Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal
Open accessAbstract
Background: Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services. Aim: Evaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). Method: Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire – 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. Results: Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = −5.90, 95% CI −7.55 to −4.25, β = −3.68, 95% CI −5.68 to −1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = −12.21, 95% CI −19.58 to −4.84, β = −10.74, 95% CI −19.96 to −1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). Conclusion: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment. Declaration of interest: None.
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For Jordans 2019, blinding of outcome assessment (detection bias) for all outcomes was judged high risk.
“Blinding of outcome assessment (detection bias) All outcomes High risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
The Methods (Procedures; page not available) state that research assessors were blinded to participants’ study-arm assignments. The paper says participants could not be blinded, but that is distinct from blinding of outcome assessors and does not support the stated high-risk assessment for detection bias. (LLM, conf=0.89)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredMotivational interviewing and/or cognitive behavioral therapy showed a lower likelihood of retention relative to usual care.
“Individual studies varied between displaying a greater likelihood of retention in home visits and psychotherapy relative to psychotherapy alone (Moraes 2010), but lower likelihood of retention in motivational interviewing and/or cognitive behavioral therapy relative to usual care (Jordans 2019; Papas 2011).”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
The Results (Sample characteristics; page unavailable) report more loss to follow-up in the depression intervention arm than in usual care (23.3% versus 15.0%), consistent with lower retention there. In the alcohol-use-disorder trial, loss to follow-up was slightly lower in the intervention arm (17.5% versus 19.5%), and the Discussion says attrition was not disproportionate across arms. The claim therefore overgeneralizes the retention pattern across the two trials. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFor Jordans 2019, blinding of participants and personnel (performance bias) for all outcomes was judged high risk.
“Blinding of participants and personnel (performance bias) All outcomes High risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
The Methods (Procedures; page not available) state that participants could not be blinded, while research assessors were blinded. The Methods (Randomization; page not available) describe counsellors being connected to participants assigned to treatment. The paper does not itself report a high-risk performance-bias judgment for all outcomes. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFor Jordans 2019, incomplete outcome data (attrition bias) for all outcomes was judged low risk.
“Incomplete outcome data (attrition bias) All outcomes Low risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
The Methods (Statistical analyses; page unavailable) say all outcome analyses used intention-to-treat and multiple imputation for missing data, and the Results (Outcomes AUD trial; page unavailable) report similar findings in available-data sensitivity analyses. These details support the citing authors’ low-risk assessment, but the paper does not itself assign a low attrition-bias rating; the Results (Sample characteristics; page unavailable) also report losses to follow-up of 15.0%–23.3% in the depression trial and 17.5%–19.5% in the AUD trial. (LLM, conf=0.78)
Experimental — accuracy not yet measuredTwelve included psychosocial treatment trials with 2106 participants reported on harmful alcohol use; all reported harmful alcohol use on a continuous scale.
“Twelve included psychosocial treatment trials with 2106 participants reported on harmful alcohol use. All of these trials reported harmful alcohol use on a continuous scale (Bolton 2014; Jordans 2019; Kane 2022; Madhombiro 2019; Madhombiro 2020; Moraes 2010; Murray 2020; Nadkarni 2017; Nadkarni 2019; Omeje 2018; Schaub 2021; Witte 2011).”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
For Jordans 2019, random sequence generation (selection bias) was judged low risk.
“Random sequence generation (selection bias) Low risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
For Jordans 2019, allocation concealment (selection bias) was judged low risk.
“Allocation concealment (selection bias) Low risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
For Jordans 2019, selective reporting (reporting bias) was judged low risk.
“Selective reporting (reporting bias) Low risk”
From Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries (2023) · cites this paper as Jordans 2019
Correct diagnosis and initiation of treatment changed significantly.
“Correct diagnosis and initiation of treatment changed significantly25”
From Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study (2020) · cites this paper as [25]
152 people received service from psychosocial counselling.
“152 (see Jordans et al 2019 for details)25”
From Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study (2020) · cites this paper as [25]
At 12 months post-treatment, there were small-to-moderate effect sizes: a 9.7-point reduction (d = 0.34) in AUD symptoms, a 6.4-point reduction (d = 0.43) in psychosis symptoms, and a 7.2-point reduction (d = 0.58) in depression symptoms.
“Changes in treatment outcomes – small-to-moderate effect sizes (9.7 – points reduction (d = 0.34) in AUD symptoms, 6.4-points reduction (0.43) in psychosis symptoms and 7.2-points reduction (d = 0.58) in depression symptoms) at 12-months post-treatment25”
From Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study (2020) · cites this paper as [25]
In a nested randomised controlled trial conducted in the PRIME implementation area, there was no added value of community counsellors-delivered psychosocial treatment (counselling for alcohol problem) over primary health worker-delivered mental healthcare in the treatment of AUD.
“In a nested randomised controlled trial conducted in the PRIME implementation area we demonstrated no added value of community counsellors-delivered psychosocial treatment (i.e. counselling for alcohol problem) over primary health worker-delivered mental healthcare in the treatment of AUD.25”
From Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study (2020) · cites this paper as [25]
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Self-citationPsychosocialization in Nepal: Notes on Translation from the Frontlines of Global Mental Health
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Self-citationEmpowering the (Extra)Ordinary
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Targets and outcomes of psychological interventions: implications for guidelines and policy
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Self-citationPublic Health Aspects and Interventions for Substance Use Disorders in South Asia
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Facilitating Behavioral Activation
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Self-citationImplementation Research in India: Lessons from the Field
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Self-citation
- Authors
- Jordans, M. J. D., Luitel, N. P., Garman, E., Kohrt, B. A., Rathod, S. D., Shrestha, P., Komproe, I. H., Lund, C., & Patel, V.
- Affiliations
- King's College London (GB)
- University of Cape Town (ZA)
- George Washington University (US)
- London School of Hygiene & Tropical Medicine (GB)
- Utrecht University (NL)
- Harvard University (US)
- Corresponding author
- Jordans, Mark J. D.
- ORCID
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2019-01-25
- Volume
- 215
- Issue
- 2
- Pages
- 485-493
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- PMC
- PMC6878117
- OpenAlex
- W2912839368
- Semantic Scholar
- 1c7a68e46aa60610a47a0eca490390d7b627d8e5
- Cited by
- 89
- References
- 36
- Citations by year
- 2026: 8 · 2025: 8 · 2024: 7 · 2023: 17 · 2022: 17 · 2021: 14 · 2020: 11 · 2019: 6 · 2018: 1
- FWCI
- 15.07
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The British Journal of Psychiatry (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- Funders
- National Institutes of Health
- National Institute of Mental Health (K01MH104310)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- depression, alcoholism, primary care, Mental Health Gap Action Programme, psychological intervention, resource-limited settings, Nepal, functional disability, symptom severity
- MeSH terms
- Adolescent, Adult, Alcoholism, Community Mental Health Services, Cost-Benefit Analysis, Counseling, Depression, Female, Humans, Male, Middle Aged, Nepal, Primary Health Care, Psychiatric Status Rating Scales, Remission Induction, Severity of Illness Index, Logistic Models, Young Adult
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