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The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: Systematic development and randomised evaluation

  • Neerja Chowdhary (a1), Arpita Anand (a2), Sona Dimidjian (a3), Sachin Shinde (a2), Benedict Weobong (a1), Madhumitha Balaji (a2), Steven D. Hollon (a4), Atif Rahman (a5), G. Terence Wilson (a6), Helena Verdeli (a7), Ricardo Araya (a8), Michael King (a9), Mark J. D. Jordans (a10), Christopher Fairburn (a11), Betty Kirkwood (a8) and Vikram Patel (a12)...
Abstract
Background

Reducing the global treatment gap for mental disorders requires treatments that are economical, effective and culturally appropriate.

Aims

To describe a systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare.

Method

The treatment was developed in three stages using a variety of methods: (a) identifying potential strategies; (b) developing a theoretical framework; and (c) evaluating the acceptability, feasibility and effectiveness of the psychological treatment.

Results

The Healthy Activity Program (HAP) is delivered over 6–8 sessions and consists of behavioral activation as the core psychological framework with added emphasis on strategies such as problem-solving and activation of social networks. Key elements to improve acceptability and feasibility are also included. In an intention-to-treat analysis of a pilot randomised controlled trial (55 participants), the prevalence of depression (Beck Depression Inventory II ⩾19) after 2 months was lower in the HAP than the control arm (adjusted risk ratio = 0.55, 95% CI 0.32–0.94, P = 0.01).

Conclusions

Our systematic approach to the development of psychological treatments could be extended to other mental disorders. HAP is an acceptable and effective brief psychological treatment for severe depression delivered by lay counsellors in primary care.

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Copyright
This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.
Corresponding author
Vikram Patel, Sangath, H No 451 (168), Bhatkar Waddo, Succour, Porvorim, Bardez, Goa 403501, India. Email address: vikram.patel@lshtm.ac.uk
Footnotes
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This research has been entirely funded by a Wellcome Trust Senior Research Fellowship to V.P. (Grant no. 091834/Z/10/Z).

Declaration of interest

None.

Footnotes
References
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The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: Systematic development and randomised evaluation

  • Neerja Chowdhary (a1), Arpita Anand (a2), Sona Dimidjian (a3), Sachin Shinde (a2), Benedict Weobong (a1), Madhumitha Balaji (a2), Steven D. Hollon (a4), Atif Rahman (a5), G. Terence Wilson (a6), Helena Verdeli (a7), Ricardo Araya (a8), Michael King (a9), Mark J. D. Jordans (a10), Christopher Fairburn (a11), Betty Kirkwood (a8) and Vikram Patel (a12)...
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eLetters

Challenges in developing feasible and cost effective culturally adapted therapy that can be used by the local health systems in LAMICs. Authors Farooq Naeem, Shanaya Rathod, Nasar S Khan, Muhammad Ayub

Farooq Naeem, Professor, Department of Psychiatry, Queens University, Kingston, Canada
Shanaya Rathod, Consultant Psychiatrist, Southern Health NHS Foundation Trust Antelope House, Brintons Terrace Southampton, UK
Muhammad Nasar S Khan, Professor, Department of Psychiatry, Services Institute of Medical Sciences & Services Hospital Lahore Pakistan
Muhammad Ayub, Professor, Department of Psychiatry, Queens University, Kingston, Canada
13 May 2016

