Author
Amy Abraham

 

Mentors
Kimberly D. Becker & Wendy Chu

 

 

Abstract

The mental health treatment gap in India is part of a growing public health crisis, with over 95% of those in need of services never receiving them. In India, a dearth of mental health professionals contributes to unmet mental health needs, and paraprofessionals may play a unique role in addressing the mental health crisis. This study aimed to analyze several factors of paraprofessional-led mental health interventions including setting, treatments delivered, treatment models, and client outcomes. A narrative literature review was conducted to synthesize the current available research on paraprofessional-led mental health interventions in India. Twelve studies published between 2010 and 2020 were included in the review. Most studies (n = 10, 83%) were conducted in both peri-urban and rural areas, and in a variety of different clinical settings (e.g., healthcare facilities, schools). All (100%) paraprofessional-led interventions used evidence-based treatments to address mental health problems, including psychotherapy and pharmaceutical treatment. Paraprofessionals provided services under a collaborative stepped care model in many studies (n = 9, 75%). Of the studies that used quantitative methods to evaluate changes in client outcomes, all ten (100%) found that paraprofessionals significantly reduced the severity of symptoms of mental disorders and improved client functioning. These findings provide support for the efficacy of paraprofessional-led interventions in treating the mental health needs of the Indian population. Moreover, they illustrate that paraprofessionals can be a solution to mitigating the mental health treatment gap in India.

 

 

The Role of Paraprofessionals in the Mental Health Structure of India

 

India is a low- and middle-income country (LMIC) that has garnered interest because of its large population and emerging mental health crisis. In 2017, India had a population of about 1.34 billion, with at least 197.3 million people, or 14.7% of the population, suffering from at least one mental disorder (Sagar et al., 2020). However, these figures likely underestimate the actual prevalence, as many people with mental health disorders remain undiagnosed. With the growing mental health crisis in India, there is great unmet mental health needs or a treatment gap, as up to 95% of Indians who could benefit from services never receive them. Moreover, finding solutions to the mental health crisis in India would inform similar solutions in other LMICs.

Although there is a growing prevalence of mental disorders, the treatment gap in India continues to expand due to many systemic barriers to treatment. Firstly, mental health issues in India are rarely acknowledged by the government as a public health issue (Roy et al., 2019). Secondly, the stigma surrounding mental health is pervasive within Indian society (Shidhaye & Kermode, 2013). Thirdly, mental health care is often limited to overburdened government-funded primary care centers (Murray & Jordans, 2016). Finally, there is a significant shortage of trained mental health professionals to address the total mental health needs in India. Currently, there are only 1.93 trained mental health workers for every 100,000 people in India, in comparison to the 71.7 professionals per 100,000 people found in high-income countries (Michelson et al., 2020).

Of the barriers mentioned above, the most feasible to address is the dearth of trained mental health professionals in India. One solution is the use of paraprofessionals, also referred to as lay-health counselors, to administer mental health treatment. Mental health paraprofessionals are defined as individuals with no previous professional mental health training or background (e.g., licensed practitioner after receiving accredited graduate education) who are employed to help treat and manage common mental health disorders. The use of paraprofessionals may be particularly advantageous to LMICs such as India because of their ability to address many different treatment barriers unique to low-resource contexts. For example, in addition to supplementing the presently limited workforce, paraprofessionals would also be able to operate within their own communities, eliminating any barriers related to travel or physical distance (Patel et al., 2011). Moreover, because paraprofessionals are typically a part of the communities they serve and therefore trusted by members, they can reduce stigma surrounding mental disorders and seeking mental health treatment in said communities (Michelson et al., 2020).

Studies involving mental health paraprofessionals have already been conducted in many other LMICs with similar contexts to India. For instance, the Thinking Health Project exemplifies how paraprofessionals can be leveraged to address mental health needs in Pakistan (Rahman et al., 2008). This study harnessed the use of paraprofessionals to treat perinatal depression in pregnant women in rural Pakistan. The paraprofessionals, who were trained to deliver a cognitive behavior therapy-based intervention, were effective in reducing rates of depression (Rahman et al., 2008). In Uganda, another study examined the efficacy and effectiveness of paraprofessionals delivering interpersonal psychotherapy to treat depression in adult populations (Bolton et al., 2003). Results indicated the trained paraprofessionals were able to effectively deliver interpersonal psychotherapy and improve clinical depression outcomes in their target population over time (Bolton et al., 2003). These studies demonstrate that paraprofessionals are not only capable of delivering evidence-based mental health treatments in LMICs after receiving training, but they are also effective at improving client outcomes.

