IMPlementation of evidence-based facility and community interventions to reduce the treatment gap for depRESSion
Funding agency: National Institute of Mental Health, USA
Duration: October 2018 – September 2023
Principal Investigator: Dr. Abhijit Nadkarni
Host institute: Sangath, Goa, India
Depression is the leading cause of disability worldwide and accounts for about 40% of the disability-adjusted life years (DALYs) attributable to mental and substance use disorders. Present estimates suggest that the prevalence of depression in India is 2.7%, and the treatment gap stands at 85%.
IMPRESS aims to reduce this treatment gap by addressing both supply and demand side barriers by combing two strategies previously developed by Sangath. The supply-side will be targeted by scaling up the Healthy Activity Program (HAP), a manualised psychological treatment based on behavioural activation, which was shown to reduce symptom severity and increase remission among depressed participants in Sangath’s PREMIUM study. The VISHRAM program was a community-based mental health intervention with a goal of increasing mental health demand through the enhancement of mental health literacy.
Our program is comparing two scalable models for delivering the HAP in a low-and-middle-income country context. One model will be the implementation of the HAP in health centers alone, while the other will be the implementation of HAP in health centers in parallel with VISHRAM in the community.
Sangath is partnering with the Government of Goa’s Directorate of Health Services to implement IMPRESS across Goa. The facility component (HAP) will be implemented within primary and community health centers, while the community component (VISHRAM) will be implemented in the surrounding communities.
First, the formative and pilot research will be used to adapt the HAP and VISHRAM components to the study context for scaling up. A mixed-methods study including ‘theory of change’ workshops with various stakeholders, a contextual adaptation of training and supervision platforms, and piloting of the full intervention will be carried out across primary and community health centers.
The trial phase will consist of an effectiveness-implementation hybrid type 2-cluster RCT comparing the two models for the delivery of the HAP. A facility-only model arm with the HAP being delivered by counsellors identified during the formative phase will be compared with a community model arm in which the VISHRAM intervention is implemented in addition to the HAP.
Our program will provide the first systematic attempt in an LMIC to scale up an empirically supported psychological treatment in primary care, while simultaneously implementing an evidence-based community intervention to increase contact and effective coverage. In doing so, IMPRESS addresses one of the major unanswered challenges in global mental health: the methods, acceptability, effectiveness, and cost-effectiveness of integrated community and primary care-based approaches to reduce the treatment gap for depression.