Integrated Care for Depression Yields Extended Benefits, Malawi Study Shows
Incorporating depression treatment into care for chronic health conditions improved well-being for both patients and their families
• Research Highlight
In many low- and middle-income countries, significant public health resources are dedicated to addressing health conditions like HIV and malaria, but most people with depression and other mental disorders receive no mental health treatment.
Integrating mental health care into routine medical care offers a promising approach to bridging this treatment gap, according to a study led by RAND researchers Ryan K. McBain, Sc.D., Sc.M. , and Glenn Wagner, Ph.D . This integrated approach may also improve patients’ other health conditions and family members’ well-being, benefits that are often underestimated in cost-effectiveness evaluations.
What did the researchers do in the study?
The research team conducted a cluster randomized controlled trial across 14 chronic health care facilities in Neno District, a remote region in Malawi. These health facilities are HIV clinics that also offer screening, diagnosis, and treatment for chronic conditions such as high blood pressure, diabetes, and asthma. Clinic staff received initial training on the study procedures, refresher training, and ongoing supervision.
Clinic patients were eligible to participate if they were newly diagnosed with depression (determined by a standard depression screening and a brief diagnostic interview) and actively receiving care from one of the 14 clinics. A total of 487 participants were included in the study analyses.
The study began with a 3-month baseline period during which all 14 clinics delivered care as usual. Participants with symptoms of depression who attended the clinics while receiving care as usual were provided psychoeducation and, if needed, referred to a mental health care provider in Neno District or a regional hospital.
Then, every 3 months, two or three clinics transitioned to providing integrated depression treatment while the other clinics continued with care as usual. By the end of the study, all clinics were providing integrated depression treatment. Clinic counselors provided treatment recommendations based on participants’ depression symptoms, but each participant could select the option they preferred: group therapy only, group therapy and antidepressant medication, or antidepressant medication only. Group therapy consisted of a standardized approach called Problem Management Plus, which covers topics such as managing stress, strengthening social connections and support, and developing daily routines that support well-being.
The researchers compared integrated treatment with care as usual, measuring changes in participants’ depression symptoms, daily functioning, and chronic health conditions every 3 months over the 27-month trial period. They also measured changes in depression symptoms, functioning, and perceived burden of care among a subset of household members, from just before the start of treatment to 6 months later.
The researchers calculated the intervention costs by estimating the costs associated with all intervention activities, including training, screening, diagnosis, and delivery of care.
What did the study find?
Most participants selected standalone group therapy as their preferred treatment.
Overall, receiving any type of depression treatment as part of ongoing health care led to a decrease in participants’ depressive symptoms and an increase in their functioning over time. Participants also showed a slight decrease in systolic blood pressure while receiving depression treatment.
The effects of integrated depression treatment also extended to members of their households. Household members were less likely to experience a depressive episode and showed improvement in depression symptoms, daily functioning, and perceived burden of care for supporting their family member.
After accounting for improved well-being among both participants and their household members, the researchers determined that integrated depression treatment led to a 32% increase in cost-effectiveness relative to care as usual.
What do the results mean?
The study results suggest that integrating treatment for depression into care for chronic health conditions improves well-being at both the individual and household levels and could be a cost-effective approach to care in low-resource settings.
The authors note that the study took place during the height of the COVID-19 pandemic, which may have influenced individuals’ willingness to participate. They also note that the sample was 82% women—further research could help clarify why men may or may not choose to participate and whether men show similar improvements with integrated depression treatment.
The findings highlight the importance of considering how mental health treatment effects may extend to a person’s family, friends, and broader social network. McBain and colleagues note that researchers, clinicians, public health workers, and policy makers are likely to underestimate the benefits of mental health care, especially in low-resource settings, when they focus solely on benefits to the person receiving care.
Reference
McBain, R. K., Mwale, O., Mpinga, K., Kamwiyo, M., Kayira, W., Ruderman, T., Connolly, E., Watson, S. I., Wroe, E. B., Munyaneza, F., Dullie, L., Raviola, G., Smith, S. L., Kulisewa, K., Udedi, M., Patel, V., & Wagner, G. J. (2024). Effectiveness, cost-effectiveness, and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): A stepped-wedge, cluster-randomised, controlled trial. The Lancet, 404(10465), 1823-1834. https://doi.org/10.1016/S0140-6736(24)01809-9