Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries

18 January, 2020

Below are the citation and summary of a new paper by HIFA member and supporter Vikram Patel in The Lancet Psychiatry:

CITATION: Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review

Prof Corrado Barbui et al.

Lancet Psychiatry 2020

Published:January 13, 2020DOI:https://doi.org/10.1016/S2215-0366(19)30511-5

SUMMARY

Background: Mental health conditions are leading causes of disability worldwide. Psychosocial interventions for these conditions might have a key role in their treatment, although applicability of findings to poor-resource settings might be a challenge. We aimed to evaluate the strength and credibility of evidence generated in low-income and middle-income countries (LMICs) on the efficacy of psychosocial interventions for various mental health outcomes.

Methods: We did an umbrella review of meta-analyses of randomised studies done in LMICs. Literature searches were done in Medline, Embase, PsychINFO, CINAHL, Cochrane Library, and Epistemonikos from Jan 1, 2010, until May 31, 2019. Systematic reviews of randomised studies investigating the efficacy of psychosocial interventions for mental health conditions in LMICs were included. Systematic reviews of promotion, prevention, and protection interventions were excluded, because the focus was on treatment interventions only. Information on first author, year of publication, outcomes, number of included studies, and reported summary meta-analytic estimates was extracted from included meta-analyses. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects, and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was assessed using quantitative umbrella review criteria, and credibility of evidence using the GRADE approach. This study is registered with PROSPERO, number CRD42019135711.

Findings: 123 primary studies from ten systematic reviews were included. The evidence on the efficacy of psychosocial interventions in adults with depression in humanitarian settings (standardised mean difference 0·87, 95% CI 0·67–1·07; highly suggestive association, GRADE: moderate) and in adults with common mental disorders (0·49, 0·36–0·62; highly suggestive association, GRADE: moderate) was supported by the most robust evidence. Highly suggestive strength of association was found for psychosocial interventions in adults with schizophrenia for functional outcomes, in adults with depression, and in adults with post-traumatic stress disorder in humanitarian settings. In children in humanitarian settings, and in children with disruptive behaviour, psychosocial interventions were supported by suggestive evidence of efficacy.

Interpretation: A relatively large amount of evidence suggests the benefit of psychosocial interventions on various mental health outcomes in LMICs. However, strength of associations and credibility of evidence were quite variable, depending on the target mental health condition, type of population and setting, and outcome of interest. This varied evidence should be considered in the development of clinical, policy, and implementation programmes in LMICs and should prompt further studies to improve the strength and credibility of the evidence base.

Below are the citation and selected extract in a linked editorial:

CITATION: Evidence for efficacy of psychosocial interventions in LMICs (Editorial)

Kathryn L Lovero et al

Published:January 13, 2020

DOI:https://doi.org/10.1016/S2215-0366(19)30531-0

'In The Lancet Psychiatry, Corrado Barbui and colleagues present a timely umbrella review to synthesise findings and extract actionable conclusions from existing systematic reviews of psychosocial interventions in LMICs [https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30511-5/fulltext]. By use of a rigorous and multidimensional assessment, they evaluate both the quality and strength of evidence for psychosocial interventions across more than 120 studies and 20 000 participants... The authors found the most robust support (highly suggestive strength of association, moderate credibility of evidence) for the efficacy of psychosocial interventions in LMICs for adults with common mental disorders in the general population (standardised mean difference 0·49, 95% CI 0·36–0·62) and adults with depression in humanitarian settings (0·87, 0·67–1·07). Highly suggestive strength of association was also found for adults with schizophrenia (0·84, 0·49–1·19) and depression (1·09, 0·89–1·30) in the general population as well as post-traumatic stress disorder (PTSD) in humanitarian settings (1·07, 0·79–1·35), although credibility of evidence was low. Evaluating specific interventions, the most compelling evidence was found for cognitive behavioural therapy (highly suggestive strength of association for adult depression and PTSD) and interpersonal therapy (highly suggestive strength of association for adult common mental disorders), both established, evidence-based interventions. These findings dissipate concerns that mental health care might have little effect in impoverished or unstable settings and show that implementation of these interventions must move forward. To advance inclusion of psychosocial interventions in LMIC health services, a substantial increase in global and local commitment to mental health is needed in these regions. In particular, following progress made toward the WHO Mental Health Action Plan objectives, LMICs must continue to improve policy and financing for expansion of mental health services.'

The full text notes the role of lay / community health workers: 'Depending on local culture and traditions, programmes aimed at fostering task-shifting initiatives between non-specialist mental health providers and informal community care providers could be developed to improve pathways to mental health care.' 'In LMICs... very few mental health professionals might be available; therefore, for feasibility reasons, mental health interventions might be delivered by non-specialist professionals, including nurses without psychiatric training, lay health workers, or peer support workers.'

Best wishes, Neil

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org