IMPlementation of evidence based facility and community interventions to reduce the treatment gap for depRESSion (IMPRESS)

Depression is a leading cause of disability worldwide, and accounts for substantial morbidity, disability, and loss of productivity. Despite the availability of evidence based drug and psychological treatments for depression, the treatment gap in low and middle income countries (LMIC), including in India (the study setting), approaches 90%. Access to mental healthcare in LMICs remains limited due to both demand and supply side barriers such as lack of mental health professionals, low recognition rates of depression, stigma associated with mental disorders and the lack of contextualized evidence based psychosocial interventions. The goal of IMPRESS is to reduce the treatment gap for depression through the integrated implementation of evidence based interventions in facility and community platforms, in Goa, India. The project will evaluate, through an Effectiveness Implementation Hybrid cluster randomized controlled trial, the additional impact of an evidence based community intervention (“the Community Model”) to enhance the demand for, and improve the outcomes of, an evidence based, brief psychological treatment for depression (the Healthy Activity Program) delivered by non-­specialist health workers in primary health care facilities (“the Facility Model”). Our hypothesis is that the Community Model will be superior to the purely Facility Model in: a) increasing the demand for depression treatment in primary care;; b) increasing uptake of treatment by patients with depression;; c) increasing treatment completion rates;; d) reducing symptoms of depression;; and being e) cost-­effective. We will assess three specific mediation pathways for the additional impact of the community based interventions: improved mental health literacy in the community;; improved treatment adherence;; and increased patient-­reported activation. Overall, the Community Model would be more effective and cost-­effective in reducing the treatment gap for depression through an increase in ‘contact coverage’ (the proportion of affected individuals who seek help) and ‘effective coverage’ (the proportion of persons seeking care who ultimately derive the desired outcomes from the intervention). The proposal builds on a substantial body of evidence in the study settings, led by the program PIs, over the past two decades. Its most innovative aspect is that it integrates two different platforms to address the global burden of depression, and in doing so attempts to tackle one of the major unanswered questions in global mental health i.e. the coordination between community and primary care based approaches to reduce the treatment gap for depression.