Incorporating depression treatment into chronic disease care improved the well-being of both patients and their families
• Research Highlight
In many low- and middle-income countries, significant public health resources are devoted to addressing health conditions such as HIV and malaria, but the majority of people with depression and other mental disorders do not receive mental health treatment.
Integrating mental health care into routine medical care offers a promising approach to closing 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 can also improve other health conditions of patients and the well-being of their families, 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 centers in Neno district, a remote region of Malawi. These health centers are HIV clinics that also offer screening, diagnosis and treatment of 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 (determined by a standard depression screening and brief diagnostic interview) and were receiving active care at one of the 14 clinics. A total of 487 participants were included in the study analyses.
The study began with an initial three-month period during which all 14 clinics provided usual care. Participants with symptoms of depression who attended the clinics while receiving usual care received psychoeducation and, if necessary, were referred to a mental health care provider in Neno district or a regional hospital.
Then, every 3 months, two or three clinics transitioned to providing integrated treatment for depression, while the other clinics continued with usual care. At the end of the study, all clinics provided integrated treatment for depression. Clinical counselors provided treatment recommendations based on participants’ depression symptoms, but each participant could select the option they preferred: group therapy only, group therapy and antidepressant medication, or antidepressant medication only. Group therapy consisted of a standardized approach called Problem Management Plus, which covers topics such as managing stress, strengthening social connections and support, and developing daily routines that support well-being.
The researchers compared integrated treatment with usual care, measuring changes in participants’ depression symptoms, daily functioning, and chronic health conditions every 3 months during the 27-month trial period. They also measured changes in depressive symptoms, functioning, and perceived burden of care among a subset of household members, from just before the start of treatment to 6 months later.
The researchers estimated intervention costs by estimating the costs associated with all intervention activities, including training, screening, diagnosis, and care delivery.
What did the study find?
Most participants selected independent group therapy as their preferred treatment.
Overall, receiving any type of depression treatment as part of ongoing medical care led to a decrease in participants’ depressive symptoms and an increase in their functioning over time. Participants also showed a slight decrease in systolic blood pressure while receiving treatment for depression.
The effects of integrated depression treatment also extended to members of their households. Household members were less likely to experience a depressive episode and showed improvement in depressive symptoms, daily functioning, and perceived burden of caregiving in supporting their family member.
After accounting for improved well-being among both participants and their household members, the researchers determined that integrated depression treatment led to a 32% increase in cost-effectiveness relative to usual care.
What do the results mean?
Study results suggest that integrating depression treatment into chronic disease care improves well-being at both the individual and family levels and could be a cost-effective approach to care in low-resource settings.
The authors note that the study was conducted during the height of the COVID-19 pandemic, which may have influenced individuals’ willingness to participate. They also point out that the sample was made up of 82% women; More research could help clarify why men may or may not choose to participate and whether men show similar improvements with integrated depression treatment.
The findings highlight the importance of considering how the effects of mental health treatment can extend to a person’s family, friends and broader social network. McBain and colleagues note that researchers, clinicians, public health workers and policymakers are likely to underestimate the benefits of mental health care, especially in low-resource settings, when they focus solely on the benefits to the person. that receives the attention.
Reference
McBain, R.K., Mwale, O., Mpinga, K., Kamwiyo, M., Kayira, W., Ruderman, T., Connolly, E., Watson, S.I., Wroe, E.B., Munyaneza, F., Dullie, L. ., Raviola, G., Smith, SL, Kulisewa, K., Udedi, M., Patel, V. and Wagner, GJ (2024). Effectiveness, cost-effectiveness and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): a stepwise, cluster-randomized controlled trial. the lancet, 404(10465), 1823-1834. https://doi.org/10.1016/S0140-6736(24)01809-9
