Depressionisaleadingcauseofdisabilityworldwide,andaccountsforsubstantialmorbidity, 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.ThegoalofIMPRESSistoreducethetreatmentgapfordepressionthroughthe integratedimplementationofevidencebasedinterventionsinfacilityandcommunityplatforms, 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(?theCommunityModel?)toenhancethedemandfor,andimprovetheoutcomes 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) increasinguptakeoftreatmentbypatientswithdepression;?c)increasingtreatmentcompletion rates;?d)reducingsymptomsofdepression;?andbeinge)cost-effective.Wewillassessthree specificmediationpathwaysfortheadditionalimpactofthecommunitybasedinterventions: improved mental health literacy in the community;? improved treatment adherence;? and increasedpatient-reportedactivation.Overall,theCommunityModelwouldbemoreeffective andcost-effectiveinreducingthetreatmentgapfordepressionthroughanincreasein?contact coverage?(theproportionofaffectedindividualswhoseekhelp)and?effectivecoverage?(the proportion of persons seeking care who ultimately derive the desired outcomes from the intervention).Theproposalbuildsonasubstantialbodyofevidenceinthestudysettings,led bytheprogramPIs,overthepasttwodecades.Itsmostinnovativeaspectisthatitintegrates twodifferentplatformstoaddresstheglobalburdenofdepression,andindoingsoattempts totackleoneofthemajorunansweredquestionsinglobalmentalhealthi.e.thecoordination between community and primary care based approaches to reduce the treatment gap for depression.
IMPRESS comprises a cluster RCT to evaluate the impact of the integration of a community intervention to address demand side barriers to depression care on contact and effectiveness coverageofanevidencebasedbriefpsychologicaltreatmentfordepressioninprimarycareinIndia.
