Much of the global evidence supporting psychological treatments comes from specialist settings in high-income countries and the generalisability of the findings to low-income and middle-income countries can be limited2.
The goal of the Program for Effective Mental Health Interventions in Under-Resourced Health Systems (PREMIUM) was to develop and assess scalable psychological treatments that are culturally appropriate, affordable, and feasible for delivery by non-specialist health workers and apply these treatments to the two leading mental health disorders. The Healthy Activity Program (HAP) was designed to address and manage moderately severe to severe depression through:
- Lay counsellors in primary health care. Lay counsellors are health workers with limited specialised knowledge of mental healthcare
- Strategies to address depression include interpersonal communication, rumination, sleep problems, tobacco cessation, and relaxation as needed.
Various adaptations were made to enhance the contextual acceptability and feasibility of the treatment including:
- Home-based delivery
- Use of pictorial patient resource materials
- Strategies to encourage involvement of a significant other in treatment
- Utilizing peer groups to mitigate the burden of supervision by experts
Randomized Controlled Trial
Participants between 18-65 years of age with a probable diagnosis of moderately severe to severe depression, ascertained with a Patient Health Questionnaire 9 score of more than 14 were recruited for the trial in 10 primary health centres in Goa, India. The study involved conducting a randomized controlled trial with 493 participants who were randomized (1:1) to receive:
- Enhanced usual care (i.e. usual care at primary health center, screening results provided to patient and clinician, a contextualized manual for treating depression by the World Health Organization’s Mental Health Gap Action Program)
- EUC and HAP (treatment arm) that consisted of 6-8 sessions lasting 30-40 minutes focusing on behavioural activation, psychoeducation, activity monitoring, activity management, problem solving and social network activation