New approach reduces mental health gap in low and middle income countries

Depression is a leading contributor to the global burden of disease, including in low and middle income countries, where treatment availability is poor. The University of Groningen (UG) and University of Amsterdam (Amsterdam University Medical Centres, AMC), in collaboration with Atma Jaya Catholic University of Indonesia, Jakarta, have conducted the first adequately powered randomized clinical trial of an internet-based intervention for depression in a low or middle-income country: Indonesia. Their results, published in Lancet Psychiatry this week, demonstrate that online behavioural activation with lay support is efficacious in treating depression. This opens up new ways to bridge the mental health gap in low and middle-income countries.

Depression is a leading contributor to the global burden of disease, including in low and middle-income countries, where depression prevalence is reported to be around 4.2%. However, treatment availability is far from ideal in many countries, especially low and middle-income countries — an issue known as the mental health gap (World Health Organization). Furthermore, the distance to mental healthcare facilities can be large. Indonesia is one of these low and middle-income countries. The need to improve treatment availability for mental health problems in Indonesia is widely recognized.

Because Indonesia is an archipelago with five large islands and over 1000 smaller ones, mental health facilities are unequally distributed. Therefore, innovative strategies to address the mental health gap and improve access to treatment in Indonesia and other low and middle-income countries need to be developed, including use of technology in combination with delivery by non-specialists to facilitate access. Guided Act and Feel Indonesia (GAF-ID) is an internet-based intervention for depression that is guided by trained lay counsellors and based on a treatment protocol for behavioural activation that has been adapted to the Indonesian context (Retha Arjadi, Maaike Nauta and Claudi Bockting, UG/AMC).

Significantly lower

In a randomized clinical trial, the researchers investigated the efficacy of internet-based behavioural activation with lay counsellor support compared with online minimal psychoeducation without support for depression in 313 participants in Indonesia (Arjadi et al., Lancet Psychiatry). Professor Claudi Bockting: ‘Depressive symptoms were significantly lower over 10 weeks and chance of remission was 50% higher in the GAF-ID group than in the online psychoeducation group¹. The effect was sustained over time – with an effect size 0·27 at 6 months. This opens up new ways to bridge the mental health gap in low and middle-income countries.’

₁ Mean difference –1·26 points [95% CI –2·29 to –0·23]; p=0·017), and participants in the GAF-ID group had a 50% higher chance of remission at 10 weeks (relative risk 1·50 [95% CI 1·19 to 1·88]; p<0·0001