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Original Investigation
February 3, 2021

Implementation and Effectiveness of Nonspecialist-Delivered Interventions for Perinatal Mental Health in High-Income Countries: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Psychiatry, Sinai Health, Toronto, Ontario, Canada
  • 2Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
  • 3Lunenfeld Tanenbaum Research Institute, Toronto, Ontario, Canada
  • 4Women’s College Hospital, Canada, Toronto, Ontario, Canada
  • 5Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC
  • 6Department of Psychology, McGill University, Montreal, Quebec, Canada
  • 7Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
  • 8Li Ka Shing Knowledge Institute, St Michael’s Hospital, Ontario, Canada
  • 9Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
  • 10Sangath, Alto Porvorim, Goa, India
JAMA Psychiatry. 2021;78(5):498-509. doi:10.1001/jamapsychiatry.2020.4556
Key Points

Question  Are nonspecialist providers (such as lay counselors, nurses, midwives, and teachers with no formal training in counseling interventions) effective at preventing and treating perinatal depression and anxiety, and what are the relevant implementation processes for nonspecialist-delivered interventions?

Findings  This systematic review of 46 trials (18 321 participants) and meta-analysis of 44 trials (18 101 participants) found that, compared with control groups, nonspecialist-delivered interventions were associated with lower depressive and anxiety symptoms for both preventive and treatment interventions, but there was high heterogeneity among the included trials. The majority of interventions were implemented in Australia, UK, and US, conducted by nurses and midwives, and delivered in person, in person combined with the telephone, or via telephone only, with only 2 interventions delivered online.

Meaning  This study found evidence in high-income countries to support that nonspecialist providers may be effective in preventing and treating perinatal depressive and anxiety symptoms, which suggests that integrating nonspecialist providers to deliver evidence-based counseling interventions has the potential to address the significant burden of perinatal depression and anxiety worldwide.

Abstract

Importance  Task sharing—or training of nonspecialist providers with no formal training in counseling—is an effective strategy to improve access to evidence-based counseling interventions and has the potential to address the burden of perinatal depression and anxiety.

Objectives  To identify the relevant implementation processes (who, what, where, and how) and to assess the effectiveness of counseling interventions delivered by nonspecialist providers for perinatal depression and anxiety in high-income countries.

Data Sources  CINAHL, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, and Embase through December 31, 2019. Relevant systematic reviews were also considered.

Study Selection  Randomized clinical trials of counseling interventions that assessed depression or anxiety after intervention, delivered by a nonspecialist provider for adults, and that targeted perinatal populations in a high-income country were included. Self-help interventions that did not include a provider component were excluded.

Data Extraction and Synthesis  Four researchers independently reviewed abstracts and full-text articles, and 2 independently rated the quality of included studies. Random-effects meta-analysis was used to estimate the benefits of the interventions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed.

Main Outcomes and Measures  For implementation processes, the frequencies represented by a total or percentage were estimated, where the denominator is the total number of eligible trials, unless otherwise indicated. For effectiveness, primary and secondary outcome data of depression, anxiety, or both symptoms were used, with separate analyses for prevention and treatment, stratified by depression or anxiety. Subgroup analyses compared outcome types (anxiety vs depression) and study objectives (treatment vs prevention).

Results  In total, 46 trials (18 321 participants) were included in the systematic review; 44 trials (18 101 participants) were included in the meta-analysis. Interventions were implemented across 11 countries, with the majority in Australia, UK, and US. Two-thirds (65%) of counseling interventions were provided by nurses and midwives, lasted a mean of 11.2 weeks (95% CI, 6.4-16.0 weeks), and most were delivered face to face (31 [67.4%]). Only 2 interventions were delivered online. A dearth of information related to important implementation processes, such as supervision, fidelity, and participant sociodemographic characteristics, was observed in many articles. Compared with controls, counseling interventions were associated with lower depressive symptoms (standardized mean difference [SMD], 0.24 [95% CI, 0.14-0.34]; 43 trials; I2 = 81%) and anxiety scores (SMD, 0.30 [95% CI, 0.11-0.50]; 11 trials; I2 = 80%). Treatment interventions were reported to be effective for both depressive symptoms (SMD, 0.38 [95% CI, 0.17-0.59]; 15 trials; I2 = 69%) and anxiety symptoms (SMD, 0.34 [95% CI, 0.09-0.58]; 6 trials; I2 = 71%). However, heterogeneity was high among the trials included in this analysis.

Conclusions and Relevance  This study found evidence in high-income countries indicating that nonspecialist providers may be effective in delivering counseling interventions. Additional studies are needed to assess digital interventions and ensure the reporting of implementation processes to inform the optimal delivery and scale-up of these services.

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    1 Comment for this article
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    The data doesn't support effectiveness for nonspecialist providers to treat or prevent 'anxiety' or 'depression' in perinatal populations
    Alice Dwyer, MBBS MPsych FRANZCP | The Centennial Practice, Woollahra, Sydney
    The data presented in the article “Implementation and Effectiveness of Nonspecialist-Delivered Interventions for Perinatal Mental Health in High-Income Countries: A Systematic Review and Meta-analysis ,” does not support the conclusions of the authors. The article argues that “This study found evidence in high-income countries to support that non-specialist providers may be effective in preventing and treating perinatal depressive and anxiety symptoms, which suggests that integrating nonspecialist providers to deliver evidence-based counselling interventions has the potential to address the significant burden of perinatal depression and anxiety worldwide.”

    The aim of the authors is laudable and the right one –
    significant gaps in mental health care require attention and staffing; but it is problematic as it purports that nonspecialist providers (NSP) can adequately fill this gap, even though the data quoted doesn’t support this. Indeed, the data used in the article suggests that NSP interventions have minimal effects on treatment or prevention of anxiety or depression for people in the perinatal population. Scaling up interventions that are not effective in a reasonable proportion of the population is not a solution to gaps in health care, no matter how cheap or appealing they may sound. Indeed, this could create further problems, as administrators or policy makers may assume that a need has been met, when it hasn’t.

    Putting aside the high heterogeneity of the studies, which is acknowledged by the authors, and the methodological flaws of some of the studies included, in particular the lack of clarity around level of clinical severity as opposed to the presence of self-reported symptoms on screening tools, the core problem is that low effect sizes are listed for NSP interventions, and high NNTs would be required. For example, the effect sizes for treatment of either anxiety or depression is 0.38, for anxiety only 0.34, and for depression only 0.19. These effect sizes would require more than 8 patients to be treated by an NSP for anxiety before any potential gain for one patient. The NNT would be higher for depression. According to this data, then, NSP interventions may assist up to 12.5% of the perinatal population, but probably a lower proportion.

    Taken together – the high heterogeneity of the studies, the low effect sizes and the high NNTs one cannot confidently argue that “..this study synthesizes a compelling evidence base that suggests that NSPs effectively deliver preventive and treatment interventions to manage perinatal depression and anxiety symptoms in HICs.” Nor does it convincingly support the contention that “… NSPs can be trained to fulfil an important gap in the provision of effective psychological interventions for both depression and anxiety treatments.”

    The data does not support the laudable intentions and hopes of the authors.
    CONFLICT OF INTEREST: None Reported
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