Task-shifted psychotherapy for depression in people living with HIV
Authors: Eirini Karyotaki, John A Naslund
Journal: The Lancet Global Health (2020)

People living with HIV face high amounts of distress and are more likely to have common mental disorders compared with the general population.1Chibanda D Cowan F Gibson L Weiss HA Lund C Prevalence and correlates of probable common mental disorders in a population with high prevalence of HIV in Zimbabwe.BMC Psychiatry. 2016; 16: 55Crossref PubMed Scopus (31) Google Scholar Psychological health problems, such as depression, are associated with delayed diagnosis of HIV, poor adherence to antiretroviral therapy, and increased likelihood of disease progression.2Gaynes BN O'Donnell J Nelson E et al.Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential.Gen Hosp Psychiatry. 2015; 37: 277-282Crossref PubMed Scopus (30) Google Scholar Managing the symptoms of mental health problems in people living with HIV is imperative to improve the disease prognosis and reduce the risk of virus transmission. In The Lancet Global Health, Etheldreda Nakimuli-Mpungu and colleagues3Nakimuli-Mpungu E Musisi S Wamala K et al.Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; (published online Feb 5)https://doi.org/10.1016/S2214-109X(19)30548-0Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar report the results of a multicentre trial aimed at examining the effects of group support psychotherapy delivered by trained lay health workers in reducing depressive symptoms of people living with HIV in Uganda. Importantly, this study builds on well-established evidence that psychotherapy is effective in reducing symptoms of depression.4van Luenen S Garnefski N Spinhoven P Spaan P Dusseldorp E Kraaij V The benefits of psychosocial interventions for mental health in people living with HIV: a systematic review and meta-analysis.AIDS Behav. 2018; 22: 9-42Crossref PubMed Scopus (24) Google Scholar Further, given the shortage of trained clinicians and mental health specialists in low-income and middle-income countries (LMICs), shifting tasks from professionals to lay health workers offers a promising way to deliver evidence-based psychotherapy.5Raviola G Naslund JA Smith SL Patel V Innovative models in mental health delivery systems: task sharing care with non-specialist providers to close the mental health treatment gap.Curr Psychiatry Rep. 2019; 21: 44Crossref PubMed Scopus (29) Google Scholar Ample evidence has supported the effectiveness of task-shifted psychotherapy for depression.6Singla DR Kohrt BA Murray LK Anand A Chorpita BF Patel V Psychological treatments for the world: lessons from low- and middle-income countries.Annu Rev Clin Psychol. 2017; 13: 149-181Crossref PubMed Scopus (226) Google Scholar However, relatively less is known about the effects of psychotherapy delivered by lay health workers for people with comorbid depression and HIV. Nakimuli-Mpungu and collegues3Nakimuli-Mpungu E Musisi S Wamala K et al.Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; (published online Feb 5)https://doi.org/10.1016/S2214-109X(19)30548-0Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar randomly assigned 30 HIV care centres to deliver either group supported psychotherapy (n=578 participants) or group HIV education (n=562 participants). The authors found that significantly fewer people who followed the group support psychotherapy had major depression and such individuals had higher function scores compared with those who followed the group HIV education at 6 months post-treatment. The authors also reported that the intervention resulted in sustained improvements in suicide risk, hazardous alcohol use, and post-traumatic stress symptoms.3Nakimuli-Mpungu E Musisi S Wamala K et al.Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; (published online Feb 5)https://doi.org/10.1016/S2214-109X(19)30548-0Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar In addition to these striking findings, several other aspects are worth noting. First, the trial showed compelling cost-effectiveness outcomes. So far, evidence of the cost-effectiveness of psychological interventions in LMICs has mainly been derived from cost-modelling studies or trials done in high-income countries.6Singla DR Kohrt BA Murray LK Anand A Chorpita BF Patel V Psychological treatments for the world: lessons from low- and middle-income countries.Annu Rev Clin Psychol. 2017; 13: 149-181Crossref PubMed Scopus (226) Google Scholar, 7Levin C Chisholm D Chapter 12. Cost-Effectiveness and affordability of interventions, policies, and platforms for the prevention and treatment of mental, neurological, and substance use disorders.in: Patel V Chisholm D Dua T Mental, neurological, and substance use disorders: disease control priorities. 