Mental illness is a serious problem worldwide, but individuals with mental illness in low- and middle-income countries are especially disadvantaged given scarcity of mental health resources available for prevention and treatment. Mobile technology-delivered interventions offer a potential solution to expand access to care, and large majorities of individuals in low- and middle-income countries have access to technology.
An international group of researchers conducted a narrative review of the current literature to assess evidence for the use of mobile, digital, or remote technologies to prevent or treat mental illness in low- to middle-income countries. Their review was published in the Lancet Psychiatry. They reviewed evidence for the feasibility, acceptability, and potential effectiveness of these technologies for prevention, treatment, diagnosis, and management of mental disorders in over 20 low- and middle-income countries. Studies that focused on mental health training and education for health care workers delivered via technology were also reviewed. The researchers identified low- and middle-income countries based on World Bank classifications, and they included countries that had recently transitioned from middle- to high-income classifications.
Forty-nine studies were included in the review after inclusion and exclusion criteria were applied. They were grouped based on the following categories: technology supporting health care workers’ clinical care and education, mobile tools for diagnosis of mental illness, technologies supporting adherence to treatment and recovery, online self-help programs, and substance misuse prevention and treatment programs. Many of the studies they reviewed were exploratory in nature.
Of the 49 studies included in the review, 14 focused on technology supporting health care workers in Somaliland, South Africa, Brazil, and India. This technology took the form of telepsychiatry programs, such as video conferencing consultations with mental health professionals, to facilitate diagnosis and treatment. In general, studies suggested that these interventions were feasible and acceptable. Overall, healthcare workers and other professionals reported increased knowledge as a result of participating in the consultations, and they were generally satisfied with the programs.
Only four studies evaluated mobile tools for detection and diagnosis of mental illness; three were conducted in India and one in South Africa, and all four were pilot studies assessing feasibility, acceptability, and reliability of mobile screening tools to diagnose mental disorders. Overall, screening tools were reliable detectors of depression; studies suggested that these tools are especially helpful for non-mental health workers in low resource settings.
Thirteen studies conducted in countries like Nigeria, Niger, China, and Sri Lanka assessed technologies for promoting adherence to treatment and recovery. Treatments were delivered via telephone coaching, SMS messaging, online programs, or often a combination of these modalities. Many of the studies were randomized clinical trials (RCTs) targeting symptom reduction. Others assessed the use of technology (e.g., SMS reminders) to enhance adherence to clinical visits, as well as feasibility and acceptability of the technologies. In general, these treatments were feasible and acceptable to participants, and although the results were mixed, many were also associated with improvements in mental health symptoms.
Online self-help programs for mental disorders, in particular, anxiety and depression, were implemented in thirteen studies in countries including Mexico, Romania, Russia, and Malaysia. Some of these studies also targeted trauma victims in China and Iraq. They included RCTs and pilot studies, and many of the programs were evidence-based psychoeducation or cognitive behavioral therapy interventions. Overall, the programs appear to reduce symptoms, and in some cases, the effects were sustained 3 to 6 months post-intervention. Despite these potentially beneficial findings, strategies are needed to reduce attrition and promote adherence as several studies were affected by high dropout rates.
Lastly, the researchers reviewed 6 studies evaluating technologies to prevent and treat alcohol or substance misuse. These studies were either RCTs or naturalistic studies that employed telephone-based support and online self-help programs in Brazil, Uruguay, and Thailand. While these programs showed promise, they were also limited by high rates of attrition and limited adherence to study protocols.
In general, technology driven interventions to prevent or treat mental health disorders or substance misuse in low- and middle-income countries were evaluated as feasible and acceptable according to participants. Online programs, text messaging, and telephone support programs may also facilitate diagnosis, encourage adherence to treatment, promote recovery, and improve mental health symptoms, especially when implemented in low-resource settings. These findings are preliminary and should be interpreted with caution as many of the studies were limited by design, as well as attrition and low adherence to treatment. Further research is needed to evaluate the effects of these technologies in rigorously designed randomized controlled trials.
Written By: Suzanne M. Robertson, Ph.D