Bringing Depression Treatment to Texas With Lessons Learned in India

The researchers also compared the cost effectiveness of the different training methods. They found that face-to-face training cost $209 per participant while digital training cost $150 per participant with coaching and $121 per participant without coaching, making the digital methods considerably more cost-effective.

The HMS team performed the study with local and international collaborators in Madhya Pradesh state in 2019. The project built on decades of research and systems strengthening to deliver mental health care in communities with limited access to health care or mental health specialists. That includes work led by the study’s senior author Vikram Patel, the Paul Farmer Professor and Chair of the Department of Global Health and Social Medicine at HMS, with colleagues from universities around the world; India’s National Health Mission and Ministry of Health and Family Welfare; and Sangath, an Indian organization dedicated to research in the areas of child development, adolescent health, and mental health.

Global epidemic of depression

More than five percent of adults around the world suffer from depression, according to the World Health Organization, and it’s on track to be the world’s leading cause of illness and disability in the coming years. While there are effective treatments available for mild, moderate, and severe depression, less than nine percent of people with depression in the world receive adequate treatment. Even in high-income countries, only a third of people with depression receive mental health treatment.

“The tragedy of depression is that so many people suffer without access to care when there are scientifically proven treatments which can be effectively delivered by front-line providers and so many people in communities around the world who are ready and willing to help,” Patel said.

Patel and global colleagues have spent decades showing that some of these evidence-backed treatments can be delivered by people without specialized clinical training.

For the study in India, community health workers were trained to deliver a brief course of behavioral activation therapy (called the Healthy Activity Program), a form of talk therapy focused on encouraging patients to engage in activities that they find meaningful and rewarding and to notice how changing their behavior impacts their mood. The idea is that when they do things that help them feel better, it breaks cycles of isolation and rumination and establishes a virtuous circle of improving wellness.

Until recently, the logistical challenges and expense of bringing qualified trainers to teach these techniques to care providers was a major obstacle to delivering these interventions to patients in the many communities around the world with insufficient access to mental health care.

The researchers are hopeful that the results of this study will change that. When they saw how encouraging the preliminary data were, they quickly moved to find other places they could deploy these promising digital training tools.

Communities calling for help with mental health challenges in Texas

In 2021, the Mental Health for All Lab was invited to bring digital training for behavioral activation therapy to Texas as part of the Lone Star Depression Challenge, a collaborative project funded by Lyda Hill Philanthropies and led by the Meadows Mental Health Policy Institute, which aimed to strengthen health systems’ ability to increase the rate of recovery from depression.

The team quickly learned that there were also opportunities to help outside of traditional health systems, bringing the needed skills directly to community organizations whose members have recognized the deep needs of their communities, Naslund said.

The community-based work accelerated when leaders from a multidenominational group of churches in San Antonio approached the lab. They knew that many of their community members were confronting extreme mental health challenges, and they didn’t know where to turn for help. An initial group of eight local churches formed the Congregational Collective, most recently expanding to over 15 churches, to work together to become leaders in community mental health and wellness. The HMS researchers adapted the training they had piloted in India for the churches, tested it, and are now helping put together structures to make sure it is effectively delivered and sustainably linked to the existing health system.

In the last five years, the Mental Health for All Lab has worked on additional projects that have trained more than 500 frontline providers across the United States to deliver mental health care, including more than 400 individuals in Texas, consisting of community health workers, students, veterans, teachers, guidance counselors, and volunteers, hailing from faith- and community-based organizations, schools, federally qualified community health centers, and city and state health departments.

Next steps for community mental health

The lab is shifting from trialing the effectiveness of the training to researching how to best implement care once providers are trained, support the newly trained, and build bridges with clinical experts and existing health systems to meet any needs that require higher levels of care.

Each project begins by asking community members about the mental health challenges that they face and about the assets and values that the community can bring to help solve these problems. For example, participants from the Congregational Collective noted the power of bringing together a collection of individual churches to share resources, experiences, and an understanding of how spirituality intersects with mental health, the researchers said. The lab has built a strong collaboration with Baylor University’s Program for the Future Church, which convenes professors and church and community leaders to pilot solutions to new and emerging challenges for communities of faith.

The lab members are currently working with several communities across Texas at different stages in the process, including in San Antonio, Houston, and El Paso as well as Starr, Hidalgo, Cameron, and Willacy counties in the Lower Rio Grande Valley to tailor programming to meet the needs of youth, veterans, women, and working people across Texas’ rural and urban communities.

Along the way, the lab has published papers documenting the process of customizing training materials to meet the needs of different communities and the early steps of getting more people trained, providing evidence that the technique works and optimizing it for better performance.

“It’s been exciting to learn from so many different kinds of people as we work with new communities and to hear from our partners what a difference the skills we’re able to teach them makes in their ability to help their neighbors,” Naslund said.