Integrating depression treatment into chronic health care improved well-being for both patients and their families
• Research Highlights
In many low- and middle-income countries, significant public health resources are devoted to addressing health conditions such as HIV and malaria, but most people with depression and other mental disorders do not receive any mental health treatment.
Integrating mental health care into routine medical care offers a promising approach to bridging this treatment gap, according to a study led by RAND researchers Ryan K. McBain, Sc.D., Sc.M. and Glenn Wagner, Ph.D . This integrated approach may also improve other patient health conditions and the well-being of family members, benefits that are often underestimated in cost-effectiveness evaluations.
What did the researchers do in the study?
The research team conducted a cluster-randomized controlled trial in 14 chronic health care facilities in the Neno district, a remote area in Malawi. These health facilities are HIV clinics that also offer screening, diagnosis and treatment for chronic conditions such as high blood pressure, diabetes and asthma. Clinic staff received initial training on study procedures, refresher training, and ongoing supervision.
Clinic patients were eligible to participate if they were newly diagnosed with depression (as determined by a standard depression screening and brief diagnostic interview) and were actively receiving care from one of the 14 clinics. A total of 487 participants were included in the study analyses.
The study began with a 3-month baseline period during which all 14 clinics provided care as usual. Participants with depressive symptoms attending the clinics while receiving care as usual were provided with psychoeducation and, if necessary, referred to a mental health provider in the Neno area or a regional hospital.
Thereafter, every 3 months, two or three clinics switched to providing comprehensive depression treatment, while the other clinics continued with care as usual. By the end of the study, all clinics provided comprehensive depression treatment. Clinic counselors provided treatment recommendations based on participants’ depressive symptoms, but each participant could choose the option they preferred: group therapy only, group therapy and antidepressants, or antidepressants only. Group therapy consisted of a standardized approach called Problem Management Plus, which covers topics such as managing stress, strengthening social connections, and supporting and developing daily routines that support well-being.
The researchers compared the integrated treatment with care as usual by measuring changes in participants’ depressive symptoms, daily functioning and chronic conditions every 3 months during the 27-month trial period. They also measured changes in depressive symptoms, functioning, and perceived burden of caregiving in a subset of household members from shortly before treatment to 6 months later.
The researchers estimated intervention costs by calculating the costs associated with all intervention activities, including education, screening, diagnosis, and care delivery.
What did the study find?
Most participants chose stand-alone group therapy as their preferred treatment.
Overall, receiving any type of depression treatment as part of ongoing health care led to a reduction in participants’ depressive symptoms and an increase in their functioning over time. Participants also experienced a slight reduction in systolic blood pressure while receiving depression treatment.
The results of comprehensive depression treatment extended to their household members. Household members were less likely to experience a depressive episode and showed improvement in depressive symptoms, daily functioning, and perceived burden of caregiving to support their family member.
After accounting for the improved well-being of both participants and their household members, the researchers determined that comprehensive depression treatment resulted in a 32% increase in cost-effectiveness relative to care as usual.
What do the results mean?
Study results suggest that integrating depression treatment into chronic health care improves well-being at both the individual and household levels and could be a cost-effective approach to care in low-resource settings.
The authors note that the study took place during the height of the COVID-19 pandemic, which may have affected subjects’ willingness to participate. They also note that the sample was 82% female—further research could help clarify why men may or may not choose to participate, and whether men experience similar improvements with comprehensive depression treatment.
The findings highlight the importance of considering how the effects of mental health treatment may extend to a person’s family, friends and wider social network. McBain and colleagues note that researchers, clinicians, public health workers, and policy makers are likely to underestimate the benefits of mental health care, especially in low-resource settings, when they focus solely on individual benefits who receives care.
Reference
McBain, RK, Mwale, O., Mpinga, K., Kamwiyo, M., Kayira, W., Ruderman, T., Connolly, E., Watson, SI, Wroe, EB, Munyaneza, F., Dullie, L. ., Raviola, G., Smith, SL, Kulisewa, K., Udedi, M., Patel, V., & Wagner, GJ (2024). Effectiveness, cost-effectiveness and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): A cluster-randomised controlled trial. The Lancet, 404(10465), 1823-1834. https://doi.org/10.1016/S0140-6736(24)01809-9
