Integrating depression care within NCD provision in Bangladesh and Pakistan: a qualitative study

Abstract

Background: Co-morbidity of depression with other non-communicable diseases (NCDs) worsens clinical outcomes for both conditions. Low- and middle-income countries need to strengthen mechanisms for detection and management of co-morbid depression within NCDs. The Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON) study explored the acceptability and feasibility of integrating a brief depression intervention (behavioural activation, BA) into NCD services in healthcare facilities in Bangladesh and Pakistan. Methods: Face-to-face qualitative interviews were conducted with 43 patients and 18 health workers attending or working in NCD centres in four healthcare facilities in Bangladesh and Pakistan, and with three policy makers in each country. The interviews addressed four research questions (1) how NCD care is delivered, (2) how NCD patients experience distress, (3) how depression care is integrated within NCD provision, and (4) the challenges and opportunities for integrating a brief depression intervention into usual NCD care. The data were analysed using framework analysis, organised by capability, opportunity and motivation factors, cross-synthesised across countries and participant groups. Results: Patients and health workers described NCD centres as crowded and time pressured, with waiting times as long as five hours, and consultation times as short as five minutes; resulting in some patient frustration. They did not perceive direct links between their distress and their NCD conditions, instead describing worries about family and finance including affordability of NCD services. Health worker and policy maker accounts suggested these NCD centres lacked preparedness for treating depression in the absence of specific guidelines, standard screening tools, recording systems or training. Barriers and drivers to integrating a brief depression intervention reflected capability, opportunity and motivation factors for all participant groups. While generally valuing the purpose, significant challenges included the busy hospital environment, skill deficits and different conceptions of depression. Conclusions: Given current resource constraints and priorities, integrating a brief psychological intervention at these NCD centres appears premature. An opportune first step calls for responding to patients’ expressed concerns on service gaps in provisioning steady and affordable NCD care. Acknowledging differences of conceptions of depression and strengthening psychologically informed NCD care will in turn be required before the introduction of a specific psychological intervention such as BA.

Behavioural activation for co- morbid depression in people with non-communicable disease in India: Protocol for a randomised controlled feasibility trial (BEACON)

“…The initial content was based on treatment manuals and workbooks from previous adaptations of BA for multimorbidity and for delivery by lay counsellors in the UK (12) and India (13). The research team also looked at training packages from the WHO mhGAP (7) relevant to the delivery of BA and formative research exploring the implementation of BA in similar settings in South Asia (14).…”

Protocol for integrating mental health services into primary healthcare facilities: a qualitative study of the perspectives of patients, family members and healthcare providers in rural Bangladesh

“…However, there are no plans or strategies to integrate mental healthcare into NCD care at government primary healthcare facilities 30. A sister project of the current study titled ‘Behavioural Activation for Comorbid Depression in Non-communicable Disease (BEACON)’ reported about the lack of preparedness of NCD centres for managing the treatment of CMDs such as depression and the absence of guidelines, proper recording systems and training 31…”