Lay worker-administered behavioral treatments for psychological distress in resource-limited settings: Time to move from evidence to practice?

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Exposure to nonlethal violence is, apart from its resulting physical injury or other adverse health sequelae, one of the most consistently estimated causal risk factors for psychological distress, mental and substance use disorders, suicidal behaviors, and completed suicide [1][2][3][4][5][6][7].Throughout sub-Saharan Africa, a strong gendered patterning in these exposures has been observed, and the rates of intimate partner and nonpartner violence against women in this region are among the highest in the world [8][9][10][11].Even were health systems in sub-Saharan Africa equipped, contrary to fact [12,13], to handle the additional burden of mental health service delivery for affected populations, most survivors of violence never seek or obtain proper treatment [8].In many settings, care-seeking behaviors are severely compromised by stigma, gender-inequitable norms, and inadequate legal protections [14].Further, screening of asymptomatic women has not been shown to be a useful approach for improving health outcomes [15,16].In the face of these significant structural challenges, considerable progress has been made in the past 2 decades on the development, implementation, and evaluation of behavioral interventions in resource-limited settings.Recently published studies have convincingly demonstrated that lay health workers can be trained and supervised to deliver low-intensity behavioral interventions ("task shifting") of adequate dose and timing to improve health outcomes in a variety of vulnerable populations, including pregnant women [17][18][19][20][21]; adults with common mental disorders [22][23][24][25], schizophrenia [26], and alcohol use disorders [27]; and survivors of torture and other forms of interpersonal violence [28][29][30].Thus, task shifting should be viewed as a valid and effective approach for expanding access to evidence-based psychological interventions in settings where underfunded mental health systems lack the capacity to address unmet population mental health needs.It is in this context that we celebrate the publication, in this issue of PLOS Medicine, of the findings from a randomized controlled trial by Bryant and colleagues [31] designed to estimate the efficacy of a brief, manualized, lay worker-administered, behavioral intervention ("Problem Management Plus," or PM+) on reducing psychological distress among women survivors of interpersonal violence living in periurban settlements near Nairobi, Kenya.Of note, the PM+ intervention tested in this study-and in a companion study conducted in Pakistan, the findings of which were recently published by Rahman and colleagues [32]-is of lower

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