There is increasing awareness about the relevance of mental health as an important component of individual health and its relation to societal development. Mental health does not only refer to mental diseases or conditions, but also to the capacity of the individual to adapt and live in harmony with the social, cultural, family, affective, and work environment. Because of this, the increase of mental health conditions and the associated burden is cause of preoccupation worldwide. The lifetime prevalence of mental health conditions in adult populations worldwide is estimated to be between 12.2–48%, and up to one third of the burden of non-communicable disorders can be attributed to mental disorders (1). The burden of these conditions does not only affect the individual, but it extends to family and friends, to the environment and to the society as a whole. Moreover, mental health conditions not only increase the risk of self-harm, but in the long-term can lead to impoverishment due to disability and a reduction in a productive workforce.
In conflict-affected populations, it has been estimated that one in four people are affected by mental disorders at any point in time (2–4). In Colombia, more than 50 years of internal conflict has contributed to an increased prevalence of mental health conditions and its impact in the society. Therefore, mental health in the country is a particular challenge that requires a multifactorial approach, accounting for its health, economic, social and cultural consequences. This underscores the need for devising innovative strategies that both alleviate the individual suffering due to mental health conditions and restore the harmony between the individual and the environment, by addressing stigma, rebuilding trust, and reducing inequalities.
Because of this, Colombia has embraced strategies aimed at addressing its national mental health needs and prioritizing the role of mental health in the wellbeing in the population, such as the Mental Health Gap Action Programme (mhGAP) (1) launched by the World Health Organization in 2008. With this antecedent, a legal framework is currently under construction, which has resulted in the inclusion of specific goals in mental health in the country’s development plans, such as the Colombian National Development Plan 2012 – 2021. Within this framework, health providers, both institutions and healthcare workforce, are being trained and devising strategies to accomplish the goals of the Plan Decenal de Salud Pública (5), regarding mental health. Growing evidence has demonstrated the effectiveness and cost-effectiveness of multiple strategies to improve the delivery of mental health services, especially in remote and poorer areas, for example, using technology-based approaches and capacity-building among non-specialized healthcare providers. Nevertheless, evidence is missing about the challenges and opportunities to scale-up these strategies to a population level. Such evidence is required to increase awareness and provide technical resources for decision making in health policy and programs development.
Within this framework, the US National Institute on Mental Health established a Research Partnership for Scaling Up Mental Health Interventions in Low- and Middle- Income countries. The aim is to conduct research about evidence-based mental health interventions and to develop research capacity in these countries, in order to generate and to use scientific evidence that could be used to devise and implement these interventions. In response to this invitation, the Project DIADA was designed as a multicore strategy to evaluate evidence-based interventions to scale up the delivery of mental health interventions in primary care (6). This project, led by the Pontificia Universidad Javeriana in Colombia and the Dartmouth College in the United States, has three principal objectives.
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First, the administrative core supports an organizational structure and management approach to obtain the maximum benefit from a broad array of stakeholders and to ensure efficient and successful coordination and integration of the activities across the project cores. In this core, we aim (a) to provide scientific and programmatic leadership to ensure efficient and successful coordination and integration of the activities across the Hub’s projects and (b) to provide a novel infrastructure to enhance synergy among an interdisciplinary expert team, by facilitating productive communication, centralization of knowledge and resources, and integration of methods and results across research activities.
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Second, the scale-up core supports the conduct of systematic, multi-site mental health implementation research in both rural and urban primary care settings with a broad group of stakeholders in the US and Latin America.
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Third, the capacity building core uses science-based methods and information to build sustainable capacity for conducting mental health implementation research and informing mental health policies and programs in Latin America. In this core, we aim (a) to establish resources and an infrastructure to aid Colombia and its regional partners of Chile and Perú to build capacity for mental health implementation research and (b) to build sustainable capacity to use science-based methods and information for developing mental health policies and programs.
Within the scale-up core of the model, we conducted formative research where we examined technology use (e.g., internet, mobile devices) among patients in primary care sites in Colombia. We also conducted focus groups and in-depth interviews with multiple stakeholders to explore perceptions, abilities, attitudes, practices and experiences of health professionals, administrators, patients and community organizations on access, continuity, integration, quality and resolution of problems in mental health in primary care. And, we adapted a tool to assess the integration of a mental healthcare model in Colombia, the Behavioral Health Integration in Medical Care (BHIMC) model. This formative research aided in informing the design and implementation procedures of a technology-based mental health model of care, aimed at increasing the diagnosis and care of patients with depression and unhealthy alcohol use, in primary care sites in Colombia.
The implementation of the model started in February 2018 in six primary care sites, and as of today, has contributed to increase diagnosis and treatment from nearly 0% to about 7.5% and 1% the diagnosis of General Practitioner-confirmed depression and unhealthy alcohol use, respectively, among patients seeking medical care in these sites. The innovative strategies implemented in our model transcends the identification of the patient through universal screening to also improve the training of a non-specialized healthcare workforce and provide digital health tools (digital decision support tools for clinicians and a software-based digital therapeutic tool for patients). This model has contributed to reducing the gaps in the identification and access to mental healthcare in the sites where the study has been implemented.
The main goal of this Special Issue of the Revista Colombiana de Psiquiatría is to disseminate findings from the scale-up core of the Project DIADA, both from the formative research and the model implementation research. Through the dissemination of these findings, we expect to enhance a dialogue about the challenges and opportunities for the implementation of innovative strategies to reduce the barriers for delivery of mental healthcare services among people with mental health conditions.
Conflict of interestDr. Marsch is affiliated with the business that developed the mobile intervention platform used in this research. This relationship is extensively managed by Dr. Marsch and her academic institution. The other authors report no financial relationships with commercial interests.
Research reported here was funded under award number 1U19MH109988 by the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH) (Multiple Principal Investigators: Dr. Lisa A. Marsch and Dr. Carlos Gómez-Restrepo). The contents are solely the opinion of the authors and do not necessarily represent the views of the National Institutes of Health or the U.S. Department of Health and Human Services.
Please cite this article as: Gómez-Restrepo C, Marsch LA. Escalando las intervenciones en salud mental para la depresión y el uso riesgoso de alcohol en Colombia. Rev Colomb Psiquiat. 2021;50:1–3.
