4.1. Community Components in Mental Health Care from Reviewed Literature
We identified community components reported in the academic literature based on a review-of-reviews strategy that included 23 systematic reviews of intervention trials in LMIC. Eight studies were identified relating to common mental disorders involving Brazil, China, Colombia, the Democratic Republic of Congo (DRC), Pakistan, Sri Lanka, Thailand, and Uganda. For perinatal mental disorders, 19 studies were identified involving Chile, China, India, Mexico, Pakistan, South Africa, Turkey, and Uganda. For psychosis, 13 studies were identified including China, India, Iran, South Africa, and Turkey. For substance use disorders, four studies involving from Mexico, Vietnam, and Malaysia. For mental disorders affecting children and adolescents, there were 122 studies, most of which were school-based programs, from LMIC across world regions.
Common reasons for using community platforms (Domain 1. Why?) were delivery of care when primary care services were not accessible or acceptable, enhancing quality of and engagement with clinical care, involving family members, and promoting social and economic inclusion (see Figure 2
). The sites of community platforms (Domain 2. Where?) were homes, schools, other physical structures in the community, and technological platforms. One study highlighted the autonomy that comes with community designs, which allows for flexibility in organization and continuation of engagement after cessation of formal programs [104
]. In a study of group interpersonal psychotherapy for caregivers of children with nodding syndrome in Uganda, the community platform (i.e., meeting under a tree in a rural area) was advantageous because the group continued to informally meet without a health worker present after the trial ended, and they started microfinance groups [112
The common activities (Domain 3. What?) were population-wide awareness programs, psychoeducation, skills training, psychosocial rehabilitation, case management, and psychological treatments. In HIC settings, psychoeducation and crisis monitoring reduce involuntary hospitalizations [113
], and there may be similar benefits in LMIC. One relevant study published after the included reviews, is VISHRAM, a grass-roots community-based mental health program in India. VISHRAM demonstrated a six-fold increase in contact coverage for depression by increasing mental health literacy in communities [114
The facilitators (Domain 4. Who?) were community health workers, other health professionals, formal providers outside the health system, and non-formal providers. As a whole, these non-specialists were effective when delivering psychological treatments for adults [26
] and other mental health services for children and adults [44
]. Reflecting wider concerns in global health [115
], three of the reviews called for more attention to low motivation among non-specialists, potential harms associated with non-specialist delivered care, and the potential burden to non-specialists, particularly among women [26
]. The WPA has raised the issue of resistance among professionals and practitioners to community-oriented care [11
], but this was not addressed in the reviews. Another area not addressed was how community-based approaches can facilitate greater service user autonomy in providing consent for mental health treatment [118
]. One community stakeholder group not included in the current studies is law enforcement. Involvement of law enforcement is crucial to diverting persons with mental disorders from incarceration to treatment services, and mental health training for law enforcement personnel reduces human rights abuses of persons with mental disorders [119
]. Police involvement is also recommended in the Disease Control Priorities
]. A model for law enforcement and mental health collaboration through Crisis Intervention Teams (CIT) in Liberia has been piloted [120
] and should be more rigorously evaluated as a key component of comprehensive community mental health care. Peers were also surprisingly absent from the currently evaluated models and research is needed to address this major gap.
The implementation processes (Domain 5. How?) involved consultation with mental health service users, community-based case detection, recruitment of facilitators, training and supervision of facilitators, assuring quality during implementation, sustaining motivation of facilitators, integration with other platforms, and addressing implementation barriers throughout the program. Integration with primary care varied widely.
Implementation approaches were characterized by manualized interventions but lacked structured guidelines and practices for evaluating competency, fidelity, and quality. Moreover, most reviews did not contain information on how quality would be monitored in the context of ongoing services after trial conditions concluded. Technological interventions were increasingly prominent in recent reviews. Technological innovations represent modalities for greater reach of services as well as greater quality of services when non-specialists have technological aids to guide their intervention [45
], such as the avatar assisted delivery of the Thinking Healthy Program in Pakistan [121
Potential negative consequences (Domain 6. Harms and Risks) included poor adherence to treatment in community settings, high economic costs of comprehensive community programs, maintaining motivation among non-specialists while competing with other professional, familial, and social demands, training and supervision to achieve minimum competency standards, and stigmatization of the community-based providers. There is also evidence that, in some contexts, community services may provide limited additional benefits over primary care services alone. In a recent cohort study in Nepal, persons with psychosis received community counseling and participated in peer support groups. These individuals did not have different outcomes when compared with a control condition only receiving primary care services and medication [122
]. This may have been due to the benefit achieved with medication and underpowering to detect the additional benefit of community services. Moreover, the short duration of the trial may not have captured long-term benefits of the community component.