The Healthy Activity Program lay counsellor delivered treatment for severe depression in India: systematic development and randomised evaluation.
BACKGROUND
Reducing the global treatment gap for mental disorders requires treatments that are economical, effective and culturally appropriate.


OBJECTIVE
To describe a systematic approach to the development of a brief psychological treatment for patients with severe depression delivered by lay counsellors in primary healthcare.


METHODS
The treatment was developed in three stages using a variety of methods: (a) identifying potential strategies; (b) developing a theoretical framework; and (c) evaluating the acceptability, feasibility and effectiveness of the psychological treatment.


RESULTS
The Healthy Activity Program (HAP) is delivered over 6-8 sessions and consists of behavioral activation as the core psychological framework with added emphasis on strategies such as problem-solving and activation of social networks. Key elements to improve acceptability and feasibility are also included. In an intention-to-treat analysis of a pilot randomised controlled trial (55 participants), the prevalence of depression (Beck Depression Inventory II ⩾19) after 2 months was lower in the HAP than the control arm (adjusted risk ratio = 0.55, 95% CI 0.32-0.94,P= 0.01).


CONCLUSIONS
Our systematic approach to the development of psychological treatments could be extended to other mental disorders. HAP is an acceptable and effective brief psychological treatment for severe depression delivered by lay counsellors in primary care.
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Neerja
N
Chowdhary
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Arpita
A
Anand
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Sona
S
Dimidjian
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Sachin
S
Shinde
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Benedict
B
Weobong
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Madhumitha
M
Balaji
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Steven D
SD
Hollon
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Atif
A
Rahman
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
G Terence
GT
Wilson
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Helena
H
Verdeli
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Ricardo
R
Araya
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Michael
M
King
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Mark J D
MJ
Jordans
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Christopher
C
Fairburn
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK.
Betty
B
Kirkwood
Neerja Chowdhary, MD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Arpita Anand, MSc, MA, Sangath, Goa, India; Sona Dimidjian, PhD, University of Boulder, Boulder, Colorado, USA; Sachin Shinde, MPA, Sangath, Goa, India; Benedict Weobong, PhD, Sangath, Goa, India and London School of Hygiene & Tropical Medicine, London, UK; Madhumitha Balaji, MSc, Sangath, Goa, India; Steve D. Hollon, PhD, Vanderbilt University, Nashville, Tennessee, USA; Atif Rahman, PhD, University of Liverpool, Liverpool, UK; G. Terence Wilson, PhD, Rutgers University, New Brunswick, New Jersey, USA; Helena Verdeli, PhD, Teachers College, Columbia University, New York, USA; Ricardo Araya, PhD, London School of Hygiene & Tropical Medicine, London, UK; Michael King, PhD, University College, London, UK; Mark J. D. Jordans, PhD, King's College, London, UK; Christopher Fairburn, PhD, Oxford University, Oxford, UK; Betty Kirkwood, PhD, London School of Hygiene & Tropical Medicine, London, UK; Vikram Patel, FMedSi, Sangath, Goa, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India and London School of Hygiene & Tropical Medicine, London, UK vikram.patel@lshtm.ac.uk.
Vikram
V
Patel
D000328:Adult; D000072117:Counselors; D003865:Major Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011320:Primary Health Care / Q000379:methods; D016730:Program Development; D011614:Psychotherapy, Brief / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult