People with noncommunicable diseases (NCDs) have a two- to threefold increased risk of depression (Lloyd et al., 2018; Mendenhall et al., 2014). There is a bidirectional relationship between depression and AIDS (Singer et al., 2017), with one condition negatively influencing the outcome of the other. Adverse effects go beyond adverse health outcomes and include financial burden due to increased health care costs and loss of earnings; and lower quality of life (Holt et al., 2014; Lloyd et al., 2012; Mommersteeg et al., 2013; Sartorius, 2018).
Worryingly, the prevalence of both depression and NCDs is increasing rapidly in low- and middle-income countries (LMIC), even more so than in high-income countries with more robust and stable health systems (Mendenhall et al., 2014). . The saving grace is that depression can be treated with relatively simple, inexpensive and culturally adaptable psychological and/or pharmacological treatments (WHO, 2014; Hendriks et al., 2018).
A systematic review and meta-analysis by Zavala and colleagues (2023) aimed to provide an in-depth assessment of the effects of psychological interventions on depression among people with CVD (eg, cardiovascular disease, type 2 diabetes, chronic obstructive pulmonary disorder, stroke, and cancer); and individual, organizational, and policy-level barriers and facilitators to implementing and scaling up these interventions in two South Asian countries: Bangladesh and Pakistan.
A systematic review by Zavala et al (2023) evaluated the effectiveness of psychological therapy for depression in people with non-communicable diseases.
Methods
Eight databases, ASSIA, CINAHL, Embase Classic, Embase, Global Health, IMEMR (WHO Global Health Index Medicus), ISMEAR (WHO Global Health Index Medicus), Ovid MEDLINE and APA PsycInfo were searched from inception to October 2021. A search was conducted for research on barriers and facilitators and policy documents for intervention development related to depression treatment in NCDs in Bangladesh and Pakistan.
A systematic review of efficacy included randomized controlled trials and quasi-experimental studies in adults (aged 18 years) diagnosed with depression with CVD (CVD, type 2 diabetes, chronic obstructive pulmonary disease, stroke and cancer). In South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) (South Asia, 2020). Interventions include psychotherapy (eg, counseling, cognitive behavioral therapy, or behavioral activation). Quantitative, qualitative and mixed methods studies are conducted to identify barriers and facilitators. Documents related to the policy were also examined.
Study selection involved full text review followed by title/abstract screening.
Quality assessment included the Cochrane risk of bias (RoB) tool 2 and the Mixed Methods Assessment Tool (MMAT) for assessing risk of bias. Meta-analyses presenting pooled standardized mean difference (SMD) were performed. Narrative synthesis was used to present the barriers and objects analyzed using the theoretical fields framework (TDF) (Atkins et al., 2017) and findings from the policy review.
Results
There were 2,823 records identified, of which 5 studies for effectiveness and 14 studies for analysis of barriers and facilitators met the inclusion criteria. Policy information and 35 papers (15 from Bangladesh and 20 from Pakistan) on barriers and facilitators to implementing psychological interventions were also included.
Of the 5 efficacy studies, 4 were RCTs and 1 was quasi-experimental. All assessed depression outcomes also measure anxiety with 4 years. One study was conducted on women only, while the other four included 30-60% of women. All 5 included studies used a brief for depression (<6 ay) və uzunmüddətli (>(12 months) reported sustained results for improvement; and short-term for anxiety symptoms.
Meta-analyses
Pooled results from a meta-analysis for efficacy psychological therapy Shown:
- significant improvement depression symptoms (SMD = -2.31, 95% CI = -4.16 -0.45);
- significant improvement anxiety ((SMD = -2.22, 95% CI = -3.57 -0.86).
However, there was high heterogeneity informed (I2 96% and 86% respectively), which means we cannot trust these results and more (higher quality) research is needed.
Analysis of barriers and facilitators and narrative synthesis of policy document reviews
Seven barriers to intervention implementation has been determined. Five were patient-related (lack of materials in the patient's own language, pessimism around beliefs about ability and competence to engage in the intervention, stigma, lack of staff familiarity with psychological treatments, inability to distinguish between depression and NCD) and practitioner-level barriers (time constraints and mental lack of health knowledge) and two barriers were related to intervention development.
Five mediators are defined, including:
- For patients:
- supportive community environment,
- and family mark;
- For practitioners:
- providing training,
- identifying community assets to tailor intervention to patient needs;
- For intervention delivery:
- providing treatments in a clinical setting and using simple, visual materials.
The policy study found that both Bangladesh and Pakistan are recognized for mainstreaming mental health services, but lack of a clear roadmap for implementation and limited funding and resources pose significant challenges.
Based on the quality assessment, overall studies evaluating the effectiveness of psychological treatments were done Low qualityas the majority of studies examining barriers and opportunities for intervention development were classified as high quality (n=8) and the remainder as having some concerns (n=4) or low quality (n=2).
This study identified barriers and facilitators to health care delivery for people with depression and NCDs in Bangladesh and Pakistan. Now we need a clearly funded plan to implement.
Results
- Findings suggest that psychological therapy is effective for treating depression in people with NCDs, but the evidence is limited and of low quality.
- In these settings, contextual barriers and facilitators to intervention development and implementation must be considered.
Strengths and limitations
As part of this study, a rigorous literature search and evaluation was conducted. There are no language or date restrictions.
The included studies were mostly of low quality and the pooled results showed considerable heterogeneity, which calls for caution in the interpretation of the results. Some relevant studies may have been missed because gray literature and local databases were not searched due to time and resource constraints.
Implications for practice/research
- Integrating depression treatment within the NCD care pathway may improve patient health outcomes.
- Policy initiatives that support training and support for health professionals to recognize and manage depression can help address the growing dual burden of mental health problems and NCDs.
- Higher-quality, adequately powered trials, including cost analyses, can provide evidence of the approach's cost-effectiveness. Future research should focus on understanding real-life issues by implementing depression treatment as part of the NCD care pathway.
Integrating depression treatment within the NCD care pathway may improve patient health outcomes.
Statement of interest
A group of 5 co-authored this blog: Bilal Jawaid, Mehreen Faisal, Rubia Zafar, Sawera Hanif, Syeda Nadia Bokhari. This work was done as part of a blogging workshop run by The Mental Elf The IMPACT Center – an NIHR Global Health Research Center created to improve mental and physical health together: https://www.impactsouthasia.com/
Connections
Primary paper
Zavala GA, Jennings HM, Afaq S, Alam A, Ahmed N, Aslam F, Arsh A, Coales K, Ekers D, Nabi M, Naz A, Shakur N, Siddiqui N, Wright JM, Kellar I. (2023) Efficacy and Implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: A systematic review and meta-analysis. Int J Ment Health. 2023 Apr 24;52(3):260-284. https://doi.org/10.1080/00207411.2023.2202431
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