Preliminary studies have shown great potential for the effectiveness of paraprofessionals on mental health outcomes within India (Rajaraman et al., 2012). However, a synthesis of the existing literature on paraprofessionals in India has not yet been conducted. As the treatment gap in India continues to widen, and more people continue to suffer, it is imperative to explore effective and sustainable methods, such as the use of paraprofessionals, in which mental health needs can be addressed. The current study aims to synthesize the literature on mental health paraprofessionals in India into a narrative review. Specifically, this narrative review that focuses exclusively on India has four primary goals: (1) describe the settings in which paraprofessionals deliver mental health services, (2) describe the mental disorders addressed and treatments used by paraprofessionals, (3) describe the mental health treatment models that paraprofessionals operate within, and (4) describe the efficacy of paraprofessionals in treating mental disorders.

 

Methods

This study used a comprehensive literature search method to identify relevant articles on mental health professionals in India. In order for an article to be included in this study, it had to be (1) published in a peer-reviewed scholarly journal, (2) describe a study that took place in India, (3) focus on mental health policy, treatment, or services, and (4) study paraprofessionals. We conducted the literature search in October 2020. A Boolean search term method was used in Google Scholar, PubMed, and PsycINFO to identify articles. Namely, various combinations of the following search terms were used: India, mental health, lay health counselors, paraprofessionals, collaborative stepped care, scalability, etc.

 

Results

Using the search strategy described, 12 studies published between 2010-2020 were identified and included in this narrative review (Table 1). In six studies (50%), the participants in the population treated by paraprofessionals were youth aged 11 to 17 (Malla et al., 2019; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Rajaraman et al., 2012; Shinde et al., 2017). In the remaining six studies (50%), the population treated were adults over the age of 17 (Balaji et al., 2012; Chowdhary et al., 2016; Mendenhall et al., 2014; Patel et al., 2010, 2011; Weobong et al., 2017).

Aim 1: Describe the Settings in which Paraprofessionals Deliver Treatments

The studies were conducted in several Indian states and territories including Goa (Balaji et al., 2012; Chowdhary et al., 2016; Patel et al., 2010, 2011; Rajaraman et al., 2012; Weobong et al., 2017), Maharashtra (Balaji et al., 2012), Tamil Nadu (Balaji et al., 2012), Kashmir (Malla et al., 2019), Madya Pradesh (Mendenhall et al., 2014), Bihar (Shinde et al., 2017), and Delhi (Michelson et al., 2020a, 2020b; Parikh et al., 2019). Most studies (n = 10, 83%) were conducted in both peri-urban and rural settings (Balaji et al., 2012; Chowdhary et al., 2016; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Patel et al., 2010, 2011; Rajaraman et al., 2012; Shinde et al., 2017; Weobong et al., 2017). The remaining two studies (17%) described paraprofessionals delivering treatments in exclusively rural settings (Malla et al., 2019; Mendenhall et al., 2014).

Treatments were administered by paraprofessionals to clients in a variety of different clinical settings. Four studies (33%) detailed paraprofessionals delivering services in healthcare facilities (Chowdhary et al., 2016; Patel et al., 2010, 2011; Weobong et al., 2017). Of those studies, two (50%) took place in public government or private primary care centers (Patel et al., 2010, 2011). Another setting in which paraprofessionals treated Indian youth were government-run secondary schools (n = 5, 42%) (Michelson et al., 2020a, 2020b; Parikh et al., 2019; Rajaraman et al., 2012; Shinde et al., 2017). Three (60%) of these studies took place in schools that were located in New Delhi (Michelson et al., 2020a, 2020b; Parikh et al., 2019), while one study (20%) took place at a secondary school located in Bihar (Shinde et al., 2017), and another (n = 1, 20%) in secondary schools of Goa (Rajaraman et al., 2012). Paraprofessionals also operated within community settings (n = 3, 25%), such as local religious centers (Balaji et al., 2012; Malla et al., 2019; Mendenhall et al., 2014).

