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People with non-communicable diseases (NCDs) are at two-three times increased risk of depression (Lloyd et al., 2018; Mendenhall et al., 2014). There is a bidirectional relationship between depression and NCDs (Singer et al., 2017), with one condition adversely affecting the outcome for the other. The negative impacts extend beyond adverse health outcomes and include financial burden due to increased healthcare 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 (LMICs), which is even greater than those for high-income countries (Mendenhall et al., 2014) with more established and stable healthcare systems.  The saving grace is that depression can be treated with psychological and/or pharmacological therapies which are relatively simple, low-cost and culturally adaptable (WHO, 2014; Hendriks et al., 2018).

The systematic review and meta-analysis by Zavala and colleagues (2023) aimed to provide an in-depth evaluation of the effects of psychological interventions on depression among people with NCDs (i.e. cardiovascular disease, type 2 diabetes, chronic obstructive pulmonary disorder, stroke, and cancer); and individual, organisational, and policy-level barriers and facilitators for implementation and scaling-up of these interventions in two South Asian countries: Bangladesh and Pakistan.

The systematic review by Zavala et al (2023) evaluated the effectiveness of psychological therapy for depression in people with non-communicable diseases.  

The 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. An additional exhaustive search was performed for studies related to barriers and facilitators to intervention development and policy documents related to depression care in NCDs in Bangladesh and Pakistan.

For effectiveness, the systematic review included included randomised controlled trials and quasi-experimental studies of adults (age 18 years) with a diagnosis of depression with NCDs (cardiovascular disease, type 2 diabetes, chronic obstructive pulmonary disorder, stroke, and cancer),  living in South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) (South Asia, 2020). Interventions included psychotherapy (e.g. counselling, cognitive behaviour therapies, or behavioural activation). For identification of barriers and facilitators searches for conducted for quantitative, qualitative and mixed methods studies. Policy related documents were also searched.

Study selection involved title/abstract screening followed by full-text review.

Quality assessment included use of Cochrane risk of bias (RoB) tool 2 and Mixed Methods Appraisal Tool (MMAT) was used to assess the risk of bias. Meta-analyses were carried out presenting pooled standardised mean difference (SMD). Narrative synthesis was employed for presentation of barriers and facilities analysed using the theoretical domains framework (TDF) (Atkins et al., 2017), and policy review findings.

Results

There were 2,823 records identified out of which 5 studies for effectiveness and 14 studies for analysis of barriers and facilitators, met the inclusion criteria. Thirty-five documents (15 Bangladesh and 20 Pakistan) for policy information and about barriers and facilitators to implement psychological interventions were also included.

Out of the 5 effectiveness studies, 4 were RCTs and 1 quasi-experimental. All evaluated depression outcomes with 4 also measuring anxiety. One study was exclusively on women and the other four included between 30 and 60% of women. All 5 of the included studies reported continuous outcomes for improvement as short (<6 months) and long-term (>12 months) for depression; and short-term for anxiety symptoms.

Meta-Analyses

The pooled results from the meta-analysis for effectiveness of psychological therapy indicated:

  • a significant improvement in depression symptoms (SMD = -2.31, 95% CI = -4.16 to -0.45);
  • a significant improvement in anxiety ((SMD = -2.22, 95% CI = -3.57 to -0.86).

However, there was high heterogeneity reported (I2 96% and 86% respectively), which means we cannot rely on these results, and more (better quality) research is needed.

Narrative synthesis of barriers and facilitators analysis and policy document review

Seven barriers to intervention delivery were identified. Five were related to patients (lack of availability of materials in patient’s own language, pessimism around beliefs about capability and ability to engage with the intervention, stigma, lack of staff’s familiarity with psychological therapies, and inability to differentiate between depression and NCDs), and practitioner level barriers (time constraints and lack of knowledge related to mental health) and two barriers were related to intervention development.

Five facilitators were identified including:

  • For patients:
    • a supportive community environment,
    • and family engagement;
  • For practitioners:
    • delivery of training,
    • identification of community assets for tailoring of intervention according to patient needs;
  • For intervention delivery:
    • provision of therapies in clinical settings and use of simple, visual materials.

