The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation.

The 2010 Global Burden of Disease reported that depression ranks second in the league table of years of life lived with disability1 with a mean population point prevalence of about 5%.2 Social factors, particularly those related to economic or social disadvantages such as low education and violence, are major determinants.3 Depression is associated with profound functional impairment, increased mortality and a range of other global health concerns (for example poor infant growth,4 diabetes, cardiovascular disease and HIV5). A key grand challenge in global mental health is to develop and evaluate psychological treatments that can be delivered economically and appropriately.6 There is a robust evidence base in high-income countries that supports the efficacy of antidepressant medication and structured psychological treatments, particularly for moderate and severe depression.7 However, most people with depression do not receive either of these treatments.8,9 This so-called treatment gap is close to 90% in some countries.9 Adapting ‘off the shelf’ treatments, which have been developed in ‘Western’ cultural contexts for delivery by mental health professionals, to low- and middle-income countries has been associated with low acceptability and delivery challenges.10 The scarcity of mental health specialists in low- and middle-income countries, and the fact that even fewer work in primary care settings where most patients with depression present, has led to a focus on the role of non-specialist health workers in delivering treatments.11 Task-sharing, in which provision of psychological treatments are moved from specialists to workers with fewer qualifications following task-specific training and close supervision, has been shown to be an effective healthcare strategy to address this supply-side barrier.12 Ensuring contextual appropriateness would be expected to enhance patient acceptability and address demand-side barriers. The work described in this paper was carried out from October 2010 to September 2013 under the aegis of PREMIUM (a Program for Mental Health Interventions for Under-resourced Health systems) in India.13 The overall aim of the PREMIUM programme is to investigate a systematic, reproducible method for developing psychological treatments that incorporate global evidence, are contextually appropriate and can be delivered by non-specialist health workers. The specific objective of this paper is to describe the application of this systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare. By lay counsellor, we mean a person who has no professional qualification in mental healthcare although they may have other professional qualifications. Our work focused on developing a psychological treatment for three reasons. First, psychological treatments are comparable in effectiveness with antidepressants, have lower relapse rates and enhance recovery rates in antidepressant non-responders.14–16 Second, we observed low rates of adherence with antidepressants in our earlier research in India, even with adherence support measures provided by a case manager.17 Third, such treatments may be scalable in the context of the increased acceptability of counselling as a healthcare intervention in many countries, including India where this programme is being implemented. We focused on severe depression because evidence-based guidelines developed by the World Health Organization (WHO) and other regulatory bodies recommend structured psychological treatments for severe depression.7,18