Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries

Abstract

Common mental disorders, including depression, anxiety, and posttraumatic stress, are leading causes of disability worldwide. Treatment for these disorders is limited in low- and middle-income countries. This systematic review synthesizes the implementation processes and examines the effectiveness of psychological treatments for common mental disorders in adults delivered by nonspecialist providers in low- and middle-income countries. In total, 27 trials met the eligibility criteria; most treatments targeted depression or posttraumatic stress. Treatments were commonly delivered by community health workers or peers in primary care or community settings; they usually were delivered with fewer than 10 sessions over 2-3 months in an individual, face-to-face format. Treatments included common elements, such as nonspecific engagement and specific domains of behavioral, interpersonal, emotional, and cognitive elements. The pooled effect size was 0.49 (95% confidence interval = 0.36-0.62), favoring intervention conditions. Our review demonstrates that psychological treatments-comprising a parsimonious set of common elements and delivered by a low-cost, widely available human resource-have moderate to strong effects in reducing the burden of common mental disorders.

Keywords: common elements; global mental health; implementation processes; low- and middle-income countries; meta-analysis; psychological treatments; systematic review.

Figure 1

The taxonomy of treatment components of psychological treatments for common mental disorders delivered to adults in low- and middle-income countries.

Figure 2

Implementation processes related to the who, what, where, and how of delivering psychological treatments in low- and middle-income countries.

Figure 3

Flow chart for identifying eligible articles. Abbreviation: RCT, randomized controlled trial.

Figure 4

Specific and nonspecific elements used to address common mental disorders in 27 trials in low- and middle-income countries.

Figure 5

Techniques used in sessions to address common mental disorders in 27 trials in low- and middle-income countries.

Figure 6

(a) Forest plot of the effects of psychological treatments on primary outcomes for common mental disorders in 24 trials in low- and middle-income countries. (b) Forest plot of the effects of psychological treatments on outcomes for common mental disorders in low- and middle-income countries by condition (N = 35). Abbreviation: CI, confidence interval; df, degrees of freedom; SD, standard deviation. Bolton 2014a(i): BMC Psychiatry, behavioral activation experimental condition versus control; Bolton 2014a(ii): BMC Psychiatry, cognitive processing therapy experimental condition versus control; Bolton 2014b, PLoS Medicine, common elements treatment approach (CETA) experimental condition versus control; Weiss 2015(i): BMC Psychiatry, cognitive processing therapy experimental condition versus control; Weiss 2015(ii): BMC Psychiatry, common elements treatment approach (CETA) experimental condition versus control.

Figure 7

The effects of treatment-specific and nonspecific elements on trial effectiveness. (a) Model 1: comparison of specific and nonspecific elements on treatment effectiveness. (b) Model 2: comparison of nonspecific element domain with specific element domain showing effects on treatment effectiveness. β represents standardized beta. Treatment effectiveness is the effect size or standardized mean difference between the intervention and control groups at the primary endpoint.