Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV

Abstract

BackgroundThere is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale.MethodWe trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention.ResultsOf 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention.ConclusionWe have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial.Trial registrationISRCTN: ISRCTN25476759

Adapting a blended motivational interviewing and problem-solving intervention to address risky substance use amongst South Africans

“…Our finding that the use of peer counsellors was highly acceptable to recipients of the intervention further supports the appropriateness of assigning this intervention to non-speciality personnel. These findings support emerging evidence, which indicates that lay counsellors or non-speciality health personnel can be trained to deliver brief psychosocial interventions (Patel et al, 2011), including PST (Chibanda et al, 2011;van't Hof et al, 2011) for mental disorders with positive outcomes. This is important, as task-shifting responsibility for the delivery of these interventions to non-speciality personnel will in all likelihood improve the feasibility of implementing these interventions in LMICs as it circumvents one of the major barriers to the implementation of psychosocial interventions in these settings, namely the shortages of health professionals (Kakuma et al, 2011).…”

“…Although most of these 31 studies were conducted in high-income countries, several recent studies conducted in low-and middle-income countries (LMIC) provide emerging evidence that PST may be effective for reducing psychological distress (van't Hof, Stein, Marks, Tomlinson, & Cuijpers, 2011) and treating depression and anxiety (Chibanda et al, 2011) in these settings. Although these mental disorders often co-occur alongside substance userelated problems and while cognitive-behavioural therapy (CBT) is a well-established modality for addressing substance-related problems, very few studies have examined the efficacy of PST for addressing substance-related problems (D'Zurilla & Nezu, 2006).…”

“…Screening for substance use identifies whether patients' use places them and others at risk and hence warrants a brief intervention. Furthermore, recent studies have consistently shown that lay counsellors or non-speciality health personnel (e.g., community health workers) can be trained to effectively deliver brief psychosocial interventions (Patel, Chowdhary, Rahman, & Verdeli, 2011), including PST for mental disorders (Chibanda et al, 2011). The advantage of using PST within a task-shifting approach is that, PST follows clearly defined steps that are simple to teach to non-professional staff and easy to manualize; decreasing the risk of intervention drift and facilitating fidelity to the intervention.…”

Prevalence and correlates of probable post-traumatic stress disorder and common mental disorders in a population with a high prevalence of HIV in Zimbabwe

“…Psychosocial interventions such as the Friendship Bench (Chibanda et al, 2011, 2016) seem to reduce the perception of lack of control among affected populations (Miller & Rasmussen, 2010). The Zimbabwean Friendship Bench programme is a low-intensity psychological intervention that is successfully reducing the treatment gap for CMDs at the primary health-care (PHC) level.…”

Lean economies and innovation in mental health systems

“…Research in low-income settings in the US has shown investment in collaborative community partnerships, alongside service developments, is crucial for improving engagement and outcomes. 7 Moreover, mobilising communities through training laypersons to engage people with mental illness has demonstrated improvements in public mental health 8 and is particularly important in the context of limited effectiveness of current drug and psychological therapies. Social context helps explain variations in care and help-seeking, independent of healthcare resources.…”