We read Chodhary et al’s paper(1) with interest. The authors’ conducted this research under aegis of PREMIUM (a Program for Mental Health Interventions for Under-resourced Health systems) in India. They state the overall aim of this programme in their introduction; “programme is to investigate a systematic, reproducible method for developing psychological treatments that incorporate global evidence, are contextually appropriate and can be delivered by non-specialist health workers”. In this paper authors set out to develop an intervention that was to be delivered by lay health workers. Their intention is to address the treatment gap for mental health. The elaborate methodology they adopted to develop this intervention requires a highly skilled research team such as their own. There are simpler and economical methods for cultural adaptation of evidence-based therapies (2,3) that have been tested in similar culture and well described. We are not clear about the rationale for their use of a complex and expensive methodology given the aim of “reproducible method for developing psychological treatments”. The authors started with a pool of techniques that were considered to be useful. These techniques were mostly based on CBT. However, based on expert advice they adapted The Behavioral Activation for Depression: A Clinician’s Guide manual. A massive evaluation found this intervention to be unfeasible. Therefore, they further adapted the intervention and tested it in a pilot. The title does not reflect the fact that it was an adaptation of existing intervention and not development of a new intervention. They used a complex, time consuming and resource intensive process that is highly unlikely to be repeatable in a LAMIC setting.

We have adapted CBT for the local population in Pakistan and for the ethnic minority population in England (2,3). These methods of adaptation have been described in detail and have been tested for depression (4) and schizophrenia (5,3) and in a Guided Self-help format for depression (6). The methodology evolved over the years resulting in the development of semi-structured interviews that can be conducted by students and easily analyzed using a framework analysis method (5). This low-cost methodology is being used in China and the Middle East to adapt CBT. We hope the authors find this work useful in their future attempts to adapt therapy.

The issue of cost becomes even more important in the delivery of therapy. In our two-pronged approach, therapy in secondary care was delivered by psychology graduates (typical monthly salary of $200 per month), and by carers using a culturally adapted CBT based self-help manual developed locally. No financial help was provided to the carers. We believe it is not just the development or adaptation of intervention that is important; it should also be deliverable by existing mechanisms. This leads to our second concern, “how practical it is to create a new workforce in a low-income country - of lay therapists?”. This lack of understanding of the ground realities has possibly resulted in a minimum change in health settings in LAMICs. For example, to the best of our knowledge The Healthy Thinking Program (7) contrary to the initial hope is currently not being practiced in mainstream health care in any part of Pakistan. There is a need for researchers in this area to consider the local resources. Otherwise, there is a risk that the highly funded programs will not produce evidence that can address the treatment gap. We, therefore, believe the paper best describes a strategy that is not consistent with the current methods of culturally adapting therapy, and is too costly to be replicated in LAMICs”.

Declaration of interest

Authors have published on culturally adapted interventions from Pakistan and England

References

1. Chowdhary N, Anand A, Dimidjian S, Shinde S, Weobong B, Balaji M, et al. The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation. Br J Psychiatry. 2015 Oct 22;bjp.bp.114.161075.

2. Naeem F, Phiri P, Munshi T, Rathod S, Ayub M, Gobbi M, et al. Using cognitive behaviour therapy with South Asian Muslims: Findings from the culturally sensitive CBT project. Int Rev Psychiatry Abingdon Engl. 2015;27(3):233–46.

3. Rathod S, Phiri P, Harris S, Underwood C, Thagadur M, Padmanabi U, et al. Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: A randomised controlled trial. Schizophr Res. 2013 Feb;143(2–3):319–26.

4. Naeem F, Gul M, Irfan M, Munshi T, Asif A, Rashid S, et al. Brief Culturally adapted CBT (CaCBT) for depression: A randomized controlled trial from Pakistan. J Affect Disord. 2015 May 15;177:101–7.

5. Naeem F, Saeed S, Irfan M, Kiran T, Mehmood N, Gul M, et al. Brief culturally adapted CBT for psychosis (CaCBTp): A randomized controlled trial from a low income country. Schizophr Res [Internet]. 2015 [cited 2015 Apr 6];0(0). Available from: http://www.schres-journal.com/article/S0920996415001206/abstract

6. Naeem F, Sarhandi I, Gul M, Khalid M, Aslam M, Anbrin A, et al. A multicentre randomised controlled trial of a carer supervised culturally adapted CBT (CaCBT) based self-help for depression in Pakistan. J Affect Disord. 2014 Mar;156:224–7.

7. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008 Sep 13;372(9642):902–9.

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Conflict of interest: Authors have culturally adapted and tested CBT for similar population

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