Due to limited resources, low and middle-income countries (LMICs) have been unable to implement World Health Organization (WHO) models for improving depression outcomes, in which community health workers (CHWs) deliver cognitive behavioral therapy (CBT) and other psychological treatments. We will develop and evaluate an mHealth intervention that can increase the reach and effectiveness of mental health care in LMICs. Building on our established foundation of collaborative mHealth research in Bolivia, we will develop and test AniMvil, a scalable mHealth service designed to monitor patients' depressive symptoms and deliver tailored behavioral activation messages derived from CBT principles.
In Aim 1, we will collaborate with Bolivian mental health professionals, potential CHWs, and people with depression to develop AniMvil's mHealth components, including automated phone (IVR)- and text message (SMS)-based patient monitoring and psychoeducation, plus smartphone resources that will enable CHWs to deliver brief, structured CBT by telephone. Patients' depressive symptoms and CBT skill-practice will be reported weekly via IVR, and patients will receive tailored behavioral activation messages during those calls. Patients will report their mood daily via SMS and receive reinforcement and follow-up based on those reports. Patients with severe depression will be stepped up to receive a minimum of 3 CHW-delivered telephone CBT sessions. CHWs will use smartphone tools to: access information about CBT training, manage appointments and clinical records, share information with one another and their supervisor regarding challenging cases, and request supervisory consults.
In Aim 2, we will conduct a randomized trial among 114 depressed patients to determine the impact of AniMvil on depression-related outcomes. Patients will be randomized to the intervention or an enhanced control condition in which they receive written materials and report daily mood information via automated SMS. The primary outcome will be the proportion of patients with remitted depression at 3 months. SMS daily mood reports in both arms will be a key secondary outcome. The trial includes an evaluation of intervention processes such as use of mHealth tools by patients and CHWs, and program costs. By emphasizing collaborative engagement with Bolivian co-investigators, we will increase their capacity for independent mHealth scientific discovery. If effective, AniMvil could improve population-based mental health care in LMICs, as well as the efficiency and quality of CHW training and supervision for delivering WHO-recommended treatments. Evidence from this study will directly inform decision-making by the Bolivian Ministry of Mental Health regarding national scale-up and financial sustainability. Results also will guide the design of larger effectiveness trials and international dissemination efforts. By combining SMS/IVR monitoring and patient activation with smartphone support for CHWs and supervisors, Animvil can serve as a prototype for mHealth services that increase access to care management for LMIC patients with other high priority non-communicable diseases.

Public Health Relevance

In this study, we will work with leaders in mental health care in Bolivia to develop and begin testing a new program that uses text messages and automated cell-phone calls to monitor patients' depressive symptoms and give self-care advice. Participants with more severe depression will receive telephone counseling by a community health worker, who will use mobile health feedback from patients and a psychologist supervisor to guide patients in making changes that improve their mood. We hope that this new mobile health service and the research training we will deliver to our collaborators improve access to quality care for patients suffering with depression in low and middle-income countries.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
Project #
Application #
Study Section
Special Emphasis Panel (ZRG1)
Program Officer
Pringle, Beverly
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Michigan Ann Arbor
Schools of Public Health
Ann Arbor
United States
Zip Code
Janevic, Mary R; Aruquipa Yujra, Amparo C; Marinec, Nicolle et al. (2016) Feasibility of an interactive voice response system for monitoring depressive symptoms in a lower-middle income Latin American country. Int J Ment Health Syst 10:59