Innovation summary

In Nigeria it is estimated that less than 10% of people with mental disorders access medical treatment in a year.1 The treatment gap is likely higher for common mental disorders like depression. This implementation research project aims to address the treatment gap by informing the implementation and scale-up of the World Health Organization’s mental health gap intervention guidelines (mhGAP-IG) for depression.2

The implementation components of this project include:

  • Adapting mhGAP-IG for depression to be delivered in primary care in Nigeria
  • Incorporating proactive adherence management using mobile phone support
  • Training non-specialist health professionals in one district of Lagos (Ikeja) to deliver the intervention
  • Implementing the intervention (screening, treatment, adherence management) in Ikeja​

Research components of the project include:

  • Studying influences on the progress and effectiveness of implementation
  • Evaluating the intervention, including its clinical and cost-effectiveness
  • Disseminating evaluation results to promote full scale-up

This study is funded by Grand Challenges Canada

Innovation details

There is a growing evidence base for the use of stepped-care models to deliver care for depression in low- and middle-income countries (LMIC).3-4 Evidence from Nigeria suggests that interventions combining antidepressants with psychotherapy and proactive management in primary care settings are cost-effective and can provide 30% better coverage than other models of care.5 mhGAP-IG also recommends antidepressants, brief psychological therapy and psycho-education to be delivered in a stepped-care model.2

This project aims to implement a cost-effective and scalable intervention for depression in Nigeria by integrating mhGAP-IG into the local primary care deliver structure using a stepped-care model. The intervention is adapted and enhanced to improve its effectiveness in a Nigerian context. A Theory of Change exercise was used to plan the delivery of the intervention in partnership with local communities. In order to provide proactive management in this setting, m-health systems were adopted to assess and support retention in care and adherence to medication.

The project was formerly launched in 2012. Presently the following stages have been completed:

  • Identifying potential and actual influences on the progress and effectiveness of the implementation project
  • Developing and refining the integrated intervention package, adding m-health for proactive adherence management
  • Training of primary health care workers in a select geographical district of Lagos state to deliver the intervention

The next stage of the project will include:

  • Implementing the intervention in the district
  • Evaluating the intervention implementation and its clinical and cost-effectiveness

Reviewing the results of the evaluation and presenting the results to the scientific community and to policymakers with the aim of adoption for full scale-up

Key drivers

This intervention is designed to be sustainable within the existing primary health care system:

  • Intervention uses existing human resources
  • Addressing both physical and mental health issues in primary care avoids inefficiencies of a vertical model

Challenges

The major challenges faced in implementing the innovation include:

  • Difficulties working with policy-makers and government employees
  • Difficulties reducing stigma and getting primary care workers to focus on mental health issues
  • Issues with trade unions and associations especially with the acceptance of task-shifting

Continuation

After evaluation, this intervention will be further adapted as needed for scale up to a larger population. While the intervention is currently targeted at clients using the government-operated primary care system, scale-up would extend to all private health facilities and secondary care in the state. This will require the adoption of the project recommendations by the state Ministry of Health. 

Partners

Funders

Key Partners

Evaluation methods

A quasi-experimental design will be used to evaluate the impact of the intervention on client outcomes and its cost-effectiveness.

Cost of implementation

$909,087 USD funding has been secured for implementation research. The cost-effectiveness of the intervention itself will be evaluated as part of this project.

Impact details

This project expects to improve outcomes for people with depression and their families/carers in Lagos State, Nigeria.

Short term outcomes that will be evaluated as part of this project include:

  • Client access to evidence-based interventions for depression in the Ikeja division
  • Health worker capacity to identify and treat depression in the Ikeja division
  • Health outcomes in clients with depression receiving the intervention in the Ikeja division
  • Health worker and organizational capacity to practice task-shifting and collaborative stepped care
  • Mental health stigma among health workers and clients receiving the intervention

References

  1. Gureje O et al. (2006) Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. British Journal of Psychiatry. 188: 465-471.
  2. WHO (2010). mhGAP. Geneva: World Health Organization.
  3. Graciela R et al. (2007) Treatment of postnatal depression in primary care in low and middle income women in Santiago, Chile: a randomized controlled trial. Lancet 361: 995-1000.
  4. Patel V et al (2010). Effectiveness of an intervention led by lay health counselors for depressive and anxiety disorders in primary health care in Goa, India (MANAS): a cluster randomized controlled trial. Lancet 376: 2086-2095
  5. Gureje O et al (2007).Cost-effectiveness of an essential mental health intervention package in Nigeria. World Psychiatry. 2007 February; 6: 42–48.

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