This Cochrane Review update aims to assess the effects of engaging community-based workers, such as primary-care workers and teachers, to help people with mental disorders or distress. The review focused on studies from low- and middle-income countries and found 95 studies for inclusion (including 23 from the previous review).
Key messages
Primary health professionals, lay health workers, teachers, and other community workers may be able to help people with mental health issues if they are trained. However, more evidence is needed.
What was studied in the review?
In low- and middle-income countries, many people with mental illness do not receive the care they need because of stigma and difficulty accessing services. One solution is to offer services through ‘primary-level workers’. These are people who are not mental health specialists but who receive some mental health training, including primary health professionals (e.g. doctors, nurses); lay health workers; community volunteers; and other community members (e.g. teachers, social workers). Primary-level workers deliver these services alone or in collaboration with specialists.
What are the main results of the review?
95 relevant trials from 30 low- or middle-income countries were found.
The review authors searched for evidence about the effects of these strategies on the number of people who had mental health problems, the number who recovered, their symptom severity, quality of life, day-to-day functioning, use of health services, and negative effects of treatment. All results were measured one to six months after treatment completion, except in group 5, in which results were measured immediately after treatment completion. When results are not presented, this is because there was no evidence, or because the evidence was very uncertain. Evidence of the results below is of low to moderate certainty.
1. Adults with depression and anxiety
Treatments from lay health workers compared to usual care:
a. may increase recovery;
b. may reduce the number of people with depression/anxiety;
c. may improve quality of life;
d. may slightly improve day-to-day functioning; and
e. may reduce risk of suicidal thoughts/attempts.
Treatments from primary-level workers in collaboration with mental health specialists compared to usual care:
a. may increase recovery;
b. may reduce the number of people with depression/anxiety although the range for the actual effect indicates they may have little or no effect;
c. may slightly reduce symptoms;
d. may slightly improve quality of life;
e. probably have little to no effect on day-to-day functioning; and
f. may reduce referral to mental health specialists.
2. Women with depression related to pregnancy and childbirth
Treatments from lay health workers compared to usual care:
a. may increase recovery;
b. probably slightly reduce symptoms of depression;
c. may slightly improve day-to-day functioning;
d. may have little to no effect on risk of death.
3. Adults in humanitarian settings with post-traumatic stress or depression and anxiety
Treatments from lay health workers compared to usual care:
a. may slightly reduce depression symptoms; and
b. probably slightly improve quality of life.
Treatments from primary health professionals compared to usual care:
a. may reduce the number of adults with post-traumatic stress and depression.
4. Adults with alcohol or substance use problems
Treatments from lay health workers compared to usual care:
a. may increase recovery from harmful/hazardous alcohol use although the range for the actual effect indicates they may have little or no effect;
b. probably slightly reduce the risk of harmful/hazardous alcohol use;
c. may have little to no effect on day-to-day functioning; and
d. may have little to no effect on the number of people who use methamphetamine;
Treatments from primary health and community professionals compared to usual care:
a. probably have little to no effect on recovery from harmful/hazardous alcohol use;
b. probably slightly reduce risk of harmful/hazardous alcohol and substance use; and
c. probably have little to no effect on quality of life.
5. Adults with severe mental disorders (e.g. schizophrenia)
Treatments from lay health workers compared to mental specialists alone:
a. may have little to no effect on caregiver burden.
Treatments from primary health professionals alone or in collaboration with mental health specialists:
a. may improve day-to-day functioning.
6. Adults with dementia and their carers
Treatments from lay and professional health workers, compared to usual care:
a. may have little to no effect on the severity of behavioural symptoms in dementia patients; and
b. may reduce carers' mental distress.
7. Children in humanitarian settings with post-traumatic stress or depression and anxiety
Treatments from lay health workers, compared to usual or no care:
a. may have little to no effect on post-traumatic stress symptoms;
b. probably have little to no effect on depressive symptoms nor on day-to-day functioning; and
c. may make little or no difference in risk of adverse events.
Treatments from community professionals (teachers and social workers) compared to no care:
a. may have little to no effect on depressive symptoms; and
b. may make little or no difference in adverse events.
How up-to-date is this review?
Originally published in November 2013, this update includes studies published up to 20 June 2019.
PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.
Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.
To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.
MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).
Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.
PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).
Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).
Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.
For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.
Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.
Description of studies
95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).
Risk of bias
Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.
Intervention effects
*Unless indicated, comparisons were usual care at T2.
“Probably”, “may”, or “uncertain” indicates "moderate", "low," or "very low" certainty evidence.
Adults with common mental disorders (CMDs)
LHW-led interventions
a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56);
b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96);
c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16);
d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69);
e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15);
f. may reduce AEs (risk of suicide ideation/attempts);
g. may have uncertain effects on SU.
Collaborative-care
a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43);
b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01);
c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08);
d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53);
e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03);
f. may reduce SU (referral to MH specialists);
g. may have uncertain effects on AEs (death).
Women with perinatal depression (PND)
LHW-led interventions
a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54);
b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14);
c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04);
d. may have little-to-no effect on AEs (death);
e. may have uncertain effects on SU.
Collaborative-care
a. has uncertain effects on symptoms/QOL/SU/AEs.
Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings
LHW-led interventions
a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15);
b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15);
c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs.
PHP-led interventions
a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);
b. may have uncertain effects on symptoms/functioning/SU/AEs.
Adults with harmful/hazardous alcohol or substance use
LHW-led interventions
a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74);
b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03);
c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);
d. may have uncertain effects on SU/AEs.
PHP/CP-led interventions
a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10);
b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence);
c. may have uncertain effects on prevalence (cannabis use)/SU/AEs.
PW-led interventions for alcohol/substance dependence
a. may have uncertain effects.
Adults with severe mental disorders
*Comparisons were specialist-led care at T1.
LHW-led interventions
a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);
b. may have uncertain effects on symptoms/functioning/SU/AEs.
PHP-led or collaborative-care
a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47);
b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.
Adults with dementia and carers
PHP/LHW-led carer interventions
a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08);
b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);
c. may have uncertain effects on QOL/functioning/SU/AEs.
Children with PTS or CMDs
LHW-led interventions
a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14);
b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);
c. may have little-or-no effect on AEs.
CP-led interventions
a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;
b. may have uncertain effects on recovery/symptoms(PTS)/functioning.