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BackgroundUpwards of ninety percent of individuals living with depression in India do not have access to evidence-based treatments, especially in rural areas. Integrating these treatments into primary care is essential for bridging this care gap. This trial aims to evaluate whether a remote coaching implementation support strategy, referred to as Enhanced Implementation Support, is superior to routine support, referred to as Routine Implementation Support, in supporting the delivery of collaborative depression care in rural primary care centers.MethodsEmploying a cluster-randomized hybrid type-III implementation trial design, 14 primary care facilities in Sehore district, Madhya Pradesh, will implement a collaborative depression care package based on the WHO's mhGAP program. Facilities will be randomized to either Enhanced Implementation Support or the Routine Implementation Support control condition. Enhanced Implementation Support consists of remote coaching and technical assistance, supplemented with in-person visits, and guided by the Plan-Do-Study-Act implementation cycles. The primary implementation outcome is the proportion of outpatients screened for depression by facility staff, with secondary outcomes including the proportions of outpatients who screen positive for depression, are referred to the medical officer, and initiate treatment. Secondary patient outcomes include proportion of patients who achieve reduction in depression symptom severity at 3-month follow up. Acceptability, feasibility, and fidelity of the depression care package will be assessed through routine observations collected during field visits, facility audits, and qualitative exit interviews with facility staff. Costs of delivering the Enhanced Implementation Support strategy will also be estimated.DiscussionThis trial can inform efforts to integrate depression care in rural primary care facilities in a low-resource setting, and illuminate whether external coaching support is superior relative to existing implementation support for achieving these goals. Trial RegistrationNCT05264792.

IntroductionThe mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.MethodsA narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.ResultsThe initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.DiscussionThis landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. The purpose of this article is to provide an evidence-based overview of the adverse mental health impacts on healthcare workers during times of crisis and other challenging working conditions and to highlight the importance of prioritizing and protecting the mental health and well-being of the healthcare workforce, particularly in the context of the COVID-19 pandemic. First, we provide a broad overview of the elevated risk of stress, burnout, moral injury, depression, trauma, and other mental health challenges among healthcare workers. Second, we consider how public health emergencies exacerbate these concerns, as reflected in emerging research on the negative mental health impacts of the COVID-19 pandemic on healthcare workers. Further, we consider potential approaches for overcoming these threats to mental health by exploring the value of practicing self-care strategies, and implementing evidence based interventions and organizational measures to help protect and support the mental health and well-being of the healthcare workforce. Lastly, we highlight systemic changes to empower healthcare workers and protect their mental health and well-being in the long run, and propose policy recommendations to guide healthcare leaders and health systems in this endeavor. This paper acknowledges the stressors, burdens, and psychological needs of the healthcare workforce across health systems and disciplines, and calls for renewed efforts to mitigate these challenges among those working on the frontlines during public health emergencies such as the COVID-19 pandemic.

Objective: Youth with mental illnesses often engage in unhealthy behaviors associated with early mortality from physical diseases in adulthood, but interventions to support positive health behaviors are rarely offered as part of routine mental health care for this group. Digital health technology that is desirable, accessible, and affordable has the potential to address health behaviors in public mental health settings where many adolescents with severe mental health problems receive care. The aims of this study were to examine how adolescents receiving public mental health services use digital technology and social media and to explore their preferences using technology to support health and wellness.Methods: Using a convergent parallel mixed methods design, we surveyed adolescents ages 13–18 from four community mental health centers in one state and conducted focus group interviews to explore their perspectives on using digital technology and social media to receive health coaching and connect with peers to support healthy behaviors. The survey and focus group data were merged to inform the future development of a digital health intervention for adolescents receiving public mental health services.Results: Of 121 survey respondents (mean age 15.2, SD = 1.5), 92% had a cell phone, 79% had a smartphone, 90% used text messaging, and 98% used social media. Focus group interviews revealed that adolescents were interested in receiving strengths-based mobile health coaching, and they preferred structured online peer-to-peer interactions in which a professional moderator promotes positive connections and adherence to privacy guidelines.Conclusions: Adolescents receiving public mental health services in this study had access to smartphones and were frequent social media users. These data suggest that digital health interventions to promote health and wellness among adolescents may be scalable in community mental health settings. Adolescent participants suggested that digital health interventions for this group should focus on strengths and online peer support for health promotion should include a professional moderator to foster and manage peer-to-peer interactions.