The policy review revealed that in both Bangladesh and Pakistan, there is recognition for incorporating mental health services into essential healthcare services, however, lack of a clear roadmap for implementation, limited funding and resources pose significant challenges.

Based on quality appraisal, overall the studies assessing effectiveness of psychological therapies were of low quality, where as the majority of studies exploring barriers and facilities to intervention development were of high quality (n=8) with rest classed as having some concerns (n=4) or of low quality (n=2). 

This review has identified the barriers and facilitators to delivering healthcare for people with depression and NCDs in Bangladesh and Pakistan. Now we need and clear funded plan for implementation.

This review has identified the barriers and facilitators to delivering healthcare for people with depression and NCDs in Bangladesh and Pakistan. Now we need a clear funded plan for implementation.

Conclusions

  • Findings suggest that psychological therapies are effective for treating depression in people with NCDs, but the evidence is limited and of low quality.
  • Contextual barriers and facilitators should be considered for intervention development and implementation in this setting.

Strengths and limitations

A rigorous search and evaluation of the literature was conducted as part of this review. No language or date restrictions were imposed. 

Included studies were mostly of low quality and pooled results showed significant levels of heterogeneity which warrants caution in interpretation of the results. Some relevant studies may have been missed as grey literature and local databases were not searched due time and resource constraints.

Implications for practice/ research

  • Integration of depression care within the NCD care pathway can improve health outcomes for the patients.
  • Policy initiatives supporting provision of training and support to healthcare professionals for recognition and management of depression can help tackle the rising dual burden of mental health problems and the NCD disease.
  • More high quality, adequately powered trials including cost analysis can provide evidence regarding cost-effectiveness of the approach. Future research should focus on understanding the real-life challenges through implementation of depression care as part of the NCD care pathway.
Integration of depression care within the non-communicable disease care pathway can improve health outcomes for patients.

Integration of depression care within the non-communicable disease care pathway can improve health outcomes for patients.

Statement of interest

A group of 5 people 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 for the Centre for IMPACT – a NIHR Global Health Research Centre established to improve mental and physical health together: https://www.impactsouthasia.com/

Links

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, Siddiqi N, Wright JM, Kellar I. (2023) Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis. Int J Ment Health. 2023 Apr 24;52(3):260-284. https://doi.org/10.1080/00207411.2023.2202431

Other references

Hendriks, T., Schotanus-Dijkstra, M., Hassankhan, A., Graafsma, T. G. T., Bohlmeijer, E., & de Jong, J. (2018). The efficacy of positive psychological interventions from non-western countries: A systematic review and meta-analysis. International Journal of Wellbeing, 8(1), 71–98. https://doi.org/10.5502/ijw.v8i1.711

Holt, R. I., de Groot, M., & Golden, S. H. (2014). Diabetes and depression. Current Diabetes Reports, 14(6), 491. https://doi.org/10.1007/s11892-014-0491-3

Lloyd, C. E., Nouwen, A., Sartorius, N., Ahmed, H. U., Alvarez, A., Bahendeka, S.,Basangwa, D., Bobrov, A. E., Boden, S., Bulgari, V., Burti, L., Chaturvedi, S. K., Cimino, L. C., Gaebel, W., de Girolamo, G., Gondek, T. M., de Braude, M. G., Guntupalli, A., Heinze, M. G., … Xin, Y. (2018). Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries. Diabetic Medicine, 35(6), 760–769. https://doi.org/10.1111/dme.13611

Lloyd, C. E., Roy, T., Nouwen, A., & Chauhan, A. M. (2012). Epidemiology of depression in diabetes: International and cross-cultural issues. Journal of Affective Disorders, 142 Suppl, S22–S29. https://doi.org/10.1016/S0165-0327(12)70005-8

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Sartorius, N. (2018). Depression and diabetes. Dialogues in Clinical Neuroscience, 20(1), 47– 52. https://doi.org/10.31887/DCNS.2018.20.1/nsartorius

Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. Lancet, 389(10072), 941–950. https://doi.org/10.1016/S0140-6736(17)30003-X

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