Article Text

Download PDFPDF
Primary healthcare workers could help to reduce the burden of common mental disorders in low-income nations
  1. Jane Fisher
  1. Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Jane Fisher, jane.fisher{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

What is already known on this topic?

The greatest burden of the common mental disorders (CMD) of depression and anxiety is experienced by people living in low-income and middle-income countries.1 ,2 International expert groups believe that training primary healthcare workers to recognise people experiencing CMD and to implement standardised intervention packages is a priority for the reduction of this burden.1–3

What does this paper add?

  • The study improved on previous studies by using a cluster randomised controlled design, by focusing on harder to recognise, non-psychotic—rather than psychotic—disorders and by separating evaluation and training functions.

  • Workers who have not been trained are generally unable to recognise depression and anxiety in clinic attendees.

  • These data demonstrate that short, postservice structured training involving active learning opportunities can increase the capability of primary healthcare workers in low-income countries to diagnose CMD and to distinguish it from other conditions.


The study aim (stated only in the Abstract), to examine the impact of a mental health training package on accuracy of diagnosis of malaria and musculoskeletal problems as well as depression, is somewhat confusing. Although the potential for symptoms common to these conditions to lead to misdiagnoses is a plausible rationale for the selected approach, this argument is not made with logic or clarity. Detailed new data about participants who were diagnosed inaccurately or accurately with malaria are not presented in the Results, but in the Discussion which contributes to the difficulty in understanding this aspect of the study completely.

What next in research?

  • Brief structured psychosocial interventions to assist people who are depressed are available2 but further research is needed to investigate their acceptability and relevance to people of different ages and life stages in diverse nations.

  • Researchers must also evaluate appropriately adapted versions and establish their effectiveness and cost-effectiveness.

Could these results change policy and why?

Yes, these results could change policy. Primary healthcare workers are trusted community members and an integral element of health services in low-income countries. These data confirm that they are also an effective human resource for mental health care that could provide nations with a mechanism to reduce the burden of CMD. This will require them to develop and implement policies about integration of mental health into existing primary healthcare programs; the content of preservice and postservice training for health workers and pathways to and resources for specialist care for people with severe and persistent symptoms.



ABSTRACT FROM Kauye F, Jenkins R, Rahman A. Training primary health care workers in mental health and its impact on diagnoses of common mental disorders in primary care of a developing country, Malawi: a cluster-randomized controlled trial. Psychol Med 2014;44:657–66.

Participants Two thousand six hundred consecutive adult patients (aged 16 years and over) were included. Children and ‘very ill’ patients were excluded.

Setting Eighteen primary care health centres in Malawi.

Intervention An interactive 5-day training course on using a mental health toolkit, covering key concepts in mental health and illness, psychosocial skills, neurological and psychiatric conditions and the local health system. The toolkit was originally developed in Kenya, but was adapted for and validated in Malawi.

Comparison A 3-day training course, comprising lectures on key psychiatric illnesses, which has run in Malawi for several years.

Patient follow-up Two cross-sectional surveys were carried out at baseline and postintervention. Patients who took part in the baseline study were not included in the postintervention study.

Allocation Cluster randomisation by healthcare centre.

Blinding Not blinded.


Depression diagnosis At baseline the rate was 0% in both groups. Following the intervention, the diagnosis rate was significantly higher in the intervention centres (9%) compared to control centres (1%) (OR=32.1, 95% CI 7.4 to 144.3). Considering a diagnosis by a primary healthcare worker as a true positive, the diagnostic sensitivity of the intervention for depression was 60.24% and specificity 82.02%. In the control arm, the diagnostic sensitivity was 3.19% and the specificity was 66.67%.

Anxiety diagnosis At baseline the rate was 0% in both groups. Following the intervention, the diagnosis rate was reportedly significantly higher in the intervention centres (1.2%) compared to the control centres (0%) (p<0.001).

Musculoskeletal pain diagnosis rate At baseline the rate was 12% in the control group and 22% in the intervention group (OR=1.85, 95% CI 0.89 to 3.85). Following the intervention, the diagnosis rate was 8% in the control arm and 11% in the intervention arm, which was not statistically significant, either before or after adjustment for baseline differences (adjusted OR=0.62, 95% CI 0.39 to 1.01).

Malaria diagnosis rate At baseline the rate was 24% in both groups. Following the intervention, the diagnosis rate of malaria was significantly lower in the intervention arm (31%) compared to the control arm (40%), both before and after adjusting for baseline differences (adjusted OR=0.62, 95% CI 0.43 to 0.89).


  • Competing interests None.