Adaptation of problem-solving therapy for primary care to prevent late-life depression in Goa, India: the ‘DIL’ intervention

ABSTRACT

Background: Depression in late life is a major, yet unrecognized public health problem in low- and middle-income countries (LMICs). The dearth of specialist resources, together with the limited ability of current depression treatments to avert years lived with disability, underscores the need for preventive interventions that can be delivered by lay health workers in primary care settings. We describe the development of an intervention for the indicated prevention of depression in older adults at risk due to subsyndromal symptoms, attending rural and urban public primary care clinics in Goa, India.

Objectives: (1) to describe a mixed-methods approach (qualitative and quantitative)to the development of ‘DIL,’ an intervention for preventing the onset of major depression in older adults living with subsyndromal symptoms in Goa, India; (2) to describe resulting components of the ‘DIL’ intervention; and (3) to present data on the feasibility, acceptability, and benefit of DIL to participants.

Methods: We followed a mixed-methods design, including in-depth interviews, focus group discussions, a theory of change workshop to develop a logic model, and an open-case series.

Results: The mixed-method approach led to the development and adaptation of the DIL (Depression in Later Life) intervention for the indicated prevention of depression in older adults. The intervention was delivered by lay health counselors (LHCs). ‘DIL’ is a hybrid model of simple behavioral strategies grounded in Problem-solving Therapy for Primary Care, improved self-management of common, co-occurring medical disorders such as diabetes mellitus, and pragmatic assistance in navigating to needed social services. The use of ‘DIL’ in an open-case series with 19 participants led to a moderate reduction in symptoms of depression and anxiety on the General Health Questionnaire. A pictorial flipchart was developed to assist in delivering the intervention to participants with low levels of literacy. High rates of participant retention and satisfaction were achieved.

Conclusion: The DIL intervention was adapted to the local context for delivery by lay health counselors and was found to be acceptable and feasible among the elderly participants in the study.

KEYWORDS:

• late-life depression
• problem-solving therapy
• lay health counselors
• low- and middle-income countries
• indicated depression prevention

Responsible Editor Maria Emmelin, Umeå University, Sweden

Responsible Editor Maria Emmelin, Umeå University, Sweden

Acknowledgments

None.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Not required.

Paper context

Preventing depression in vulnerable older adults is a matter of increasing global health priority. In order to address the shortage of mental health specialty expertise in low- and middle-income countries, we have developed an approach to depression prevention (called ‘DIL’) that can be delivered by lay health counselors to older adults attending rural and urban primary care clinics. We describe in this paper the adaptation of problem-solving therapy in primary care (PST-PC) for the indicated prevention of major depression, and we present the results of an open-case series documenting its feasibility, acceptability, and benefit.

Additional information

Funding

National Institute of Health, NIMH 1 R34 MH096997, Prevention of Depression and Associated Anxiety Disorders in Low and Middle Income Countries (Reynolds PI); and the University of Pittsburgh Medical Center Endowed Professorship in Geriatric Psychiatry (Reynolds).

Notes on contributors

Charles F. Reynolds

Dias: local (Goa) site PI; Azariah: local (Goa) project coordinator; Sequeira: lead lay health counselor; Krishna: lay health counselor supervisor; Morse: co-investigator and expert in problem-solving therapy; Cohen: co-investigator and expert in qualitative analysis; Cuijpers: co-investigator and expert in prevention research; Anderson: co-investigator and project biostatistician; Patel: co-princiipal investigator and expert in mental health implementation research; Reynolds: project principal investigator. In preparing the manuscript for submission, Dr. Dias, Mr. Azariah and the team in Goa provided the initial draft; Drs. Cohen and Anderson verified all data; Drs. Morse, Cohen, Cuijpers, Anderson, Patel, and Reynolds reviewed and revised the submission.