# An App-Based WHO Mental Health Guide for Depression Detection: A Cluster Randomized Clinical Trial

## TL;DR

A study tested a WHO mental health app in Nepal and Nigeria to detect depression, finding it worked well in Nigeria but not in Nepal.

## Contribution

The study highlights the importance of testing digital health tools in multiple settings to ensure effectiveness and adoption.

## Key findings

- In Nigeria, the app detected 88% of depression cases compared to 33% with the standard guide.
- The app was rarely used in Nepal, leading to poor depression detection rates.
- Cost per detected case was significantly lower in Nigeria using the app.

## Abstract

What is the feasibility of using the World Health Organization’s mobile app version of the Mental Health Gap Action Programme–Intervention Guide (e-mhGAP-IG) to improve detection of depression?

This cluster randomized clinical trial of 35 primary care facilities in Nepal and Nigeria found that in Nepal, the app was used rarely, and depression detection was poor for the standard mhGAP-IG and the e-mhGAP-IG. In Nigeria, the app was commonly used, with 88% of depression cases detected in the group using the e-mhGAP-IG compared with 33% of cases using the standard mhGAP-IG.

This study demonstrated the need for feasibility testing of new technologies in multiple settings because adoption may vary and uptake cannot be generalized from a single context.

Depression detection in primary care remains limited in low- and middle-income countries despite increasing use of the World Health Organization Mental Health Gap Action Programme–Intervention Guide (mhGAP-IG).

To test an app version of the mhGAP-IG (e-mhGAP-IG) in Nepal and Nigeria to improve depression detection.

In this feasibility cluster randomized clinical trial conducted from February 14, 2021, to March 25, 2022, primary care facilities (unit of clustering) in Nepal and Nigeria were randomized to the standard mhGAP-IG training arm (control) or to training using the e-mhGAP-IG app (intervention). Primary care workers (PCWs) received training based on the arm assignment of their health care facility. Statistical analysis was conducted from July 20, 2022, through September 27, 2024.

Training using standard mhGAP-IG vs training using the e-mhGAP-IG.

Analysis was performed on an intention-to-treat basis. The main outcome was accuracy of depression detection rates by PCWs, evaluated prior to mhGAP training and 5 to 8 months after training, measured as the percentage of patients who received a depression diagnosis by their PCWs compared with the number of patients who scored 10 or more on the locally validated 9-item Patient Health Questionnaire. Costs per patient detected were calculated.

In Nepal, 25 facilities (67 PCWs; mean [SD] age, 35.3 [9.2] years; 52 men [78%]) were randomized: 13 facilities to standard mhGAP-IG training (36 PCWs) and 12 facilities to e-mhGAP-IG (31 PCWs). In Nigeria, 10 facilities (47 PCWs; mean [SD] age, 46.9 [7.5] years; 44 women [94%]) were randomized: 5 facilities to standard mhGAP-IG (25 PCWs) and 5 facilities to e-mhGAP-IG (22 PCWs). In Nepal, depression detection by PCWs in the standard mhGAP-IG arm increased from 0 of 43 patients before training to 15 of 92 patients after training (adjusted mean change [AMC], 16% [95% CI, 5%-28%]), and depression detection in the e-mhGAP-IG arm increased from 0 of 49 before training to 22 of 91 after training (AMC, 24% [95% CI, 12%-36%]). In Nigeria, depression detection in the standard mhGAP-IG arm increased from 5 of 36 patients before training to 25 of 75 patients after training (AMC, 19% [95% CI, 2%-37%]), and depression detection in the e-mhGAP-IG arm increased from 6 of 35 patients before training to 67 of 76 patients after training (AMC, 71% [95% CI, 57%-85%]). In facilities in the e-mhGAP-IG arm, the app was used for 59 of 616 assessments (10% of patients) in Nepal and 883 of 1077 assessments (82% of patients) in Nigeria. Cost per patient with depression detected using the e-mhGAP-IG was Nepali Rupiya (NPR) 1980 (US $14.79) in Nepal and naira (₦) 1462 (US $0.91) in Nigeria.

This feasibility cluster randomized clinical trial demonstrated that the use, cost, and potential clinical benefit of the e-mhGAP-IG varied by setting, highlighting the importance of multisite feasibility studies when evaluating digital innovations intended for health care systems worldwide.

ClinicalTrials.gov Identifier: NCT04522453

This cluster randomized clinical trial was conducted in Nepal and Nigeria to test an app version of the World Health Organization (WHO) Mental Health Gap Action Programme–Intervention Guide to improve depression detection.