Task-shifted interventions for depression delivered by lay primary health-care workers in low-income and middle-income countries
Authors: Bolanle Adeyemi Ola, Olayinka Atilola
Journal: The Lancet Global Health (2019)

The treatment gap for depression is worse in sub-Saharan Africa than in high-income countries.1Kohn R Saxena S Levav I Saraceno B The treatment gap in mental health care.Bull World Health Organ. 2004; 82: 858-866PubMed Google Scholar In the 2005 World Mental Health survey,2Gureje O Uwakwe R Oladeji B Makanjuola VO Esan O Depression in adult Nigerians: results from the Nigerian survey of mental health and well-being.J Affect Disord. 2010; 120: 158-164Crossref PubMed Scopus (57) Google Scholar only about 17% of people with a 12-month history of diagnosable depression in Nigeria had received any treatment. This dire situation is sustained by various factors, including an extreme shortage of specialist mental health professionals, especially in rural areas where the majority of Nigerians live;3Ola B Crabb J Adewuya A Olugbile F Abosede OA The state of readiness of Lagos state primary health care physicians to embrace the care of depression in Nigeria.Community Ment Health J. 2014; 50: 239-244Crossref PubMed Scopus (12) Google Scholar insufficient mental health knowledge and skill among non-specialist physicians superintending over the few community health facilities attended by most people with mental health morbidities;4WHOMental health atlas 2011: country profile of Nigeria. Geneva: World Health Organization, 2011.https://www.who.int/mental_health/evidence/atlas/profiles/nga_mh_profile.pdf?ua=1Date: 2011Date accessed: April 4, 2019Google Scholar and mental health policy that is absent, poorly conceived, or not driven by evidence-based interventions.5Gureje O Lasebikan VO Use of mental health services in a developing country. Results from the Nigerian survey of mental health and well-being.Soc Psychiatry Psychiatr Epidemiol. 2006; 41: 44-49Crossref PubMed Scopus (86) Google Scholar In the absence of training resources to provide enough specialist manpower to bridge the huge gap in depression treatment, enhancement of the skill of primary care physicians in Nigeria has been the intervention model of choice, showing some promise.4WHOMental health atlas 2011: country profile of Nigeria. Geneva: World Health Organization, 2011.https://www.who.int/mental_health/evidence/atlas/profiles/nga_mh_profile.pdf?ua=1Date: 2011Date accessed: April 4, 2019Google Scholar Unfortunately, with a physician density of around 3–4 per 10 000 people6Nigerian Ministry of HealthThe national strategic health development plan framework (2009–2015).https://www.uhc2030.org/fileadmin/uploads/ihp/Documents/Country_Pages/Nigeria/Nigeria%20National%20Strategic%20Health%20Development%20Plan%20Framework%202009-2015.pdfDate: July, 2009Date accessed: April 4, 2019Google Scholar, physician-driven depression care is not pragmatic in Nigeria and other low-income and middle-income countries (LMICs). With the continuing reality of unmet treatment needs for depression and a shortage of professional resources, LMICs must continue to explore effective ways of closing treatment gaps that are less resource intensive. Some LMICs have explored task-shifted psychological or pharmacological interventions delivered by lay health workers (such as nurses and health technicians), but the evidence base is limited by the small number and low quality of available studies.7Oladeji BD Kola L Abiona T Montgomery AA Araya R Gureje O A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria.BMC Psychiatry. 2015; 15: 96Crossref PubMed Scopus (22) Google Scholar In addition, differences between the available studies, such as the model of task-shifted intervention adopted, the quality of supervision by physicians, and the regional differences in the minimum qualification, quality of training, and cognate experience of lay health workers have limited the generalisation of findings.7Oladeji BD Kola L Abiona T Montgomery AA Araya R Gureje O A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria.BMC Psychiatry. 2015; 15: 96Crossref PubMed Scopus (22) Google Scholar In The Lancet Global Health, Oye Gureje and colleagues8Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; (published online May 13. http://dx.doi.org/10.1016/S2214-109X(19)30148-2.)Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar report the results of a cluster-randomised trial designed to establish whether two different models of task-shifted intervention delivered by lay health workers in Nigeria could yield similar outcomes in patients with moderate to severe depression.8Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; (published online May 13. http://dx.doi.org/10.1016/S2214-109X(19)30148-2.)Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Patients in the intervention group received a fully structured and manualised intervention package that incorporated components of the WHO Mental Health Gap Action Programme intervention guide (mhGAP-IG) for depression as well as problem-solving therapy. Those in the control group received unstructured usual care, enhanced with mhGAP-IG-based training of providers in recognition of depression and basic psychological and pharmacological interventions for depression. In both groups, similar proportions of patients showed remission of depression (defined as a score of ≤6 on the nine-item patient health questionnaire) at 12 months (425 [76%] of 562 in the intervention group vs 366 [77%] of 473 in the control group; adjusted odds ratio 1·0 [95% CI 0·70–1·40]). These findings provide further evidence that task-shifted interventions for depression delivered by lay health workers are effective, irrespective of the adopted model (manualised mhGAP-IG plus problem-solving therapy or unstructured mhGAP-IG enhanced usual care). Both models are equally pragmatic and potentially useful components of primary mental health care in resource-poor settings where lay health workers constitute a high proportion of care providers. However, Gureje and colleagues' observation that the intervention group saw less frequent prescription of antidepressants compared with the control group (13% vs 32%), despite similar outcomes,8Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; (published online May 13. http://dx.doi.org/10.1016/S2214-109X(19)30148-2.)Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar raises an important issue. In the intervention group, the highly structured nature of the intervention, with the incorporation of problem-solving therapy, might have reduced the propensity of providers to prescribe antidepressants. It could be inferred that, although the mhGAP-IG training emphasises the use of both psychological and pharmacological interventions, in an unstructured intervention environment, lay health workers might have relied heavily on antidepressant medications. Critics of globalised mental health service packages such as the mhGAP-IG have raised such concerns—ie, that, in highly burdened primary-care settings in LMICs, health workers might unwittingly adopt the quick-fix allure of medications over the more culturally appropriate but time-consuming psychological intervention.9Fernando S Globalization of psychiatry—a barrier to mental health development.Int Rev Psychiatry. 2014; 26: 551-557Crossref PubMed Scopus (23) Google Scholar The training in problem-solving therapy and the manualisation of the intervention protocol might have reduced this tendency in the intervention group. Therefore, incorporation of and availability of skills in an evidence-based, culturally appropriate, and intensive psychological treatment could potentially reduce the need for and prescription of antidepressants in primary-care settings without compromising effectiveness. This will be an important consideration for Nigeria and other LMICs when scaling-up task-shifted models of care for depression among subpopulations such as adolescents and pregnant women, where antidepressant use might be unsafe. The future direction of research on intervention models for the depression treatment gap in LMICs is being shaped. Gureje and colleagues' findings must be confirmed in other countries with similar a primary-care landscape to that of Nigeria, and among special populations such as men, adolescents, and pregnant or post-partum women who are yet to be captured in previous studies. Such studies should be sufficiently powered to understand outcomes within the context of moderating and mediating factors. Furthermore, because the currently available studies are treatment-focused, there is a need to explore whether non-physician health workers in routine primary care can reliably assess and detect depression with little or no supervision by physicians. Finally, future implementation studies should assess the critical minimum qualification and cognate experience of lay health workers that yield the best outcomes in different domains. This research will provide some evidence for the standardisation of stepped-care for depression in LMICs that have wide disparities in the quality of human resources in primary-care settings. We declare no competing interests. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trialFor patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. Full-Text PDF Open AccessTask-shifting must recognise the professional role of nursesThe Nursing Now campaign and the designation of 2020 as the "Year of the Nurse and Midwife" by WHO highlights the need to acknowledge the competence, increase the influence, and maximise the contribution of nursing to the achievement of universal health coverage. However, poor perceptions and misrepresentation of the professional role of nurses persists. The cluster-randomised controlled trial by Oye Gureje and colleagues (April, 2019)1 published in The Lancet Global Health, which assessed the effectiveness of task-shifting and stepped care in the management of major depressive disorder at the primary health-care level in Nigeria, and the associated commentary by Bolanle Adeyemi Ola and colleagues,2 provide examples of how nurses are misrepresented and the need for the Nursing Now campaign. Full-Text PDF Open Access