Can Combining Psychological and Social Interventions Prevent Mental Health Problems in Low and Middle-Income Countries?

What you need to know

• Common mental health conditions like depression, anxiety and post-traumatic stress disorder are highly prevalent in low and middle-income countries.
• Both psychological interventions and programs addressing social determinants of mental health show promise for prevention, but their combined effectiveness is unknown.
• This systematic review will examine whether interventions that combine psychological and social approaches are effective for preventing common mental health conditions in low and middle-income countries.

Mental health challenges in low and middle-income countries

Common mental health conditions, including depression, anxiety, and post-traumatic stress disorder (PTSD), are highly prevalent in low and middle-income countries (LMICs). These conditions contribute significantly to the global burden of disease and disability. For example, the World Health Organization estimates that in conflict settings, the prevalence of common mental health conditions is around 22% - about five times higher than in the general population.

In LMICs, a range of social and economic factors influence mental health, including:

• Poverty
• Exposure to conflict and violence
• Malnutrition
• Gender-based violence
• Social inequalities

These are known as social determinants of mental health - the social and economic conditions that can directly impact the prevalence and severity of mental health problems across a person’s life. Research shows that common mental health conditions are strongly influenced by these social factors in populations worldwide.

The COVID-19 pandemic has further complicated this picture, exacerbating existing mental health challenges and negatively impacting many of the social determinants of mental health. This has created an even more complex environment for addressing mental health needs in LMICs.

The mental health treatment gap

In LMICs, there is a large gap between the number of people who need mental health interventions and those who are able to access such services. This treatment gap, combined with the high burden of common mental health conditions, has led global mental health experts to advocate for increased focus on prevention strategies.

Prevention aims to reduce the likelihood of future mental health disorders, either in the general population or in people identified as being at higher risk. Preventive approaches can be classified as:

• Universal: targeting the whole population
• Selective: targeting high-risk subgroups
• Indicated: targeting individuals with increased vulnerability but not yet meeting diagnostic criteria

Psychological interventions are widely used for prevention of common mental health conditions in LMICs. These typically involve brief, straightforward approaches delivered by non-specialist health workers or community workers rather than mental health professionals. This task-sharing approach helps address shortages of mental health specialists in many LMICs.

Combining psychological and social interventions

While there is growing evidence supporting the effectiveness of psychological interventions and programs targeting social determinants for preventing mental health problems, the impact of combining these approaches is not well understood. No previous systematic reviews have examined the effectiveness of interventions that integrate both psychological and social components for mental health prevention in LMICs.

This systematic review aims to address that gap by comprehensively evaluating the impact of interventions that include both psychological ingredients and components targeting social determinants of mental health. The review will focus specifically on prevention of common mental health conditions (depression, anxiety, and PTSD) in LMICs.

How the review will be conducted

The researchers will search for randomized controlled trials testing interventions that combine psychological and social components for preventing common mental health conditions in LMICs. They will include studies involving participants of any age without an existing mental health diagnosis at the start of the study.

The review will consider two main types of combined interventions:

1. Integrated interventions where psychological and social components are part of a single program
2. Interventions where psychological and social components are delivered separately but in combination

The social determinants addressed will be categorized into five domains:

1. Demographic factors
2. Economic factors
3. Neighborhood factors
4. Environmental events
5. Social/cultural factors

To be included, interventions must be delivered through a task-sharing approach by non-specialist health workers or community workers rather than mental health professionals.

The primary outcome the review will examine is the frequency of depression, anxiety or PTSD after the intervention, as determined by a formal diagnostic tool or scoring above a cutoff on a validated rating scale. Secondary outcomes include:

• Frequency of conditions at later follow-up time points
• Symptom severity
• Changes in mental health service use
• Economic outcomes like healthcare resource use and costs

The researchers will conduct meta-analyses to statistically combine results across studies where possible. They will examine results separately for children/adolescents and adults. If enough studies are available, they will also conduct subgroup analyses to explore factors that may influence effectiveness, such as:

• Type of social determinant addressed
• Type of prevention approach (universal, selective, indicated)
• Type of provider delivering the intervention
• Gender of participants
• Country income level
• Humanitarian vs non-humanitarian setting

Potential implications

This systematic review has the potential to provide important insights into effective strategies for preventing common mental health conditions in LMICs. By examining interventions that combine psychological and social approaches, it may identify promising integrated models that address both individual and societal factors influencing mental health.

The findings could help inform the development of more holistic, contextually-appropriate prevention programs in LMICs. Ultimately, this may contribute to reducing the large burden of common mental health conditions and narrowing treatment gaps in these settings.

However, it’s important to note some potential limitations. The researchers anticipate there may be significant variation across studies in terms of intervention approaches, settings, and methodologies. This heterogeneity could make it challenging to draw firm conclusions about overall effectiveness. Additionally, the quality and risk of bias of included studies will need to be carefully assessed.

Conclusions

• This systematic review will examine whether combining psychological and social interventions is effective for preventing common mental health conditions in LMICs.
• The findings may identify promising integrated prevention models that address both individual and societal factors influencing mental health.
• Results could inform development of more holistic, contextually-appropriate mental health prevention programs for LMICs.
• Potential heterogeneity across studies and methodological limitations will need to be carefully considered when interpreting the results.