Effect of a primary care-based psychological intervention on common mental disorders in Zimbabwe

1. This randomized control trial found that a culturally adapted psychological intervention for common mental disorders in Zimbabwe significantly improved symptoms at 6 months compared to control.

2. Intervention group participants had lower risk of depressive symptoms at 6 months compared to control.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Depression and anxiety are the most prevalent mental disorders across the world, and represent a major source of disease burden in sub-Saharan Africa. In Zimbabwe, despite more than 25% of all adults suffering from common mental disorders, only 10 psychiatrists serve a population of 13 million. Making matters worse, no psychological services are currently offered in the primary care setting. To address this need, researchers introduced a primary care intervention known as “problem solving therapy” at 24 primary care clinics in Harare, Zimbabwe. Patients receiving this therapy showed reduced symptoms of mental health disorders after 6 months compared to patients who received no intervention.

This study proved the efficacy of “problem solving therapy” in the primary care setting, and was strengthened by the use of validated measures and careful monitoring. However, several limitations were inherent in the design of the study. First, the sustainability of the intervention’s effects are unknown given the limited follow-up. Second, the generalizability may be limited as the study enrolled a large majority of women in a densely urban and relatively wealthy region of the nation. Third, information about prescription medication use and certain comorbidities were unavailable, and may have significantly impacted the observed results. Overall though, the study provides evidence that psychological interventions provided by lay health workers in the primary care setting may reduce the symptoms of depression and anxiety among patients in sub-Saharan Africa.

Click to read the study in JAMA

Relevant Reading: Global Prevalence of Anxiety Disorders: A Systematic Review and Meta-regression.

In-Depth [randomized controlled trial]: This study evaluated the effectiveness of a group of psychological interventions, termed “problem-solving therapy”, on reducing symptoms of common mental disorders such as depression and anxiety in Zimbabwe. This study was a cluster randomized control study conducted across 24 clinics in Harare, Zimbabwe. Patients who were 18 years or older and screened positive on the SSQ-14 were enrolled. Exclusion criteria included, an inability to comprehend the study, end-stage AIDS, pregnancy, and the presence of suicidal intent, psychosis, dementia, or intoxication. The primary outcome was improvement (lower score) in the SSQ-14 (Shona Symptoms Questionnaire) score, measured at baseline and 6 months. The secondary outcome was the prevalence of major depressive disorder measured by the PHQ-9 (Patient Health Questionnaire).

A total of 573 patients were randomized into either the intervention group—receiving “problem solving therapy”—or control group—receiving usual care plus brief supportive counselling and/or antidepressant medication. SSQ-14 scores for common mental disorders was lower in the intervention group than in the control group at 6 months (mean, 3.81; 95% CI, 3.28 to 4.34; vs 8.90; 95%CI 8.33 to 9.47; adjusted mean difference [AMD] in SSQ-14 score, −4.86; 95%CI −5.63 to −4.10; p < 0.001).

The prevalence ratio for symptoms of depression via prespecified binary variable analysis was lower in the intervention group than in the control group (13.7% vs 49.9%; adjusted rate ratio, 0.28; 95%CI 0.22 to 0.34; p < 0.001). Likewise, there was improvement in depression symptoms as measured by non-prespecified continuous variables for the PHQ-9 scores (AMD, −6.36; 95%CI −6.45 to −5.27; p < 0.001).

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