Integrating Depression Care Research Articles

Remote coaching for supporting the implementation of treatment for depression in primary care in Madhya Pradesh, India: protocol for a cluster randomized controlled trial.

Upwards of ninety percent of individuals living with depression in India do not have access to evidence-based treatments, especially in rural areas. Integrating these treatments into primary care is essential for bridging this care gap. This trial aims to evaluate whether a remote coaching implementation support strategy, referred to as Enhanced Implementation Support, is superior to routine support, referred to as Routine Implementation Support, in supporting the delivery of collaborative depression care in rural primary care centers. Employing a cluster-randomized hybrid type-III implementation trial design, 14 primary care facilities in Sehore district, Madhya Pradesh, will implement a collaborative depression care package based on the WHO's mhGAP program. Facilities will be randomized to either Enhanced Implementation Support or the Routine Implementation Support control condition. Enhanced Implementation Support consists of remote coaching and technical assistance, supplemented with in-person visits, and guided by the Plan-Do-Study-Act implementation cycles. The primary implementation outcome is the proportion of outpatients screened for depression by facility staff, with secondary outcomes including the proportions of outpatients who screen positive for depression, are referred to the medical officer, and initiate treatment. Secondary patient outcomes include proportion of patients who achieve reduction in depression symptom severity at 3-month follow up. Acceptability, feasibility, and fidelity of the depression care package will be assessed through routine observations collected during field visits, facility audits, and qualitative exit interviews with facility staff. Costs of delivering the Enhanced Implementation Support strategy will also be estimated. This trial can inform efforts to integrate depression care in rural primary care facilities in a low-resource setting, and illuminate whether external coaching support is superior relative to existing implementation support for achieving these goals. NCT05264792.

Depression care integration in tuberculosis services: A feasibility assessment in Pakistan.

The co-occurrence of depression among tuberculosis (TB) patients is a critical issue, contributing to poor treatment outcomes, prolonged hospitalisations and increased healthcare expenses. The objective of this study was to assess the feasibility of delivering a co-designed depression care pathway within TB services in Pakistan. Mixed-method study. Routine depression screening for TB patients was conducted at three TB facilities in Peshawar, Pakistan, encompassing primary, secondary and tertiary care settings. All patients aged 18 or above (male and female) attending the three TB facilities between November 2021 and February 2022 were included in the study using the consecutive sampling technique. A total of 301 people with confirmed TB, within the past 4 weeks, visited the three TB care facilities; 191/301 patients were screened for depression. Approximately 35% of the 191 TB patients screened positive for depression, with varying severity levels. Qualitative findings highlighted the acceptability of integrated depression care, emphasising the importance of open communication and empathetic attitudes. Barriers to integration include stigma, logistical challenges, patient noncompliance and cost burdens. Facilitators included the empathetic attitude of healthcare providers and the availability of mental health services within the same facility. There is a high burden of depression in patients with TB, highlighting the pressing need for mental health support in this population. Acceptability of integrated care was evident, with factors such as co-located mental health services, training healthcare providers and provider empathetic attitudes playing a crucial role. Further research is required to evaluate the effectiveness of the integrated TB-depression screening systems towards improved health outcomes, implementation, scalability and impact on the broader healthcare system. To create a more inclusive and comprehensive TB and depression care pathway, we gathered input from both service providers and service users (TB patients, their carers). Reflective meetings with community leaders, social activists and health professionals from various sectors were also conducted during pathway delivery to get their insights. Power, gender and age imbalances were addressed by encouraging participation of patients and carers across gender and age groups. This approach ensured that the perspectives of all stakeholders were considered in the development of the care pathway.

The Psychometric Properties of The Revised-Depression Attitude Questionnaire Among Primary Healthcare Physicians in Oman

