Primary‐level worker interventions for the care of people living with mental disorders and distress in low‐ and middle‐income countries

The effects of primary‐level workers on people with mental disorders and distress in low‐ and middle‐income countries

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.