Aim 2: Describe Mental Disorders Addressed and Treatments Used by Paraprofessionals

Two studies (17%) investigated paraprofessional’s treatment of depressive disorders, including major depressive disorder (Chowdhary et al., 2016; Weobong et al., 2017). One study (8%) solely described the treatment of schizophrenia in adults (Balaji et al., 2012). Most of the studies (n = 9; 75%) described paraprofessionals treating common mental disorders broadly, without specification of clinical diagnoses (e.g., general wellbeing or level of disability) (Malla et al., 2019; Mendenhall et al., 2014; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Patel et al., 2010, 2011; Rajaraman et al., 2012; Shinde et al., 2017).

Paraprofessionals employed a variety of different mental health interventions to treat their clients. As recommended by the World Health Organization (Weobong et al., 2017), all studies utilized an evidence-based treatment to address youth mental health concerns: psychotherapy or pharmaceutical treatment (Balaji et al., 2012; Chowdhary et al., 2016; Malla et al., 2019; Mendenhall et al., 2014; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Patel et al., 2010, 2011; Rajaraman et al., 2012; Shinde et al., 2017; Weobong et al., 2017). Within the realm of psychotherapy, several studies described a transdiagnostic approach (n = 3; 25%), which address a range of mental disorders or comorbid disorders (e.g., depression and anxiety) (Michelson et al., 2020a, 2020b; Parikh et al., 2019). Two studies (17%) trained paraprofessionals on behavioral activation as a strategy to treat depression by encouraging clients to engage in positive behaviors and thus increase self-efficacy in addressing their concerns (Chowdhary et al., 2016; Weobong et al., 2017). Interpersonal therapy was also implemented by paraprofessionals in seven studies (58%) to manage interpersonal and relationship problems (Balaji et al., 2012; Malla et al., 2019; Mendenhall et al., 2014; Patel et al., 2010, 2011; Rajaraman et al., 2012; Shinde et al., 2017). Pharmaceutical treatments as a supplement to psychotherapy were also used by paraprofessionals to treat mental disorders. Antidepressants, such as fluoxetine, were prescribed by physicians and medication use was monitored by the paraprofessionals (n = 2; 17%) (Patel et al., 2010, 2011).

Aim 3: Describe the Mental Health Treatment Models Paraprofessionals Operate Within

Paraprofessionals provided services under a collaborative stepped care model in many studies (n = 9, 75%) (Balaji et al., 2012; Malla et al., 2019; Mendenhall et al., 2014; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Patel et al., 2010, 2011; Rajaraman et al., 2012). Under this model, paraprofessionals work directly with clients and are supervised by a primary care physician. Paraprofessionals and physicians are also supported by specialists or psychiatrists who intervene in severe cases or provide consultation. One study (8%) used a community collaborative stepped care approach in which family members of clients were actively involved in treatment decisions and activities, such as the monitoring of client progress (Balaji et al., 2012). Another study (n = 1, 8%) used a variation of the stepped care model where the paraprofessional was supported by a psychiatrist, psychologist, and social worker (Malla et al., 2019).

Other studies (n = 3, 25%) described a traditional individual treatment model in which paraprofessionals provided one-on-one care to a client (Chowdhary et al., 2016; Shinde et al., 2017; Weobong et al., 2017). One study (8%) involved a group life-skills class along with individual treatment by a paraprofessional, which was supervised by an advisory board and a psychologist by request (Shinde et al., 2017).

