Chapter 2. Review of literature
2.2 Treatments for mental disorders through task sharing
Given the disturbing treatment gap for depression and CMDs and, by extension, perinatal depression, there have been calls to scale up treatment for mental disorders through ‘task sharing’ (WHO, 2008b). This was initiated through the landmark series in The Lancet in 2007, which called for the integration of mental health into general health care (Lancet Global Mental Health Group, 2007). Subsequently Collins et al. (2011) published a call for researchers to address this gap and evaluate whether task sharing using evidence-based psychological techniques would work for various mental disorders.
2.2.1 Task sharing using non-specialist workers
The World Health Organisation (WHO) defines task sharing as transferring specific tasks to health workers with shorter training and fewer qualifications, in order to make more efficient use of human resources (WHO, 2008b). Task sharing aims to utilise local, affordable personnel and resources, to provide services based at primary care platforms (Fairburn and Patel, 2014). This is essential as the majority of populations in LMICs seek health care only at primary levels (Singla et al., 2017).
Task sharing in mental health care involves using non-specialist health care workers, or those who have not had professional training in mental health, such as community health workers (CHWs), peer counsellors, or teachers. Other terms used for community based non-specialists include non-specialist providers and lay health workers. This thesis will use the term ‘CHWs’ as the generic term to describe non-specialists throughout, but where necessary will refer to the specific terms. This description does not include more specialised cadres such as nurses and doctors.
Task sharing aims to deliver mental health care through routine delivery systems under supervision from mental health specialists (Singla et al., 2017). The CHWs used for task sharing are usually members of communities who have no formal experience in delivering mental health treatments, and are subsequently trained in these particular projects to provide these services (Singla and Hollon, 2020). They then work with mild to moderate cases of mental illnesses, using specific techniques they have been trained in, and only refer more serious or suicidal cases to mental health specialists where available. This aims to reduce the burden on specialists and provide a basic level of mental health care for more of the population.
Recent recommendations in this field are that counsellors working in task-shared mental health interventions should come from the same community and background as the participants (Barnett et al., 2018; Verhey, Ryan
21 et al., 2020), so that they have an authentic understanding of the struggles of their participants, particularly if they are from situations of poverty or gender inequity (Pugach and Goodman, 2015; Thompson, Cole et al., 2012).
Importantly, Thomson (2016) warns that using CHWs is not a ‘cheap option’ in providing universal access to health care. Task-shared interventions that use CHWs need to invest time into understanding the social, political and economic context of the intervention and appropriately develop the skills of the CHW to meet these needs. Nevertheless, accumulating evidence suggests that CHWs can be trained to deliver evidence- based therapies effectively in LMICs, thereby increasing the number of providers who can provide these complex, multicomponent psychosocial treatments (Barnett et al., 2018).
2.2.2 Treatment modalities in task sharing
The treatment modalities most commonly used in task sharing for CMDs in adults and perinatal depression are psychoeducation, cognitive behavioural therapy (CBT), interpersonal therapy (IPT), behavioural activation, and problem solving therapy (PST). For more information on each modality see Davies et al. (2019). These were all developed in HIC (Verhey et al., 2020) and have been adapted to varying degrees for use in LMICs (Section 2.3.7 discusses this further).
The most frequently used treatment for adult depression in LMICs is CBT (Cuijpers, Karyotaki et al., 2018). In brief, CBT assists in identifying maladaptive cognitive patterns and aims to replace them with reality-based interpretations and behaviours. A few systematic reviews have analysed the effectiveness of various treatment classes, although it is difficult to compare these modalities against each other in different contexts and populations. Despite this, authors have found CBT to consistently be the most effective method in improving mental health outcomes across LMICs (Barbui et al., 2020; Cuijpers et al., 2018; Dennis, 2007; Singla et al., 2017; van‘t Hof, Cuijpers et al., 2011). The cognitive component of CBT may be quite complex for non- specialists and participants to grasp (Chibanda, Verhey et al., 2016), which may be a hinderance to conducting it effectively in LMICs. However, Papas et al. (2010) argue that the highly structured format of manualised CBT may in fact make it more feasible for non-specialists to conduct.
For treatment of perinatal common mental disorders (PCMDs) in LMICs, psychoeducation is the most predominant (at 33.3% of interventions), followed by problem solving (23.1%), CBT (17.9%), and behavioural activation or IPT (12.8%) (Singla et al., 2017). Psychoeducation, which involves the provision of information about the mental illness and providing basic strategies to manage and cope with it, is useful for task sharing because it is easy for CHWs to implement and requires less training and supervision.
22 In a review of interventions for PCMDs, Clarke et al. (2013) found that CBT or IPT treatments reported much larger effect sizes for PCMD symptoms than ‘health promotion’ interventions. In this review, health promotion interventions involved sharing of information on perinatal health (including psychoeducation), developing skills, and increasing social support. Still, these were found to have beneficial effects on PCMDs, and may have a wider reach of women than pure psychological interventions, and have the added benefit that they tend to address some of the determinants of PCMDs, such as poor maternal health, infant mortality, and lack of social support. They can also provide women an opportunity to share concerns and feelings, and receive social support from a group, which they may not do in individualised therapy (Clarke et al., 2013).