Objective: The revised-depression attitude questionnaire (R-DAQ) is one of the most widely used instruments to evaluate the attitudes of healthcare workers toward depression. This study aimed to assess the psychometric properties of the R-DAQ and validate its use among primary healthcare physicians in Oman. Materials and Methods: This assessment is part of a cross-sectional study conducted using the R-DAQ distributed as a self-administered online questionnaire to a convenient sample of primary healthcare physicians working under the Ministry of Health in 2022 to evaluate their attitudes toward depression. The exploratory factor analysis was conducted using two types of software to assess the robustness of the factor solution based on different correlation matrices and across different extraction methods. Further evaluation of the factor solution was verified by computing different indices, assessing internal replicability, and known-group validity. Results: The analyses resulted in a 16-item scale summarized by a three-factor solution. The first factor was saliently loaded by six items representing "the professional confidence in providing care for people with depression”. The second factor was saliently loaded by six items representing “the optimistic view on recognizing depression as a health condition”. The third factor was saliently loaded by four items representing “the general perspective on integrating depression care into health practice”. Overall, the total three-factor solution demonstrated internal consistency, simplicity, goodness-of-fit, and internal replicability, as well as known-group validity. Conclusion: The validation of using the R-DAQ among primary healthcare physicians in Oman uncovered a three-factor solution with adequate psychometric properties. In addition, the factor solution was conceptually consistent with the theoretical model of planned behavior.

The Belgian Integrated DEpression Care (IDECA) project: implementation and scientific evaluation protocol

Background: Depression creates a substantial personal burden for affected individuals and their families, and produces significant economic and social hardships that affect society as a whole. In Belgium, depression is a leading cause of disability, measured as disability-adjusted life years. The COVID-19 pandemic has greatly exacerbated the already substantial health and socioeconomic consequences of depression and has led to major changes in the need for and delivery of mental health services. Integrating mental health services into primary care is the most viable way to closing existing treatment gaps. The majority of people with mental disorders treated in primary care have good outcomes, particularly when linked to a network of services at secondary level and in the community. A balanced model of depression care calls for a system with community-based mental health care, delivered by primary care physicians and supported by other professionals in an eco-system of care.
 Aim: Implementation of an integrated depression care (IDECA) intervention in two regions in Flanders, Belgium with evaluation of the intervention’s working components, its acceptance by patients and care providers, and the contextual conditions which needs to be fulfilled to safeguard success of the model of care.
 Methods: A scientific steering committee including multiple academic expertise areas and patient representatives guided the development of the intervention and its scientific evaluation. Moreover, feedback was obtained from the Flemish Institute for Primary Care (VIVEL), the Family Doctors Medical Association (Domus Medica), and a mental health interest group(Psyche VZW). This resulted in an implementation design without control group and a targeted heterogeneous patient population with depression to obtain real-world evidence. IDECA consists of three intervention pillars: (i) the integration of two reference persons mental health (case management function) into general medical practice and who provide diagnostic support, coordination, follow up care, and patient education; (ii) the implementation of a validated shared care treatment protocol; and (iii) professional training on depression screening and management. The three pillars will be further operationalized in co-creation with the selected regions. The intervention will run for 15 months.
 Data will be collected from both participating care providers and patients. Evaluation will take place using a Realist Evaluation approach in combination with the NoMad questionnaire for care providers which measures the four implementation metrics of the Normalization Process Theory: i. coherence, ii. cognitive participation, iii. collective action, and iv. reflexive monitoring. NoMad process data will serve as a basis for semi-structured qualitative research on Context-Mechanism-Outcome constellations. Questionnaires will be used to measure depression and anxiety levels, health literacy, quality of life, patient satisfaction, therapy adherence and self-efficacy, and healthcare resource utilization in patients.
 Results: Patient enrollment will start at the beginning of 2023. Preliminary data on patient characteristics and first data on care providers’ acceptance and engagement with the IDECA project will be presented, next to the co-creative development process of the intervention.
 Conclusion: The IDECA-study aims at the implementation of integrated depression care and evaluation of its feasibility in two different regions in Belgium.

Improving integrated depression and non-communicable disease care in Malawi through engaged leadership and supportive implementation climate

BackgroundLow- and middle-income countries often lack access to mental health services, leading to calls for integration within other primary care systems. In sub-Saharan Africa, integration of depression treatment in non-communicable disease (NCD) settings is feasible, acceptable, and effective. However, leadership and implementation climate challenges often hinder effective integration and quality of services. The aim of this study was to identify discrete leadership strategies that facilitate overcoming barriers to the integration of depression care in NCD clinics in Malawi and to understand how clinic leadership shapes the implementation climate.MethodsWe conducted 39 in-depth interviews with the District Medical Officer, the NCD coordinator, one NCD provider, and the research assistant from each of the ten Malawian NCD clinics (note one District Medical Officer served two clinics). Based on semi-structured interview guides, participants were asked their perspectives on the impact of leadership and implementation climate on overcoming barriers to integrating depression care into existing NCD services. Thematic analysis used both inductive and deductive approaches to identify emerging themes and compare among participant type.ResultsThe results revealed how engaged leadership can fuel a positive implementation climate where clinics had heightened capacity to overcome implementation barriers. Effective leaders were approachable and engaged in daily operations of the clinic and problem-solving. They held direct involvement with and mentorship during the intervention, providing assistance in patient screening and consultation with treatment plans. Different levels of leadership utilized their respective standings and power dynamics to influence provider attitudes and perceptions surrounding the intervention. Leaders acted by informing providers about the intervention source and educating them on the importance of mental healthcare, as it was often undervalued. Lastly, they prioritized teamwork and collective ownership for the intervention, increasing provider responsibility.ConclusionTraining that prioritizes leadership visibility and open communication will facilitate ongoing Malawi Ministry of Health efforts to scale up evidence-based depression treatment within NCD clinics. This proves useful where extensive and external monitoring may be limited. Ultimately, these results can inform successful strategies to close implementation gaps to achieve integration of mental health services in low-resource settings through improved leadership and implementation climate.Trial registrationThese findings are reported from ClinicalTrials.gov, NCT03711786. Registered on 18/10/2018. https://clinicaltrials.gov/ct2/show/NCT03711786.

Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa.

Integration of mental health into routine primary health care (PHC) services in low-and middle-income countries is globally accepted to improve health outcomes of other conditions and narrow the mental health treatment gap. Yet implementation remains a challenge. The aim of this study was to identify implementation strategies that improve implementation outcomes of an evidence-based depression care collaborative implementation model integrated with routine PHC clinic services in South Africa. An iterative, quasi-experimental, observational implementation research design, incorporating the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, was applied to evaluate implementation outcomes of a strengthened package of implementation strategies (stage two) compared with an initial evaluation of the model (stage one). The first stage package was implemented and evaluated in 10 PHC clinics and the second stage strengthened package in 19 PHC clinics (inclusive of the initial 10 clinics) in one resource-scarce district in the province of KwaZulu-Natal, South Africa. Diagnosed service users were more likely to be referred for counselling treatment in the second stage compared with stage one (OR 23.15, SE = 18.03, z = 4.04, 95%CI [5.03-106.49], p < .001). Training in and use of a validated, mandated mental health screening tool, including on-site educational outreach and technical support visits, was an important promoter of nurse-level diagnosis rates (OR 3.75, 95% CI [1.19, 11.80], p = 0.02). Nurses who perceived the integrated care model as acceptable were also more likely to successfully diagnose patients (OR 2.57, 95% CI [1.03-6.40], p = 0.043). Consistent availability of a clinic counsellor was associated with a greater probability of referral (OR 5.9, 95%CI [1.29-27.75], p = 0.022). Treatment uptake among referred service users remained a concern across both stages, with inconsistent co-located counselling services associated with poor uptake. The importance of implementation research for strengthening implementation strategies along the cascade of care for integrating depression care within routine PHC services is highlighted.

Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study

BackgroundDepression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services.MethodsWe conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains.ResultsReported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care.ConclusionsDepression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

Partnering with community-based organizations to improve equitable access to depression care for underserved older adults in the U.S.: Qualitative formative research.

