Training Health Workers in Therapy Leads to Improvements and Less Medication Use

A study that compared two types of mental health interventions for depression in Nigeria found high rates of improvement, including a group that used fewer medication treatments. More than three-quarters of the patients in both groups experienced full remission of depression.

The research was led by Oye Gureje at the University of Ibadan, Nigeria. It was published in The Lancet Global Health. An accompanying commentary was written by Bolanle Adeyemi Ola and Olayinka Atilola at Lagos State University, Nigeria.

“These findings provide further evidence that task-shifted interventions for depression delivered by lay health workers are effective, irrespective of the adopted model,” according to Ola and Atilola.

The study compared two types of training for first-line medical providers in Nigeria. The providers are considered lay health workers. In Nigeria, there are very few doctors, so first-line medical providers typically have 2-3 years of postsecondary education.

In the study, both groups of providers received training in depression treatment, including “psychoeducation and counseling to address stressors and activate social networks, and pharmacotherapy when necessary.” However, one group (the “intervention” group) also received specific training in how to administer behavioral activation and problem-solving therapy—two forms of psychotherapy that follow a manualized structure and are considered to be “evidence-based” for the treatment of depression.

The researchers found that the providers who received the specific training in psychotherapy were less likely to prescribe medications—only 13% of their depressed patients received medication, compared to 32% of the patients in the other group.

Despite being prescribed less than half as many antidepressants, patients in the intervention group did just as well. The follow-up tests were done 12 months after the study, and the researchers found that 76% of those in the intervention group, and 77% of those in the control group, had experienced “remission” of depression. This means that they scored ≤ 6 on the PHQ-9, a huge improvement from the original average score of 13.7.

According to the commentary authors, critics of global mental health services have raised concerns about exporting a neocolonial model based on Western cultural mores around mental health, which might result in overdiagnosis and overuse of medication, rather than culturally sensitive approaches that value other approaches to mental health.

The authors believe that this study demonstrated that training providers in evidence-based psychotherapy approaches may reduce the reliance on unneeded medications.

“Incorporation of and availability of skills in an evidence-based, culturally appropriate, and intensive psychological treatment could potentially reduce the need for and prescription of antidepressants in primary-care settings without compromising effectiveness.”

 

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Commentary: Ola, B. A., & Atilola, O. (2019). Task-shifted interventions for depression delivered by lay primary health-care workers in low-income and middle-income countries. The Lancet Global Health, 7(7), PE829-E830. (Link)

Article: Gureje, O., Oladeji, B. D., Montgomery, A. A., Bello, T., Kola, L., Ojagbemi, A., . . . Araya, R. (2019). Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomized controlled trial. The Lancet Global Health, 7(7), e951–60. http://dx.doi.org/10.1016/ S2214-109X(19)30148-2 (Link)