on tuberculosis and mental health services, and on people with tuberculosis and their mental health.

Funding
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 17/63/130.
A plain language summary of this article is available on the NIHR Journals Library website https://doi.org/10.3310/GRWH1425.