Embedding evidenced-based programs (EBPs) like PEARLS outside clinical settings can help reduce inequities in access to depression care. Trusted community-based organizations (CBOs) reach older adults who are underserved; however, PEARLS adoption has been limited. Implementation science has tried to close this know-do gap, however a more intentional focus on equity is needed to engage CBOs. We partnered with CBOs to better understand their resources and needs in order to design more equitable dissemination and implementation (D&I) strategies to support PEARLS adoption. We conducted 39 interviews with 24 current and potential adopter organizations and other partners (February-September 2020). CBOs were purposively sampled for region, type, and priority older populations experiencing poverty (communities of color, linguistically diverse, rural). Using a social marketing framework, our guide explored barriers, benefits and process for PEARLS adoption; CBO capacities and needs; PEARLS acceptability and adaptations; and preferred communication channels. During COVID-19, interviews also addressed remote PEARLS delivery and changes in priorities. We conducted thematic analysis of transcripts using the rapid framework method to describe the needs and priorities of older adults who are underserved and the CBOs that engage them, and strategies, collaborations, and adaptations to integrate depression care in these contexts. During COVID-19, older adults relied on CBO support for basic needs such as food and housing. Isolation and depression were also urgent issues within communities, yet stigma remained for both late-life depression and depression care. CBOs wanted EBPs with cultural flexibility, stable funding, accessible training, staff investment, and fit with staff and community needs and priorities. Findings guided new dissemination strategies to better communicate how PEARLS is appropriate for organizations that engage older adults who are underserved, and what program components are core and what are adaptable to better align with organizations and communities. New implementation strategies will support organizational capacity-building through training and technical assistance, and matchmaking for funding and clinical support. Findings support CBOs as appropriate depression care providers for older adults who are underserved, and suggest changes to communications and resources to better fit EBPs with the resources and needs of organizations and older adults. We are currently partnering with organizations in California and Washington to evaluate whether and how these D&I strategies increase equitable access to PEARLS for older adults who are underserved.

A collaborative care package for depression comorbid with chronic physical conditions in South Africa

IntroductionA task-sharing collaborative care model for integrated depression care for South Africa’s burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges.MethodsThe Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of ‘modifications made’ and ‘actual implementation’ introduced in the ‘Getting messier with TIDieR’ framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts.ResultsIn the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger.ConclusionThe need for in-country co-designed collaborative care models, and ‘implementation heavy’ implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted.

High levels of mild to moderate depression among men who have sex with men and transgender women in Lima, Peru: implications for integrated depression and HIV care

ABSTRACT Depression disproportionally affects people at risk of acquiring or living with HIV and is associated with worse health outcomes; however, depression care is not routinely integrated with HIV prevention and treatment services. Selection of the best depression intervention(s) for integration depends both on the prevalence and severity of depression among potential users. To inform depression care integration in a community-based setting in Lima, Peru, we retrospectively analyzed routinely collected depression screening data from men who have sex with men and transgender women seeking HIV prevention and care services (N = 185). Depression was screened for using the Patient Health Questionnaire-9. Prevalence of any depression (PHQ-9 ≥ 5) was 42% and was significantly associated with the last sexual partner being “casual” (p = 0.01). Most (81%) depressive symptoms were mild to moderate (≥5 PHQ-9 ≤ 14). Integrating depression care with HIV prevention and treatment services in Peru should begin by implementing interventions targeting mild to moderate depression.

Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial

BackgroundMalawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease—including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes.MethodsWe will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model’s cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model.DiscussionThis study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence.Trial registrationClinicalTrials.govNCT04777006. Registered on 1 March, 2021

Proactive Community Occupational Therapy Service for Social Participation Development of Thai Adults with Depression: A Grounded Theory Study from Occupational Therapists' Perspective.

Introduction Depression in adulthood decreases social participation in the workplace, family, and community, which further results in decreased work performance and cessation and social isolation. There is a high statistic of outpatient consultation and readmission of Thais with depression, yet the mental health support for remission in community life and social participation remains limited and unclear. Further, due to the lack of mental health professional resources, particularly occupational therapists, there is much to be known regarding how such therapists work to support the development of social participation in Thai adults with depression. Objective This research was aimed at understanding the process of how occupational therapists work to redevelop the social participation of community-dwelling Thai adults with depression. Method The grounded theory methodology was used in this study. Data were collected through interviews and nonparticipatory observations of 14 participants who had experience providing mental health care in community services. The constant comparative analysis method was employed. Result Three concepts illustrated a proactive community occupational therapy service for depression (PCOTS-D), namely, integrating depression care in community occupational therapy service (COTS), supporting meaningful participation, and forming collaborative networks. The PCOTS-D supported the reconnection of social participation by leading from proactive depression care service to COTS and then working to support meaningful participation toward the patient's self-management and building collaborative networks with inter- and intraprofessional teams simultaneously. Conclusion The PCOTS-D presented a holistic view of working with community-dwelling Thai adults with depression by considering the importance of the community and researchers' network to redevelop social participation, promote health and recovery, build teams in depression care, and encourage research evidence to enhance the supportive advocacy policy for Thai people with depression.

