Abstract

Background
Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies in high-income countries have examined nonspecialist providers’ (NSPs) perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine qualitative reports of NSPs experiences delivering a brief structured behavioral intervention for depression (called “Do More, Feel Better” [DMFB]) to adults aged 55 and older.

Methods
All NSPs (N = ۴, ۱۰۰%) who delivered DMFB participated in a focus group to probe their perceptions of the acceptability, feasibility, and appropriateness of both the intervention and their delivery experience as NSPs. Two coders analyzed the qualitative data from focus groups using codebook thematic analysis.

Results
NSPs perceived the intervention and delivery experience to be acceptable, feasible, and appropriate. Qualitative results provided insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for NSPs, and the feasibility of tailoring the intervention to patient participants. NSPs also expressed difficulty managing emotional investment in patients’ success and providing therapy during a pandemic and racial violence in the US.

Conclusions
Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Introduction

In 2019, approximately one-fifth of American adults (20.6%) had a diagnosable mental health disorder [1]. Of those, less than half received any mental health services [1], meaning that 23 million adults were left untreated. Prevalence of common mental health conditions among older adults in the United States (US) mirrors that of the larger population with nearly one-third of this group living with symptoms of depression, yet relatively few receiving treatment [2]. Provider shortage is a leading cause of the mental health treatment gap in the US, with estimates that 7000 more providers are required to meet the need for services [3]. The unmet need for providers equipped to work with older adults is particularly stark [4].

A number of innovative methods to increase access to mental health treatment have been developed and applied to help close this treatment gap. These methods typically break away from the prevailing mental health model of receiving psychotherapy or pharmacotherapy from trained mental health professionals one-on-one in a clinical setting [5]. Task sharing, in which nonspecialist providers (NSPs) with no prior formal training as mental or physical health specialists are trained to effectively deliver treatment for mental or physical health conditions, is a promising implementation strategy which reduces the existing treatment gap by increasing the number of treatment providers [6,7,8]. The notion of expanding the healthcare workforce is not new; earlier writings on this issue outline the use of nonspecialists to perform essential medical tasks, often in the context of low- and middle-income countries (LMIC) [9] or in the case of nurses providing primary care health services as a substitute for physicians in high-income countries (HIC) [10]. The expanded use of such a workforce rose to prominence in addressing the HIV/AIDS crisis in sub-Saharan African and elsewhere [11] and has since been used successfully worldwide to deliver a variety of mental and physical health treatments across a range of populations, effectively reducing symptoms of depression, perinatal depression and anxiety, posttraumatic stress disorder, and alcohol use disorder [12,13,14,15].

Conclusion

This study is unique for several reasons. First, it is one of few studies in the US which used trained bachelor-level NSPs as the primary providers of treatment. Second, to our knowledge, is the first study exploring NSPs’ perceptions delivering evidence-informed treatment for depression in the US. Lastly, it is one of few studies to investigate NSPs’ perspectives on delivering a mental health treatment via telehealth during the COVID-19 pandemic. As seen in other global mental health contexts, task sharing for common mental health conditions is a potential option to increase access to services and maximize resources in the US. In this preliminary study in Washington State, bachelor’s-level NSPs perceived acceptability, feasibility, and appropriateness of a brief, structured behavioral treatment delivered to individuals with depressive symptoms. Future work holds promise for leveraging such a NSPs workforce to scale up mental health services.