The study will recruit adults with depression of at least moderate severity. The patient health questionnaire (PHQ-9) will be utilized to assess depression in recruited participants. Primary outcome, to be assessed at 6 months following recruitment, will be the proportion of cases who recover from depression.
This trial will compare two arms:
- An intervention arm, in which a manualized intervention package with medical supervision is provided
- A care as usual arm, in which an enhanced usual care is delivered.
The intervention to be provided incorporates:
- Components of the WHO mhGAP-Intervention Guide for depression, contextualized and adapted for the Nigerian health system
- Problem Solving Treatment (PST), which has been used successfully in other interventions in LMIC
Problem solving approaches have proven to be successful in the treatment of common mental disorders such as depression and anxiety3,4. The intervention proposed is pragmatic, has been fully manualized, and is based on a stepped care model.
All individuals in this arm consenting into the trial receive STEP1 consisting of a psychological intervention delivered by the physician primary health care workers (PHCWs). Those individuals with Patient Health Questionnaire (PHQ-9) score greater than 15 at baseline are immediately assessed (with General Physician (GP) support) for medication. At 8 weeks all patients are assessed again with the PHQ-9 and those not responding or whose symptoms worsen (PHQ-9 ≥11 and/or a decrease of less than 50% on PHQ-9 baseline score) are moved to STEP2.
STEP2 consists of an assessment with a GP with a view of initiating pharmacotherapy. If patients do not improve after this step, the case can be discussed with a psychiatrist by the GP in the final STEP 3, in the sequence covering up to 6 months.
Subjects who are recruited in the control clinics will be informed of their PHQ-9 results and will be advised to show these to their health care providers. Prior to the commencement of the trial, a training exercise on the recognition of depression will be conducted for all participating providers. We have conducted such training during our pilot study and found that, though it improved recognition (leading to enhanced care), it did not significantly change the therapeutic skills of the providers in the control arm.