Barriers and facilitators to the diagnosis and treatment of depression in primary care in Colombia: Perspectives of providers, healthcare administrators, patients and community representatives

IntroductionDepression represents a major disease burden in Colombia. To better understand opportunities to improve access to mental healthcare in Colombia, a research team at Javeriana University conducted formative qualitative research to explore stakeholders’ experiences with the integration of mental healthcare into the primary care system. MethodsThe research team conducted 16 focus groups and 4 in-depth interviews with patients, providers, health administrators and representatives of community organisations at five primary care clinics in Colombia, and used thematic analysis to study the data. ResultsThemes were organised into barriers and facilitators at the level of patients, providers, organisations and facilities. Barriers to the treatment of depression included stigma, lack of mental health literacy at the patient and provider level, weak links between care levels, and continued need for mental health prioritization at the national level. Facilitators to the management of depression in primary care included patient support systems, strong patient-provider relationships, the targeting of depression interventions and national depression guidelines. DiscussionThis study elucidates the barriers to depression care in Colombia, and highlights action items for further integrating depression care into the primary care setting.

Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers

BackgroundIntegration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services.MethodsBetween June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers.ResultsAlmost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow.ConclusionFindings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge.Trial registration This study reports finding of part of the formative phase of “The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building—A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi” registered as NCT03711786

Development of the Practice Readiness to Evaluate and address Perinatal Depression (PREPD) assessment

ObjectivePerinatal depression is a common pregnancy complication and universal screening is recommended. The Practice Readiness to Evaluate and address Perinatal Depression (PREPD) was developed to measure obstetric practice readiness to integrate depression care into workflows. Objectives were to describe: (1) the PREPD; (2) associated characteristics by readiness level; and (3) use of the assessment to measure change. MethodThe PREPD has four components, each scored to a 16-point maximum: (1) Environmental Scan (10% of PREPD); (2) Depression Detection, Assessment, and Treatment Questionnaire (30%); (3) Depression-related Policies Questionnaire (10%); and (4) Chart Abstraction (50%). Components were weighted and summed for an overall score. Summary and component scores were calculated by patient, practice, and provider. ResultsAverage overall PREPD score was 7.3/16 (range: 4.8–9.9); scores varied between practices. The Environmental Scan averaged 2.0/16 (range: 0–5.2); Detection, Assessment, and Treatment averaged 8.3/16 (range: 3.0–11.5); Chart Abstraction averaged 7.2/16 (range: 5.1–9.6); and Depression-related Policies averaged 10.4/16 (range: 7.5–15). ConclusionWe found wide variation in obstetric practices’ readiness to implement interventions for depression; most were minimally prepared. These data may be used to tailor practice intervention goals and as benchmarks with which to measure changes in integration of depression care over time.

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Barreras y facilitadores para el diagnóstico y tratamiento de la depresión en atención primaria en Colombia: Perspectivas de los proveedores, administradores de atención médica, pacientes y representantes de la comunidad

IntroductionDepression represents a major disease burden in Colombia. To better understand opportunities to improve access to mental healthcare in Colombia, a research team at Javeriana University conducted formative qualitative research to explore stakeholders’ experiences with the integration of mental healthcare into the primary care system. MethodsThe research team conducted 16 focus groups and 4 in-depth interviews with patients, providers, health administrators and representatives of community organisations at 5 primary care clinics in Colombia, and used thematic analysis to study the data. ResultsThemes were organised into barriers and facilitators at the level of patients, providers, organisations and facilities. Barriers to the treatment of depression included stigma, lack of mental health literacy at the patient and provider level, weak links between care levels, and continued need for mental health prioritisation at the national level. Facilitators to the management of depression in primary care included patient support systems, strong patient-provider relationships, the targeting of depression interventions and national depression guidelines. DiscussionThis study elucidates the barriers to depression care in Colombia, and highlights action items for further integrating depression care into the primary care setting.

Implementation and Scale-Up of Integrated Depression Care in South Africa: An Observational Implementation Research Protocol.

