An App-Based WHO Mental Health Guide for Depression Detection: A Cluster Randomized Clinical Trial

Brandon A. Kohrt, Center for Global Mental Health Equity, Department of Psychiatry and Behavioral Health, The George Washington University, Washington, DC.
Akin Ojagbemi, World Health Organization Collaborating Centre for Research and Training in Mental Health, Neuroscience, and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Nagendra P. Luitel, Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
Ioannis Bakolis, Centre for Mental Health Policy and Evaluation, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
Toyin Bello, World Health Organization Collaborating Centre for Research and Training in Mental Health, Neuroscience, and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Paul McCrone, Institute for Lifecourse Development, University of Greenwich, London, United Kingdom.
Tatiana Taylor Salisbury, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, United Kingdom.
Mark J. Jordans, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, United Kingdom.
Nicole Votruba, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom.
Kenneth Carswell, Department of Mental Health, Brain Health and Substance Use, World Health Organization, Geneva, Switzerland.
Eric Green, Duke Global Health Institute, Duke University, Durham, North Carolina.
Evdoxia Gkaintatzi, Institute for Lifecourse Development, University of Greenwich, London, United Kingdom.
Bishnu Lamichhane, Research Department, Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
Olufisayo Elugbadebo, World Health Organization Collaborating Centre for Research and Training in Mental Health, Neuroscience, and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Lola Kola, World Health Organization Collaborating Centre for Research and Training in Mental Health, Neuroscience, and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Heidi Lempp, Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.
Neerja Chowdhary, Department of Mental Health, Brain Health and Substance Use, World Health Organization, Geneva, Switzerland.
Tarun Dua, Department of Mental Health, Brain Health and Substance Use, World Health Organization, Geneva, Switzerland.
Oye Gureje, World Health Organization Collaborating Centre for Research and Training in Mental Health, Neuroscience, and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
Graham Thornicroft, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, United Kingdom.

Document Type

Journal Article

Publication Date

5-1-2025

Journal

JAMA network open

Volume

8

Issue

5

DOI

10.1001/jamanetworkopen.2025.12064

Abstract

IMPORTANCE: Depression detection in primary care remains limited in low- and middle-income countries despite increasing use of the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). OBJECTIVE: To test an app version of the mhGAP-IG (e-mhGAP-IG) in Nepal and Nigeria to improve depression detection. DESIGN, SETTING, AND PARTICIPANTS: In this feasibility cluster randomized clinical trial conducted from February 14, 2021, to March 25, 2022, primary care facilities (unit of clustering) in Nepal and Nigeria were randomized to the standard mhGAP-IG training arm (control) or to training using the e-mhGAP-IG app (intervention). Primary care workers (PCWs) received training based on the arm assignment of their health care facility. Statistical analysis was conducted from July 20, 2022, through September 27, 2024. INTERVENTION: Training using standard mhGAP-IG vs training using the e-mhGAP-IG. MAIN OUTCOMES AND MEASURES: Analysis was performed on an intention-to-treat basis. The main outcome was accuracy of depression detection rates by PCWs, evaluated prior to mhGAP training and 5 to 8 months after training, measured as the percentage of patients who received a depression diagnosis by their PCWs compared with the number of patients who scored 10 or more on the locally validated 9-item Patient Health Questionnaire. Costs per patient detected were calculated. RESULTS: In Nepal, 25 facilities (67 PCWs; mean [SD] age, 35.3 [9.2] years; 52 men [78%]) were randomized: 13 facilities to standard mhGAP-IG training (36 PCWs) and 12 facilities to e-mhGAP-IG (31 PCWs). In Nigeria, 10 facilities (47 PCWs; mean [SD] age, 46.9 [7.5] years; 44 women [94%]) were randomized: 5 facilities to standard mhGAP-IG (25 PCWs) and 5 facilities to e-mhGAP-IG (22 PCWs). In Nepal, depression detection by PCWs in the standard mhGAP-IG arm increased from 0 of 43 patients before training to 15 of 92 patients after training (adjusted mean change [AMC], 16% [95% CI, 5%-28%]), and depression detection in the e-mhGAP-IG arm increased from 0 of 49 before training to 22 of 91 after training (AMC, 24% [95% CI, 12%-36%]). In Nigeria, depression detection in the standard mhGAP-IG arm increased from 5 of 36 patients before training to 25 of 75 patients after training (AMC, 19% [95% CI, 2%-37%]), and depression detection in the e-mhGAP-IG arm increased from 6 of 35 patients before training to 67 of 76 patients after training (AMC, 71% [95% CI, 57%-85%]). In facilities in the e-mhGAP-IG arm, the app was used for 59 of 616 assessments (10% of patients) in Nepal and 883 of 1077 assessments (82% of patients) in Nigeria. Cost per patient with depression detected using the e-mhGAP-IG was Nepali Rupiya (NPR) 1980 (US $14.79) in Nepal and naira (₦) 1462 (US $0.91) in Nigeria. CONCLUSIONS AND RELEVANCE: This feasibility cluster randomized clinical trial demonstrated that the use, cost, and potential clinical benefit of the e-mhGAP-IG varied by setting, highlighting the importance of multisite feasibility studies when evaluating digital innovations intended for health care systems worldwide. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04522453.

Department

Psychiatry and Behavioral Sciences

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