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Author for correspondence: Bradley H. Wagenaar, E-mail: [email protected]
Introduction
For adults globally, mental, neurologic, and substance-use (MNS) disorders are the greatest contributor to years lived with disability (YLDs) – accounting for almost one-third of all YLDs [Institute for Health Metrics and Evaluation (IHME), 2017]. This finding is true in both high-income and low- and middle-income countries (LMICs). Depression alone accounts for 35% of all YLDs for mental disorders in countries with a low socio-demographic index, and over 6% of YLDs from any health condition (IHME, 2017). Yet, even with this widespread recognition of MNS disorders – and depression in particular – as key drivers of global disability, the gap between knowledge of evidence-based prevention and treatment approaches in the literature and its application in community settings is large. In high-income settings, only one in five patients with depression receive minimally-adequate treatment, with gaps increasing to one in nine in upper-middle-income countries and 1 in 27 for lower-middle-income countries (Thornicroft et al., 2017). Others have written that a comprehensive ‘mental health care gap’ would likely be much larger, as it would include the biomedical treatment gap, combined with the psychosocial care gap as well as the physical health care gap (Pathare et al., 2018). The recent landmark Lancet Commission on Global Mental Health and Sustainable Development (Patel et al., 2018) highlighted that even amongst high-income countries that have increased access to, and use of, evidence-based treatments for mood disorders from 1990 to 2015, the population-level prevalence of these conditions has not decreased. In fact, from 1991 to 2016, the disability burden of MNS disorders has steadily increased across both low- and high-income countries, although the largest increases (almost a doubling) have been seen in low-income countries (Patel et al., 2018).
To address the particularly large depression care gap in LMICs, the past decade has seen increased investment in pragmatic effectiveness trials to generate the evidence-base for mental health treatment in LMICs. The Disease Control Priorities, 3rd Edition, states that sufficient evidence exists for effectiveness and cost-effectiveness for preventative, drug, physical interventions, and psychosocial interventions for individuals with depressive disorders globally (Patel et al., 2016). Due to very limited trained mental health human resources in LMICs (Saxena et al., 2007;...