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Introduction: Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings., Methods: We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period., Results: Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001)., Conclusion: Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare., Competing Interests: Competing interests: PR, PA, MB, BB, BG, PG, TKG, BK, RM, SP, JR, SSw and PT were employed by, and NC, DC, SH, DM, AR, DS, RS, SSa, SSh, AT and BA work in partnership with a non-profit healthcare company (Nyaya Health Nepal, with support from the US-based non-profit, Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic and private foundation sources. MB is a faculty at BP Koirala Institute of Health Sciences, Dharan, Nepal. NC, SH and DM are employed by, and DC, DM and SSa are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). DC is a faculty member at, DC and SH are employed part-time by and SH is a graduate student at a public university (University of Washington). SKD is a resident at an academic medical centre (Hurley Medical Center) that receives revenue through private sector fee-for-service medical transactions and a charitable private foundation. TKG is a fellow with a bidirectional fellowship program (HEAL Initiative) that is affiliated with a public university (University of California, San Francisco) that receives funding from public, philanthropic and private foundation sources. DM and BA are members on Possible’s Board of Directors, for which they receive no compensation. VN is employed at a public university (University of California, Los Angeles). DS and RS are employed at an academic medical centre (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. DS and RS are faculty members at a private medical school (Harvard Medical School). DS is employed at an academic research centre (Ariadne Labs) that is jointly supported by an academic medical center (Brigham and Women’s Hospital) and a private university (Harvard TH Chan School of Public Health) via public sector research funding and private philanthropy. RS is employed at an academic medical centre (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. SSh is a faculty member at a private college (Wheaton College). PT is a graduate student at a public university (University of New South Wales). BA is a faculty member at a public university (University of California, San Francisco). All authors have read and understood BMJ Open’s policy on declaration of interests, and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The collaborative care model is an evidence-based intervention for behavioral and other chronic conditions that has the potential to address the large burden of mental illness globally. Using the World Health Organization Health Systems Framework, the authors present challenges in implementing this model in low- and middle-income countries (LMICs) and discuss strategies to address these challenges based on experiences with three large-scale programs: an implementation research study in a district-level government hospital in rural Nepal, one clinical trial in 50 primary health centers in rural India, and one study in four diabetes clinics in India. Several strategies can be utilized to address implementation challenges and enhance scalability in LMICs, including mobilizing community resources, engaging in advocacy, and strengthening the overall health care delivery system.

Background: Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation., Partnerships Network: We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community., Conclusions: We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians' low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist's recommendations and the site's capacity to implement them.