Effect of a Primary Care–Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe: A Randomized Clinical Trial
Open accessAbstract
Importance: Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. Objective: To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care. Design, Setting, and Participants: Cluster randomized clinical trial with 6 months' follow-up conducted from September 1, 2014, to May 25, 2015, in Harare, Zimbabwe. Twenty-four clinics were randomized 1:1 to the intervention or enhanced usual care (control). Participants were clinic attenders 18 years or older who screened positive for common mental disorders on the locally validated Shona Symptom Questionnaire (SSQ-14). Interventions: The Friendship Bench intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders. Main Outcomes and Measures: Primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cutpoint of 9. The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire, with a range of 0 (best) to 27 and a cutpoint of 11. Outcomes were analyzed by modified intention-to-treat. Results: Among 573 randomized patients (286 in the intervention group and 287 in the control group), 495 (86.4%) were women, median age was 33 years (interquartile range, 27-41 years), 238 (41.7%) were human immunodeficiency virus positive, and 521 (90.9%) completed follow-up at 6 months. Intervention group participants had fewer symptoms than control group participants on the SSQ-14 (3.81; 95% CI, 3.28 to 4.34 vs 8.90; 95% CI, 8.33 to 9.47; adjusted mean difference, -4.86; 95% CI, -5.63 to -4.10; P < .001; adjusted risk ratio [ARR], 0.21; 95% CI, 0.15 to 0.29; P < .001). Intervention group participants also had lower risk of symptoms of depression (13.7% vs 49.9%; ARR, 0.28; 95% CI, 0.22 to 0.34; P < .001). Conclusions and Relevance: Among individuals screening positive for common mental disorders in Zimbabwe, LHW-administered, primary care-based problem-solving therapy with education and support compared with standard care plus education and support resulted in improved symptoms at 6 months. Scaled-up primary care integration of this intervention should be evaluated. Trial Registration: pactr.org Identifier: PACTR201410000876178.
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The Friendship Bench concept is the best known example of using human resources to build context-appropriate mental health care; use of volunteers and peer workers in new youth primary care services has been a creative response to difficulty assembling professional clinical workforces even in high-resource settings.
“The Friendship Bench concept 390 is the best known example of this strategy; however, the use of volunteers and peer workers in new youth primary care services has been a creative response to the difficulty in assembling professional clinical workforces and structures that occurs even in high-resource settings.”
From The Lancet Psychiatry Commission on youth mental health (2024) · cites this paper as [390]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredChibanda et al. have shown that the use of lay health workers for delivering problem-solving therapy ('Friendship Bench') in a resource-poor setting such as Zimbabwe may be effective in the primary care of common mental disorders.
“Similarly, Chibanda et al 230 have shown that the use of lay health workers for delivering problem‐solving therapy (“Friendship Bench”) in a resource‐poor setting such as Zimbabwe may be effective in the primary care of common mental disorders.”
From Mental health care for older adults: recent advances and new directions in clinical practice and research (2022) · cites this paper as [230]
By moving psychological treatment delivery from specialists to non-specialist community health workers, task-sharing can increase the supply of mental health providers.
“Task-sharing is a strategy that can expand the availability of mental health providers by shifting delivery of psychological treatments from specialist providers to non-specialist community health workers (Chibanda et al., 2016; Patel et al., 2011; Rahman et al., 2008; Raviola et al., 2019).”
From Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India (2019) · cites this paper as Chibanda et al., 2016
In the same trial, Friendship Bench participants had significantly greater reductions in PHQ-9 depressive symptoms than controls at 6 months (adjusted mean difference −6.36; 95% CI −6.45 to −5.27; P<0.001).
“Friendship Bench participants also showed significant reduction in depressive symptoms measured using the 9-item Patient Health Questionnaire (PHQ-9) compared to control group participants at 6-months follow up (adjusted mean difference in PHQ-9 score, −6.36; 95% CI, −6.45 to −5.27; P < 0.001).13”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [13]
In a 573-patient randomized controlled trial, Friendship Bench participants (n=286) had significantly greater reductions in SSQ-14 symptoms than standard care controls (n=287) at 6 months (adjusted mean difference −4.86; 95% CI −5.63 to −4.10; P<0.001).
“In a randomized controlled trial with 573 patients, those randomized to the Friendship Bench intervention (n=286) showed significant reductions in symptoms measured using the 14-item Shona Symptom Questionnaire (SSQ-14) compared to patients in the standard care control group (n=287) at 6-months follow up (adjusted mean difference in SSQ-14 score, −4.86; 95% CI, −5.63 to −4.10; P < 0.001).13”
From Digital Technology for Building Capacity of Nonspecialist Health Workers for Task Sharing and Scaling Up Mental Health Care Globally (2019) · cites this paper as [13]
The Latin American task-shifted treatment model was subsequently successfully adapted and replicated in other low-middle income countries.
“it was subsequently successfully adapted and replicated in other LMICs (9, 10).”
From Internet-Based Interventions for the Prevention and Treatment of Mental Disorders in Latin America: A Scoping Review (2019) · cites this paper as [10]
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- Authors
- Chibanda, D., Weiss, H. A., Verhey, R., Simms, V., Munjoma, R., Rusakaniko, S., Chingono, A., Munetsi, E., Bere, T., Manda, E., Abas, M., & Araya, R.
- Affiliations
- University of Zimbabwe (ZW)
- London School of Hygiene & Tropical Medicine (GB)
- King's College London (GB)
- Corresponding author
- Chibanda, Dixon
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2016-12-27
- Volume
- 316
- Issue
- 24
- Pages
- 2618
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2563441254
- Cited by
- 502
- References
- 31
- Citations by year
- 2026: 70 · 2025: 68 · 2024: 45 · 2023: 58 · 2022: 53 · 2021: 104 · 2020: 40 · 2019: 35 · 2018: 16 · 2017: 12 · 2016: 1
- FWCI
- 33.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by-nc-nd)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Research Portal (King's College London) (submittedVersion, cc-by-nc-nd)
- Funders
- London School of Hygiene and Tropical Medicine
- Grand Challenges Canada (KCU-0087-042)
- Medical Research Council (MR/K012126/1)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- Friendship Bench, problem-solving therapy, lay health workers, task shifting, common mental disorders, depressive symptoms, anxiety symptoms, primary care, peer support, Zimbabwe, low-income settings, HIV-infected adults, treatment gap, mental health service delivery, Shona language
- MeSH terms
- Adult, Anxiety, Mental Disorders, Community Health Workers, Depression, Female, Follow-Up Studies, HIV Seropositivity, Humans, Male, Middle Aged, Patient Compliance, Peer Group, Primary Health Care, Problem Solving, Psychotherapy, Zimbabwe, Treatment Outcome, Age Distribution, Sex Distribution, Patient Selection, Young Adult, Symptom Assessment, Culturally Competent Care
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