Prevention of common mental disorders in older adults (major depression and anxiety disorders) in Low and Middle Income Countries (LMICs) is a major challenge in global mental health research. The public health imperative for devising strategies to prevent late life depression and anxiety in LMICs includes the rapid demographic transition and aging in countries like India, increased exposure of older adults to risk factors fo depression (disability, depletion of economic and social resources, bereavement, care giving, and chronic insomnia), and workforce issues (such as a dearth of mental health specialists). The dearth of specialist resources, together with the limited ability of current depression treatments to avert years lived with disability, underscores the need for preventive interventions that can be delivered by lay health workers in non-health care or primary care settings. Such development could also benefit policy and practice in the US by clarifying appropriate roles for lay and non-specialist workers in depression and anxiety prevention for populations with few mental health resources. In this revised R34 application (R34 MH096997-01A1), we propose to build upon the MANAS trial conducted in Goa, India. Given the shortage of mental health specialists in LMICs, MANAS (which means "project to promote mental health" in the Konkani language) employed the strategy of task-shifting, that is, the rational redistribution of tasks among health workforce teams to make more efficient use of lay human resources for health. MANAS demonstrated that the use of lay health counselors (LHCs), as part of a collaborative stepped- care intervention, increases rates of recovery from common mental disorders (depression and anxiety) in public primary care facilities. In addition, preliminary evidence indicated that the MANAS model of using LHCs in a stepped-care collaborative intervention may also reduce the incidence of common mental disorders in those who initially present with subthreshold (subsyndromal) depressive and anxiety symptoms. We propose to investigate translation of depression and anxiety prevention strategies to LMICs through non-specialist delivery systems. The goal of this revised R34 application is to develop and pilot test in Goa, India an LHC-led depression and anxiety disorder prevention strategy ("MANAS/DP"), building upon the experience of the MANAS treatment trial ("MANAS/RX")1. The application represents a collaboration between the NIMH sponsored ACISR in Late-Life Depression Prevention (P30 MH090333) at the University of Pittsburgh (Reynolds, Anderson);and SHARE, the NIMH-sponsored Hub for research in global mental health at Sangath/Goa Medical College (Patel, Cohen, Dias, and Chowdhary) and the London School of Hygiene and Tropical Medicine (Patel, Cohen, Chowdhary);and the Department of Psychology at the Free University in Amsterdam (Cuijpers).
This proposal addresses specific issues of depression prevention in older adults living in low- and middle- income countries (LMICs), by developing rational, targeted, risk-reduction strategies through the use of lay health counselors, a form of task shifting already shown to be effective in the treatment of common mental disorders in LMICs.