Aim 4: Describe the Efficacy of Paraprofessionals in Treating Mental Disorders

Client outcomes were also measured using a variety of methods. Most of the studies however used either strictly quantitative (n = 5; 42%) (Chowdhary et al., 2016; Malla et al., 2019; Michelson et al., 2020b; Patel et al., 2010, 2011; Weobong et al., 2017) or strictly qualitative (n = 3; 25%) methods (Balaji et al., 2012; Mendenhall et al., 2014; Shinde et al., 2017) to evaluate client outcomes. Five studies (42%) used a mix of quantitative and qualitative client outcome measures (Chowdhary et al., 2016; Michelson et al., 2020a; Parikh et al., 2019; Rajaraman et al., 2012). The most frequently used quantitative measures were the Clinical Interview Schedule-Revised (Patel et al., 2010, 2011) which is a measure used to diagnose common mental disorders (CIS-R; Lewis et al., 1992) and Hopkin’s Symptom Checklist (Chowdhary et al., 2016; Weobong et al., 2017) which measures symptoms of anxiety and depression (Parloff et al., 1954). Of the studies that used quantitative methods to evaluate changes in client outcomes, all ten (100%) found that paraprofessionals significantly reduced the severity of symptoms of mental disorders and improved functioning (Chowdhary et al., 2016; Malla et al., 2019; Mendenhall et al., 2014; Michelson et al., 2020a, 2020b; Parikh et al., 2019; Patel et al., 2010, 2011; Rajaraman et al., 2012; Weobong et al., 2017). Of the studies that described qualitative outcomes, all six (100%) structured interviews found that clients were generally satisfied with treatment from paraprofessionals and reported positive progress in reference to their experience of mental disorders (Balaji et al., 2012; Mendenhall et al., 2014; Michelson et al., 2020a; Parikh et al., 2019; Rajaraman et al., 2012; Shinde et al., 2017).

Discussion

The purpose of the study was to assess the use of paraprofessionals in terms of the settings they operated within, the treatments they delivered, the treatment models they operated within, and finally if they were effective in mental health treatment. Many paraprofessionals worked within healthcare facilities, namely primary care centers. This is unsurprising given that most individuals living in LMICs receive mental health treatment from primary care centers. Treatment conducted by paraprofessionals in these primary care centers proved to be effective in treating mental disorders. A possible explanation for this is that paraprofessionals were trained specifically in mental disorder identification and treatment, in comparison to primary care physicians who may have knowledge in other non-mental health related topics. This finding is significant in that it means that a greater number of paraprofessionals may translate to greater detection and thus reducing treatment gaps.

Public primary care centers found much more success in utilizing paraprofessionals than private care centers. While public centers normally accommodate a much larger caseload, resulting in less time and privacy between the physician and the client, paraprofessionals were able to meet with clients for extended periods of time to address multiple concerns in a much more private manner, similarly to the normal care from private primary care centers (Patel et al., 2010). Treatment in community settings was the most accessible to clients. The proximity to the clients eliminated many of the economic barriers associated with treatment such as transportation costs. Paraprofessionals were also integrated into the community, allowing for the population to view mental disorders and their treatment as more normal. Clients were more willing to disclose to paraprofessionals in the more informal setting of a community rather than a medical facility, likely because the setting was more familiar and thus relaxing.

Paraprofessionals took advantage of evidence-based treatments. An interesting method of treatment that most paraprofessionals utilized was a transdiagnostic approach. The transdiagnostic approach combined multiple overlapping elements of disorder-specific treatment, such as addressing intrusive thoughts in managing anxiety disorders and depression (Parikh et al., 2019). Many common mental disorders are comorbid, and the transdiagnostic approach equipped paraprofessionals to treat several disorders efficiently and effectively. Treatment manuals were also developed to supplement paraprofessional delivered treatment. Paraprofessionals were given their own treatment manuals to provide guidance on delivering treatments and methods to supplement face-to-face counselling. These manuals were adapted for the skill level of the paraprofessionals, using plain language, illustrations, and example exercises. The integration of treatment manuals into transdiagnostic care will be key to future paraprofessional interventions.

The collaborative stepped care model was a treatment management model that paraprofessionals operated within to provide services. In multiple studies, paraprofessionals attributed the success of their treatment to the support provided by this model. The paraprofessionals were supervised by primary care physicians, who met with them on a regular basis to discuss cases and challenges that come up in treatment. The physicians are then further supported by mental health specialists or psychiatrists, who advise physicians on severe cases and treatment trajectories. The supervision protocols kept paraprofessionals from feeling lost when treating clients and made expert advice accessible. Further research needs to be done to examine how collaborative stepped care models can be optimized in different settings in India (e.g., rehabilitation centers).