2.2.3 Treatment for CMDs using task sharing
A number of systematic reviews and meta-analyses have examined the effectiveness of task-shared interventions for CMDs in LMICs over the years. A meta-analysis by de Silva et al. (2013) found that psychosocial interventions targeting depression in LMICs had a moderate positive effect on social functioning (standardised mean difference (SMD): 0.46, 95% CI 0.24–0.69); and another by van Ginneken et al. (2013) found that task-shared interventions may improve depression and anxiety (risk ratio (RR): 0.30, 95% CI: 0.14 to 0.64).
More recently, Singla et al. (2017) found moderate to strong evidence for task sharing in reducing the burden of common mental disorders. This review of 27 studies found stronger evidence of effectiveness of task sharing, with a pooled effect size for all CMD outcomes of 0.49 (SMD) (95%, CI: 0.36–0.62), favouring intervention conditions. A meta-analysis by Cuijpers et al. (2018) found that the overall effect of task-shared psychotherapies in LMICs was high compared to HICs, with Hedges’ g = 0.73 (95%, CI: 0.51-0.96) after adjustment for publication bias, but that these results may have been influenced by comparing the intervention to treatment as usual control conditions (which usually comprises no treatment), and of lower quality interventions. The authors also state that even if these interventions are not necessarily more effective than those in Western countries, they are not less effective, and therefore conclude that treatment for depression in LMICs through psychotherapeutic techniques is effective.
The latest review of evidence in LMICs, an umbrella review of systematic reviews and meta-analyses of interventions treating various mental health outcomes, reported similar evidence to the previous reviews (Barbui et al., 2020). They found the most robust evidence of efficacy of psychosocial interventions to be for adults with depression in humanitarian settings (standardised mean difference (SMD): 0.87, 95% CI 0.67–1.07), and for adults with CMDs in all settings (SMD: 0.49, 0.36–0.62). They endorse the findings of the previous
23 studies in that “psychosocial interventions might have a clinically relevant effect” (p. 168). They go on to emphasise that “none of these effect sizes from the systematic reviews reached the maximum of the ratings in terms of strength of association and evidence of credibility” (Barbui et al., 2020, p. 168).
There is thus evidence that suggests that CHWs can deliver evidence-based treatments for CMDs with positive effects. However, the reviews all state that many studies are of low quality, and it is therefore hard to make assumptions about which interventions are more effective (Van Ginneken et al., 2013), and how they should be implemented or replicated (Barnett et al., 2018).
2.2.4 Treatment for perinatal depression using task sharing
There have been a relatively high number of task-shared interventions specifically focused on perinatal depression in LMICs. This may be due to the fact that pharmaceutical treatments for women in the perinatal period are not always safe for the foetus or for breastfeeding infants, and psychotherapies are seen as preferable (Davies, Rahman, et al., 2019). Two thirds of the trials included in the review by Singla et al. (2017) described above targeted only women, and many of these focused on perinatal depression. Three systematic reviews examining the effectiveness of interventions for perinatal mental health specifically were published in 2013, all of which found effect sizes favouring the interventions.
Rahman and colleagues (2013) identified 13 RCTs that aimed to improve mental health of women in the perinatal period in LMICs. They found a pooled effect size of the interventions on maternal depressive symptoms of −0.38 (95% CI: –0.56 to −0.21; I2 = 79.9%), with additional effects for children such as improved mother-infant interaction, better cognitive development and growth, reduced diarrhoeal episodes and increased immunization rates.
Clarke et al. (2013) identified 10 RCTs in LMICs using lay health workers in interventions for PCMDs, and found an overall reduction in PCMDs compared to usual care when using continuous data for PCMD symptomatology (effect size: -0.34, 95% CI: -0.53 to -0.16). Last, van Ginneken et al. (2013) also found that task-shared interventions may ‘slightly’ reduce symptoms for mothers with perinatal depression (SMD: -0.42, 95% CI: -0.58 to -0.26). As with the reviews of interventions addressing CMDs, these reviews suggest that task sharing for perinatal mental health using non-specialist workers may be effective in reducing symptoms of depression in LMICs, and in benefitting infants and children, but that the quality of this evidence remains relatively poor.
The above findings leave room for some doubt about the efficacy and replicability of findings from most task- shared interventions. However, as there is currently so little provision of treatment for mental disorders in
24 LMICs, and since it is unlikely that there will ever be sufficient professionals to deliver mental health care to all who require it (Singla et al., 2017), task sharing is currently the most viable approach to improving access to treatment for perinatal depression and CMDs (Bolton, 2019). In other words, given the fact that there is currently minimal treatment, some form of treatment through task sharing is better than nothing at all. In addition, there is currently no research demonstrating deleterious effects of task sharing for CMDs in LMICs.
This indicates that more effort needs to be put into examining exactly how treatments work, so that they can more adequately address the needs of underserved communities and ultimately improve treatment outcomes (Barnett et al., 2018; Cuijpers, 2019).