3rd edn. The International Bank for Reconstruction and Development/The World Bank, Washington2016https://doi.org/10.1596/978-1-4648-0426-7_ch12Date accessed: December 30, 2019Crossref Google Scholar Nakimuli-Mpungu and colleagues3Nakimuli-Mpungu E Musisi S Wamala K et al.Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster randomised trial.Lancet Glob Health. 2020; (published online Feb 5)https://doi.org/10.1016/S2214-109X(19)30548-0Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar showed that treating depression in people living with HIV cost US$13 per DALY averted. This adds compelling evidence of the cost-effectiveness of treating depression among people living with HIV in LMICs, which can inform policymakers and implementation efforts. In light of these promising cost outcomes, future research should further examine whether cost-effectiveness of group psychological interventions delivered by lay therapists is replicable across diverse settings and countries. Second, unlike previously examined interventions in low-resource settings, the group support psychotherapy in the trial of Nakimuli-Mpungu and colleagues included content on income-generating skills. This is an interesting and potentially important intervention component since greater income inequality and poverty are associated with increased risk of depression,8Patel V Burns JK Dhingra M Tarver L Kohrt BA Lund C Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms.World Psychiatry. 2018; 17: 76-89Crossref PubMed Scopus (106) Google Scholar whereas depression is consistently linked with lower income levels and higher likelihood of unemployment.9Lund C Breen A Flisher AJ et al.Poverty and common mental disorders in low and middle income countries: a systematic review.Soc Sci Med. 2010; 71 (1982): 517-528Crossref PubMed Scopus (546) Google Scholar It would be especially informative if future subanalyses of this trial examine whether improvements in depressive symptoms contributed to better chances at securing employment or vice versa. Such analyses would inform the development of interventions aimed at improving the depression and productivity prospects of people living with HIV. Third, the finding that the effect of the intervention was larger among male participants requires further investigation. Although it is possible that group support psychotherapy is appealing to men, it is also plausible that male participants in this study were already engaged in HIV care and thus were more likely to engage and benefit from the intervention. Future research should explore whether integrating group supported psychotherapy into HIV care would attract men and better engage them in services. Finally, in the trial of Nakimuli-Mpungu and colleagues, the delivery of group support psychotherapy relied on volunteer health workers. Relying exclusively on volunteering is probably not sustainable, and such a model might be difficult to replicate in other low-resource settings where lay health workers need to be compensated for care delivery. Further, the need to integrate community services delivered by health workers into national health systems in LMICs through hiring and compensation, training and opportunities for career development, and ongoing supervision and support has been highlighted as being a crucial element to achieve universal health coverage.10Tulenko K Møgedal S Afzal MM et al.Community health workers for universal health-care coverage: from fragmentation to synergy.Bull World Health Organ. 2013; 91: 847-852Crossref PubMed Scopus (121) Google Scholar Future studies should examine efforts to work with health systems towards establishing payment models and incentives to ensure the sustainability of group psychological interventions delivered by lay health workers as part of primary care for people living with HIV in LMICs. Nakimuli-Mpungu and colleagues show that task-shifted group psychotherapy might be a promising solution in reducing symptoms of depression among people living with HIV in Uganda. These findings open new research avenues for the mental health care of people living with HIV, and to addressing the major challenges posed by comorbid depression with HIV for individuals and society, especially in LMICs where specialty mental health providers are scarce. We declare no competing interests. Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomised trialIntegration of cost-effective psychological treatments such as group support psychotherapy into existing HIV interventions might improve the mental health of people living with HIV. Full-Text PDF Open Access