Digital psychiatry in low-and-middle-income countries: New developments and the way forward

Table 1 Randomized-controlled trials of digitally-based task-shifting from low- and middle-income countries

Ref.	Details	Interventions	Findings
Chibanda et al[74], 2016	Cluster RCT with 6 months follow-up of common mental disorders from a primary-care setting in Zimbabwe (n = 573)	Culturally adapted problem-solving therapy with education and support delivered by lay health workers versus standard care with education and support. Mobile phones were used to deliver text messages or make calls to reinforce the intervention	The intervention group had fewer symptoms and lower risk of depression
Xu et al[75], 2019	RCT of patients with schizophrenia from rural community settings in China (n = 278)	Lay health worker delivered mobile text messages for medication reminders, health education, relapse prevention, and contact with primary healthcare versus non-specialists delivering and monitoring medications at home	The intervention group was more effective in in improving medication adherence, reducing relapses and re-hospitalizations
Gureje et al[76], 2019	Cluster RCT with 12 months follow-up of antenatal women with major depression from primary maternal care clinics in Nigeria (n = 686)	Interventions delivered by primary maternal care providers. Low-intensity treatment consisting of basic psychosocial treatment according to the mhGAP intervention guide versus high-intensity treatment consisting of a minimum of 8 weekly problem-solving therapy sessions. Mobile phones were used to deliver text messages or make calls to monitor, support, engage patients. Specialist supervision and consultation was conducted by mobile phones	No difference between high- or low-intensity treatments in remission of depression, infant outcomes, cost, and adverse events at 6 months postpartum. High-intensity treatment was more effective for severe depression
Gureje et al[77], 2019	Cluster RCT with 12 months follow-up of patients with moderate to severe depression from primary care clinics in Nigeria (n = 1035)	Primary healthcare worker delivered culturally adapted structured psychological intervention consisting of behavioural activation and problem-solving therapy for a minimum of 8 sessions, stepped up, if necessary, versus simple psychosocial interventions for depression. Providers were trained, supervised, and monitored by mobile phone contact	The proportion of patients with remitted depression in the 2 groups was similar at 12 months. Enhanced usual care using the mhGAP intervention guide provides a simple and affordable solution for the treatment of depression in primary-care
Rahman et al[78], 2019	Single-blind, non-inferiority RCT of technology assisted training of community health workers in delivering an evidence-based, low-intensity psychological intervention for depression (THP) from rural Pakistan (n = 80)	The Technology-Assisted Cascaded Training and Supervision system used a tablet-based application to provide standardized training to lay workers using a cascaded training model where a specialist in THP trained non-specialist workers who in turn trained the lay worker. Community health workers were supervised using net-based platforms. Digital training was compared with conventional in-person training	There were no significant differences in digitally-based versus in-person training in the competence of community health workers on the Enhancing Assessment of Common Therapeutic factors scale immediately following the training and at 3 months after completion of training
Muke et al[79], 2020	Pilot RCT of the feasibility and acceptability of a digital programme for training non-specialist health workers to deliver a brief psychological treatment for depression (THP) from a primary-care setting in India (n = 42)	Digital training was based on the digitized version of the manual for THP. It was hosted on an online learning platform that was accessible by smartphones. Non-specialist workers received technical support during training. Participants were also provided remote weekly support by research assistants through phone calls in the digital training with remote support group. The 2 digital training groups were compared with conventional in-person training of non-specialist health workers	Completion of training was highest in the digital training with remote support group. The competency of the workers improved following training with no significant differences between the 3 groups. Greater improvement in competency was observed in the digital training with remote support group and the in-person group compared to the digital training group
Nirisha et al[80], 2023	RCT of hybrid training of lay health workers to screen and refer people with mental health problems from a primary-care setting in India (n = 75)	Hybrid training consisted 1 in-person and 7 online sessions. Online learning was based on the Project ECHO (Extension of Community Health care Outcome) adapted for Indian settings. Lay workers used smartphones to access the online platform. Supervision of workers was carried out by the research team through phone calls. Digital training was compared with 1 d of in-person training	The digital training group was better at identifying alcohol use and common mental disorders, whereas the in-person group was better at identifying severe mental illnesses. Scores on knowledge, attitude, and practice did not differ between the 2 groups over time

LMICs: Low- and middle-income countries; mhGAP: World Health Organization Mental Health Gap Action Programme; RCT: Randomized-controlled trial; THP: Thinking Healthy Programme, an evidence-based psychological intervention for depression.