Paraprofessional led treatment interventions were effective at improving client mental health outcomes according to several different measures. Clients reported improvements in the severity of their symptoms and some even had complete remission. Common mental disorders specifically saw vast improvements and referrals to treatment by other community members also increased. Stigma was also reduced considerably by paraprofessional treatment deliveries. In comparison to mental health professionals and physicians, paraprofessionals were much more likely to come from the same or similar communities as the clients. As a result, more clients sought treatment for their mental disorders and saw quality of life improvements.

Emerging studies on the topic suggest that paraprofessionals may not only a feasible solution, but cost-effective as well. Globally, mental health problems account for approximately $8.5 trillion lost as a result of lowered economic productivity. By contrast, the estimated cost of implementing paraprofessional interventions for schizophrenia, depression, epilepsy, and substance abuse disorders was estimated to be $3-$4 per client in two studies conducted in LMICs (Patel et al., 2016). Costs of trained mental health professionals (i.e., those with graduate degrees and licensure) are likely to much higher. Additional research may examine the economic impact of paraprofessional-delivered interventions to further demonstrate their promising value.

Client outcomes were measured both quantitatively (e.g., standardized measures) and quantitatively (e.g., interviews) across the studies. Both forms of outcomes provided valuable information about the impact of interventions, however, more research should use quantitative methods of outcome evaluations. Quantitative data collected from randomized controlled trials can provide specific information about the statistical magnitude of effectiveness of paraprofessional-delivered interventions. Moreover, quantitative methods can aid in the comparison of effects between paraprofessional-delivered and professional-delivered interventions. To further establish the efficacy of mental health interventions delivered by paraprofessionals, it is recommended that future research leverage quantitative methods and rigorous study designs (e.g., randomized controlled trials). As the literature grows, so too does the possibility of using meta-analytic methods to summarize the effects of paraprofessional-led interventions.

There were several limitations to the present study that limited the conclusions that could be drawn. First, this study included a small sample size of articles. However, this small number reflects the current state of the literature. Second, the articles included in the study did not use consistent methodologies, especially in evaluating client outcomes. Despite the inconsistencies, accurate conclusions were drawn using the supplementary discussions from the articles as well as qualitative reports collected. Finally, data for most of the articles were self-reported from the clients, potentially introducing self-report bias.

In conclusion, there is sufficient evidence that the use of paraprofessionals to treat mental health disorders is a plausible and effective solution to the mental health treatment gap. It is imperative that India take steps to implement feasible interventions such as these to prevent a public health crisis in the future, and to aid those that are currently suffering. Paraprofessionals are a simple, accessible way to address this issue while still providing high-quality care.

 

About the Author

Amy Abraham

My name is Amy Abraham and I am from Northville, Michigan. I graduated from the University of South Carolina Honors College in December 2020 with a Bachelor of Science in Public Health. As a student, I participated in undergraduate research as a research assistant in Dr. Kimberly Becker’s lab in the Department of Psychology, which studies youth and family engagement in mental health services. I also had the opportunity to present at Discover UofSC 2021. As a post-baccalaureate, I continued to work with the Becker Lab as well as made progress towards applying to medical school. I aspire to become a pediatrician and provide healthcare services to underserved communities.

I became interested in the topic of paraprofessionals in India after having discussions with my faculty mentor, Dr. Becker, about the delivery of mental health services in low- and middle- income countries. Thus, I completed an honors thesis to summarize the empirical literature on the role of paraprofessionals in addressing the mental health needs of the people of India. My research illuminated that paraprofessionals were well-positioned to deliver scalable mental health interventions, addressing the burgeoning mental health needs in India. This thesis was a critical part of my undergraduate experience and has advanced my academic writing, data analysis, and presentation skills. I hope to expand on and learn new skills as I conduct more research.

Finally, I express my sincerest gratitude to my faculty mentor, Dr. Becker, who inspired me to conduct research to advance knowledge in an area I was passionate about, and my graduate mentor, Wendy Chu, who guided me throughout the thesis process with incredible patience.

