Innovation summary

The urgency to derive and test new interventions to increase the early detection and treatment of depression is accentuated by the fact that they often remain undiagnosed, misdiagnosed or untreated often due to the stigma associated with mental health diseases in Pakistan. Inadequate attention to mental health in the public sector has resulted in a meager estimated ratio of 2-3 psychiatrists per million people.1  Less than 5% of the national budget is spent on health care, with the amount allocated for mental health being less than 2% of the total budget.1 Approximately 72% of total health expenditure is funded privately, of which 92% are out-of-pocket expenses.2

This innovation aims to develop and test the feasibility, acceptability and efficacy of an innovative mHealth screening platform for depression and anxiety. This platform will be integrated within a community based program that improves mental health outcomes for patients through 1) positive, supportive SMS messages and 2) the triage of patients for treatment provided by trained community mental health workers. 

           

Impact summary

  • 45,392 individuals in 3 low-income communities screened for depression. Of these, 4,629 (10%) were symptomatic of depression and of these, 3,956 (85%) were willing to undergo counselling therapy provided by trained Community Mental Health Workers

  • 1,906 individuals received free counselling in their homes or at local GP clinics. Of these, 618 completed therapy with improved treatment outcomes. 15,435 individuals received daily positive support SMS messages

  • 15,435 individuals received daily positive support SMS messages

  • Over 4,000 individuals were directly reached through awareness raising sessions in the community (ranging from large sessions to small group sessions)

​"Our program aims to provide free of cost diagnosis and treatment to reduce the high prevalence of depression in women (currently at 66%) and in the general population (currently at 34%), in Pakistan."3

- Aneeta Pasha, PI of this innovation

This innovation is funded by Grand Challenges Canada.

           

Innovation details

While there is low technological usage in Pakistan, the telecommunications industry has seen a rapid increase in the number of mobile-cellular subscribers. At the end of 2011, 110 million people used mobile phones; up from the 300,000 people who used them in 2,000.  Almost every household has access to at least one mobile phone. This provides a unique opportunity for the implementation of mHealth in Pakistan, allowing cost-effective, efficient and improved access to mental healthcare-related information.

Through the mHealth component of our program, large volumes of people will be screened quickly by trained Community Mental Health Workers (CMHW), using a mobile app .  Accurate electronic medical records will be maintained in this manner. Individuals who screen positive for depression/anxiety will be referred to the CMHWs, who will provide CBT and IPT-based treatment in a structured format on a weekly basis.  At the time of screening, all individuals will be asked if they wish to receive positive support SMS messages.  Patients who are willing to receive therapy will also be enrolled in an interactive SMS program with reminders about their weekly appointments and regular questions about their well-being, on a scale. If they respond with a higher scale, the CMHW is immediately notified and will contact the person immediately and ask if they would like to schedule an appointment for the next day.  This method will allow for a community-based triage model. 

The CMHWs responsible for screening and treatment will be recruited from the communities in which the team already works, to allow for easier access to and familiarity with people. They will receive a basic counseling training on how to perform first-line counseling therapy on patients suffering from depression.  They will also conduct regular mental health awareness-raising sessions in the community as well.

A mental health advisory group will be formulated to oversee the technical aspects of the program and provide strategic direction to the program.  This group will comprise of experts with extensive experience in mental health, community work and information technology.

         

Key drivers

Mental Health Advisory Group

The Mental Health Advisory Group is in the early stages of being developed. This group should be a driver for the program because of the practical expertise and strategic insight the group will bring to the program. The group will ensure that the correct protocols are followed, that there is systematic follow-up of all patients put on treatment and determine the course of action for problematic cases.

Task-Shifting using Community-Based Counselors

The development and implementation of a basic counseling training for CMHWs to perform first-line counseling therapy on patients suffering from depression and anxiety will be a driver in that it will allow for task-shifting from highly trained and qualified experts to lay community-based counselors.

           

Challenges

Anticipated challenges include:

  • People in the target site not owning cellphones
  • Retention and quality of CMHWs
  • CMHWs not accepted as therapists by local communities
  • Discontinuation of treatment before improved mental health outcomes seen (i.e. ‘dropouts’)
  • Volatile political and security conditions in the communities in which the team works
           

Continuation

In the first year of this grant, the program will be implemented in one site in Karachi. In the second year, the program will be scaled up to two additional areas. 

Over the last five years, Interactive Research and Development (IRD) has received over USD 15 million to implement large-scale projects. In 2011, IRD received a grant from TB REACH for increasing TB case notification through verbal screening at private GP clinics using performance based incentives for screeners and through a UNITAID grant, IRD has set-up a consortium to implement the TB program in Bangladesh and Indonesia as well.  The mental health program can be integrated within these existing projects in the future.

           

Partners

Funder:

           

Evaluation methods

The intervention will be evaluated using an RCT (quantitative research methods) to assess the additive effect of positive support messages on mental health outcomes. 

         

Cost of implementation

Total funds available for this program: approximately $233,000 USD. 

         

Impact details

The project began in October 2014 and is therefore still in the planning phase. During the program phase, it is expected that 5,600 people will have positive treatment outcomes and improved mental health.

45,392 individuals in 3 low-income communities screened for depression. Of these, 4,629 (10%) were symptomatic of depression and of these, 3,956 (85%) were willing to undergo counselling therapy provided by trained Community Mental Health Workers.

1,906 individuals received free counselling in their homes or at local GP clinics. Of these, 618 completed therapy with improved treatment outcomes. 15,435 individuals received daily positive support SMS messages.

Total funds available for this program are approximately $233,000 USD. 

Over 4,000 individuals were directly reached through awareness raising sessions in the community (ranging from large sessions to small group sessions).

         

References

  1. Afridi, MI. (2008) “Mental Health: Priorities in Pakistan.” Mental Health. Vol. 58(5): 225-226.
  2. Karim, S et al. (2004) “Pakistan mental health country profile.” International Review of Psychiatry  16 (1-2):83-92.
  3. Jenkins, R et al. (2004) "Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review." BMJ 328, (7443):7.

           

Research

Associates

Aneeta Pasha

Comments

Submitted by Umair Umed Ali on Tuesday, 17th October 2017
good approach , looking forward to work with you.
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Country

Pakistan

Affiliated organizations

Interactive Research and Development (IRD)

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