People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low- and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa. Adopting a learning-health-systems approach, this study uses an onsite, iterative observational implementation science design. Stage 1 comprises assessment of the original MhINT model under real-world conditions in an urban subdistrict in KwaZulu-Natal, South Africa, to inform refinement of the model and its implementation strategies. Stage 2 comprises assessment of the refined model across urban, semiurban, and rural contexts. In both stages, population-level effects are assessed by using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework with various sources of data, including secondary data collection and a patient cohort study (N=550). The Consolidated Framework for Implementation Research is used to understand contextual determinants of implementation success involving quantitative and qualitative interviews (stage 1, N=78; stage 2, N=282). The study results will help refine intervention components and implementation strategies to enable scale-up of the MhINT model for depression in South Africa. Next steps include strengthening ongoing engagements with policy makers and managers, providing technical support for implementation, and building the capacity of policy makers and managers in implementation science to promote wider dissemination and sustainment of the intervention.

Integrating depression care within NCD provision in Bangladesh and Pakistan: a qualitative study

BackgroundCo-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan.MethodsFace-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups.ResultsPatients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression.ConclusionsGiven current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients’ expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA.

Telephone Counseling May Offer Needed Boost to Veterans With Depression

Back to table of contents Previous article Next article Clinical & ResearchFull AccessTelephone Counseling May Offer Needed Boost to Veterans With DepressionNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:12 May 2020https://doi.org/10.1176/appi.pn.2020.4a13AbstractAdding telephone-based counseling to an integrated care program at the VA increased employment productivity and reduced depression symptoms at relatively low cost.Adding a work-focused intervention to integrated depression care can lead to better employment and psychiatric outcomes in veterans, according to a study in JAMA Network Open.Researchers tested a telephone-based work intervention called “Be Well at Work.” This counseling program, which teaches stress reduction and coping skills for work-related challenges, is relatively inexpensive and has been shown to reduce employee’s depression and absenteeism in traditional work settings. This study was the first to assess whether Be Well at Work could add value to an already proven model of depression care—the Veterans Health Administration (VHA) integrated care program.“There are so many younger veterans from today’s wars who are looking to assimilate back into society.”—Debra Lerner, Ph.D.The VHA’s multidisciplinary integrated care model includes comprehensive depression screening, regular assessments, brief behavioral therapy, medication, and referral to specialists if symptoms become severe. The VA system also offers vocational rehabilitation services, but this is geared toward placing veterans in jobs and not necessarily ensuring productivity and well-being while at work.“There are so many younger veterans from today’s wars who are looking to assimilate back into society,” said lead study author Debra Lerner, Ph.D., a senior scientist and director of the Program on Health, Work, and Productivity at Tufts Medical Center. She co-developed Be Well at Work with David Adler, M.D., a senior psychiatrist at Tufts Medical Center. “The topic of employment is front and center at the VA.”Lerner and colleagues enrolled 253 veterans (average age of 46) from the Philadelphia region who had been diagnosed with depression and reported at least a 5% drop in work productivity in the previous month. The participants were randomly assigned to receive either standard integrated care at the VHA or participate in the Be Well at Work program in addition to receiving integrated care. Participants in the Be Well at Work group received eight, biweekly 50-minute telephone calls for four months—led by trained counselors—as well as one follow-up session four months later.After four months, the veterans who received the telephone intervention reported 17% greater improvements in work productivity and a 26% greater reduction in their depression symptom severity relative to veterans receiving only integrated care. These differences between the two study groups were still evident at the eight-month follow-up visit. The researchers estimated that the productivity increase saved employers about $1,800 per participant over one year, whereas the cost of the Be Well at Work intervention was $690 per participant—a 160% return on investment.“The big question we have not answered yet is, What is the best strategy in the long run?” Lerner said. “Undoubtedly some people will want to sign up for this program a second time, so we have to find the best way to integrate new and returning patients.” That would be one of the key items that can be addressed in implementation trials—studies in which new programs are set up and run in other settings to test their viability.The researchers just launched a small pilot program to implement Be Well at Work for employees at Tufts Medical Center and are looking for additional ways to expand the program. “If there are interested academic or community mental health centers, then reach out to us,” she said.“We often don’t deal directly with work issues in depression care, but depression affects job security and quality of life for many workers, including veterans,” Lerner continued. “I hope this study encourages more veterans to seek care because programs like Be Well at Work can help.”This study was supported by an award from the U.S. Department of Veterans Affairs, with additional support from researchers with the Corporal Michael J. Crescenz VA Medical Center in Philadelphia. ■“Effect of Adding a Work-Focused Intervention to Integrated Care for Depression in the Veterans Health Administration: A Randomized Clinical Trial” is posted here. ISSUES NewArchived