 

References

(* indicates included in review)

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*Chowdhary, N., Anand, A., Dimidjian, S., Shinde, S., Weobong, B., Balaji, M., Hollon, S., Rahman, A., Wilson, G., Verdeli, H., … & Patel, V. (2016). The Healthy Activity Program lay counsellor delivered treatment for severe depression in India. The British Journal of Psychiatry, 208(4), 381–388.

*Malla, A., Margoob, M., Iyer, S., Majid, A., Lal, S., Joober, R., & Issaoui Mansouri, B. (2019). Testing the effectiveness of implementing a model of mental healthcare involving trained lay health workers in treating major mental disorders among youth in a conflict-ridden, low-middle income environment. The Canadian Journal of Psychiatry, 64(9), 630–637.  

*Mendenhall, E., De Silva, M. J., Hanlon, C., Petersen, I., Shidhaye, R., Jordans, M., Luitel, N., Ssebunnya, J., Fekadu, A., Patel, V., Tomlinson, M., & Lund, C. (2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science & Medicine, 118, 33–42.

*Michelson, D., Malik, K., Krishna, M., Sharma, R., Mathur, S., Bhat, B., Parikh, R., Roy, K., Joshi, A., Sahu, R., Chilhate, B. … & Patel, V. (2020). Development of a transdiagnostic, low-intensity, psychological intervention for common adolescent mental health problems in Indian secondary schools. Behaviour Research and Therapy, 130, 103439.

*Michelson, D., Malik, K., Parikh, R., Weiss, H. A., Doyle, A. M., Bhat, B., Sahu, R., Chilhate, B., Mathur, S., Krishna, M., Sharma, R., Sudhir, P., King, M., Cuijpers, P., … & Patel, V. (2020). Effectiveness of a brief lay counsellor-delivered, problem-solving intervention for adolescent mental health problems in urban, low-income schools in India: A randomised controlled trial. The Lancet Child & Adolescent Health, 4(8), 571–582.  

Murray, L., & Jordans, M. J. D. (2016). Rethinking the service delivery system of psychological interventions in low and middle income countries. BMC Psychiatry, 16(1), 1-6.  

Parikh, R., Michelson, D., Sapru, M., Sahu, R., Singh, A., Cuijpers, P., & Patel, V. (2019). Priorities and preferences for school-based mental health services in India: A multi-stakeholder study with adolescents, parents, school staff, and mental health providers. Global Mental Health, 6, 1-12.

*Parikh, Rachana, Michelson, D., Malik, K., Shinde, S., Weiss, H., Hoogendoorn, A., Ruwaard, J., Krishna, M., … & Patel, V. (2019). The effectiveness of a low-intensity problem-solving intervention for common adolescent mental health problems in New Delhi, India: Protocol for a school-based, individually randomized controlled trial with an embedded stepped-wedge, cluster randomized controlled recruitment trial. Trials, 20, 1-18.

Patel, V., Chisholm, D., Parikh, R., Charlson, F. J., Degenhardt, L., Dua, T., Ferrari, A. J., Hyman, S., Laxminarayan, R., Levin, C., Lund, C., Medina Mora, M. E., Petersen, I., Scott, J., Shidhaye, R., Vijayakumar, L., Thornicroft, G., & Whiteford, H. (2016). Addressing the burden of mental, neurological, and substance use disorders: Key messages from Disease Control Priorities, 3rd edition. The Lancet, 387(10028), 1672–1685.

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*Patel, V., Weiss, H., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., Bhat, B., Araya, R., King, M., Simon, G., Verdeli, H., & Kirkwood, B. (2011). Lay health worker led intervention for depressive and anxiety disorders in India. The British Journal of Psychiatry: The Journal of Mental Science, 199(6), 459–466.

*Patel, V., Weiss, H. A., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., Silva, M. D., Bhat, B., Araya, R., King, M., Simon, G., Verdeli, H., & Kirkwood, B. (2010). The effectiveness of a lay health worker led intervention for depressive and anxiety disorders in primary care: The MANAS cluster randomized trial in Goa, India. Lancet (London, England), 376(9758), 2086–2095.

