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Background: Tuberculosis (TB) and depression are highly comorbid and linked to higher rates of death and disability. Several evidence-based treatments for depression have been successfully implemented in low- and middle-income countries, but more knowledge is needed on how to bring these innovations to scale within complex 'real world' public health systems. Objective: To explore whether the principles of social network analysis could be used to enhance receptivity to integrating depression treatment into primary care for individuals with and without TB in Brazil. Methods: We used existing scales to identify settings and providers with high receptivity and connectivity within the primary care network. We trained and supervised existing staff in three primary care sites to deliver a brief evidence-based intervention over one year, coupled with active dissemination activities. Afterwards, we reassessed receptivity among individuals involved, and not involved, in the pilot. Results: Highly significant changes were observed in mental health literacy, attitudes towards evidence-based practices, work self-efficacy, and implementation leadership supporting our hypothesis. Limited social connections between primary care clinics precluded the examination of the hypothesis that targeting settings with high connectivity could capitalize on the information flow between and transcend the decentralized structure of the network, but leveraging the centralized nature of the TB program to integrate mental health services emerged as a promising alternative. Conclusions: The findings of this study strongly suggest that social networks may be leveraged to change individual providers' attitudes, thereby contributing to the enhanced dissemination of evidence-based interventions.

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Refugees and migrants experience an elevated risk for mental health problems and face significant barriers to receiving services. Interpersonal counseling (IPC-3) is a three-session intervention that can be delivered by non-specialists to provide psychological support and facilitate referrals for individuals in need of specialized care. We piloted IPC-3 delivered remotely by eight Venezuelan refugee and migrant women living in Peru. These counselors provided IPC-3 to Venezuelan refugee and migrant clients in Peru (n = 32) who reported psychological distress. Clients completed assessments of mental health symptoms at baseline and one-month post-intervention. A subset of clients (n = 15) and providers (n = 8) completed post-implementation qualitative interviews. Results showed that IPC-3 filled a gap in the system of mental health care for refugees and migrants in Peru. Some adaptations were made to IPC-3 to promote its relevance to the population and context. Non-specialist providers developed the skills and confidence to provide IPC-3 competently. Clients displayed large reductions in symptoms of depression (d = 1.1), anxiety (d = 1.4), post-traumatic stress (d = 1.0), and functional impairment (d = 0.8). Remote delivery of IPC-3 by non-specialists appears to be a feasible, acceptable, and appropriate strategy to address gaps and improve efficiency within the mental health system and warrants testing in a fully powered effectiveness study.

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BACKGROUND: Task shifting approaches (rational redistribution of tasks among health workforce teams) to train lay professionals to assist with integrating mental health treatment in primary care has been recommended to close the mental health treatment gap for depression in low- and middle-income countries. This study aims to examine the a new model for depression care in a low-resource environment compared to enhanced treatment at usual (E-TAU). METHODS: We trained non-specialist community health workers (local lay employees of the public health system) to provide Interpersonal Counseling (IPC) to treat depressive symptoms in the Brazilian, São Paulo city, family health strategy (FHS). We conducted a randomized controlled trial involving 86 patients with a current major depressive disorder or dysthymia (based on DSM-IV) recruited from an FHS clinic. Participants were randomized to IPC intervention (n = 43) or E-TAU (n = 43). Participants allocated to IPC received 3-4 sessions provided by community health workers; research psychologists followed the E-TAU participants to facilitate their referral to specialized mental health care within the public system. Reduction of depressive symptoms was assessed using the Hamilton Rating Scale (HDRS-17) and the Patient Health Questionnaire (PHQ-9); minor psychiatric symptomatology (including depression, anxiety and somatoform symptoms) were measured using the Self Reporting Questionnaire (SRQ); and functioning was measured by the Clinical Global Impression Scale over a 2-month period. RESULTS: Intention-to-treat analysis showed significant improvement on symptoms for both groups over 2 months, without significant differences between them. Per-protocol analysis showed significant better HDRS-17 outcomes for the IPC group. CONCLUSIONS: Training non-specialist community health workers in low- and middle-income countries to provide IPC could be a successful strategy in reducing the burden of depression and also potentially a low-cost and effective alternative to specialist-led services that might not be possible in low income settings. TRIAL REGISTRATION: Brazilian Clinical Trials, number RBR-5qhmb5 (trial url: http://www.ensaiosclinicos.gov.br/rg/RBR-5qhmb5/) , retrospectively registered after May 1, 2013.

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Interpersonal counseling (IPC), a briefer and simplified adaptation of interpersonal psychotherapy (IPT), was used with internally displaced women (IDW) in Bogotá, Colombia, an implementation study of a mental health care pathway funded by Grand Challenges Canada. Preliminary evidence suggests that IPC led to positive outcomes for IDW and may be a feasible first line treatment for displaced women with elevated symptoms of common mental disorders. The case study demonstrates the use of IPC as an intervention to treat depression, anxiety, and posttraumatic stress symptoms in one participant across 11 sessions, from the case formulation through the termination phase.

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