*Rajaraman, D., Travasso, S., Chatterjee, A., Bhat, B., Andrew, G., Parab, S., & Patel, V. (2012). The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: A case study evaluation. BMC Health Services Research, 12(1), 1-11.

Roy, K, Shinde, S, Sarkar, BK, Malik, K, Parikh, R, Patel, V (2019). India's response to adolescent mental health: a policy review and stakeholder analysis. Social Psychiatry and Psychiatric Epidemiology, 54, 405–414.

Sagar, R., Dandona, R., Gururaj, G., Dhaliwal, R., Singh, A., Ferrari, A., Dua, T., Ganguli, A., Varghese, M., Chakma, J., Kumar, G., Shaji, K., Ambekar, A., Rangaswamy, T., … Dandona, L. (2020). The burden of mental disorders across the states of India: The Global Burden of Disease Study 1990–2017. The Lancet Psychiatry, 7(2), 148–161.  

*Shinde, S., Pereira, B., Khandeparkar, P., Sharma, A., Patton, G., Ross, D., Weiss, H., & Patel, V. (2017). The development and pilot testing of a multicomponent health promotion intervention for secondary schools in Bihar, India. Global Health Action, 10(1), 1385284.

*Weobong, B., Weiss, H. A., McDaid, D., Singla, D. R., Hollon, S. D., Nadkarni, A., Park, A.-L., Bhat, B., Katti, B., Anand, A., Dimidjian, S., Araya, R., … & Patel, V. (2017). Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial. PLOS Medicine, 14(9), e1002385.

 

 

Table 1

Characteristics of Studies Included in Review

Article	Setting	Mental Disorders	Therapeutic Intervention	Treatment Model	Data Measurement
Balaji et al. (2012)	Peri-urban and rural setting; community settings	Schizophrenia	Interpersonal therapy	Community collaborative stepped care model	Qualitative; literature review
Chowdhary et al. (2016)	Peri-urban and rural setting; healthcare facility	Major depressive disorder	Behavioral activation	Individual treatment model	Mixed; Interviews, focus groups, BDI II and PHQ-9
Malla et al. (2019)	Rural setting; community settings	Common mental disorders	Interpersonal therapy	Collaborative stepped care variation	Quantitative; GAF, Indian Disability Evaluation and Assessment Scale, WHOQOL BREF
Mendenhall et al. (2014)	Rural setting; community settings	Common mental disorders	Interpersonal therapy	Collaborative stepped care	Qualitative; Focus group discussions
Michelson et al. (2020)	Peri-urban and rural setting; government run secondary schools	Common mental disorders	Transdiagnostic approach	Collaborative stepped care	Mixed; interviews, SDQ, YTP, Session Feedback Questionnaire
Michelson et al. (2020)	Peri-urban and rural setting; government run secondary schools	Common mental disorders	Transdiagnostic approach	Collaborative stepped care	Quantitative; SDQ, YTP
Parikh et al. (2019)	Peri-urban and rural setting; government run secondary schools	Common mental disorders	Transdiagnostic approach	Collaborative stepped care	Mixed; interviews, SDQ
Patel et al. (2011)	Peri-urban and rural setting; healthcare facilities	Common mental disorders	Interpersonal therapy and antidepressant	Collaborative stepped care	Quantitative; CIS-R and WHODAS II
Patel et al. (2010)	Peri-urban and rural setting; healthcare facilities	Common mental disorders	Interpersonal therapy and antidepressant	Collaborative stepped care	Quantitative; General Health Questionnaire, CIS-R and WHODAS II
Rajaraman et al. (2012)	Peri-urban and rural setting; government run secondary schools	Common mental disorders	Interpersonal therapy	Collaborative stepped care	Mixed; Semi-structured interviews, Process indicators
Shinde et al. (2017)	Peri-urban and rural setting; government run secondary schools	Common mental disorders	Interpersonal therapy	Individual treatment model and group life skills class	Qualitative; Interviews and focus group discussions
Weobong et al. (2017)	Peri-urban and rural setting; healthcare facilities	Major depressive disorder	Behavioral activation	Individual treatment model	Quantitative; BDI II and PHQ-9