What is Depression?
Depression is more than just feeling sad; it is a serious condition that affects a person's thinking, feelings, and daily function. It can make simple tasks, like getting out of bed, talking to family or friends or going to work, feel impossible. People lose interest in activities they once enjoyed, and many experience physical symptoms like body aches, poor sleep or appetite changes.
Globally, depression is one of the most common mental health disorders worldwide and a leading cause of disability. In a country like Pakistan, it is now the second leading cause of years lived with disability, meaning it is a huge contributor to suffering and lost productivity.
Although effective treatments exist, from talking therapies to antidepressant medication, most people who need help never receive it. This is called the “mental health treatment gap”. In resource-constrained settings like Pakistan, physical and mental health are often treated by completely separate services, which makes it incredibly hard for people living with both physical and mental health issues to get comprehensive care.
What is SPIRIT-D about?
SPIRIT-D aims to reduce the treatment gap by delivering mental health care directly in primary care clinics, which are the first point of contact where people already go for their everyday health concerns.
The project is testing a model of delivering care called Collaborative Care, which brings together a team of healthcare providers: doctors, counsellors, and mental health specialists, to work in partnership. The idea is simple but powerful: delivering "joined-up", high quality effective care right within local clinics. Instead of relying only on mental health specialists who are in short supply, this model involves training non-specialist healthcare staff to deliver key treatments. This concept, called task sharing (or task shifting), is key to expanding capacity to care for more people at the primary care level.
Why is this research important?
Although Collaborative Care has strong evidence behind it, most of that comes from high-income countries. We have very limited evidence on how to deliver and maintain it in real-world, resource-constrained settings, where health systems face different challenges.
Our goal is to find out whether this model:
- Works effectively for people with depression in Pakistan,
- Is affordable and sustainable for the local health system,
- Can be implemented at scale across other similar settings.
How was the intervention developed?
We didn't just import an outside model, we worked to ensure it fit locally. Although we know the model works, we need to learn how best to roll it out (or implement) in the real-world. Therefore, a crucial part of our study was designing the implementation strategies to make sure it works in the local context. We started with trying to understand the context, resources and potential barriers: by visiting clinics to examine provision of depression care; reviewing local and provincial-level mental health policies; and by consulting stakeholders- patients, families, doctors, clinic staff, and policymakers.
We then held co-design workshops with stakeholders to jointly develop practical strategies that fit the realities of Pakistan’s primary care system, including available resources, staff capacity, and cultural factors around mental health.
A key part of the intervention is Behavioural Activation (BA): a simple, effective form of brief therapy for depression. Our team had culturally adapted it for use in Pakistan in a previous research programme, ensure the intervention is locally suitable, can be delivered on a larger scale, and sustained in the longer-term.
Who is behind SPIRIT-D?
We are a diverse international team combining clinical expertise, research experience, and community insight. Our project is funded by the NIHR Global Health Research Centre for Improving Mental and Physical Health Together, and the study is led by Chief Investigator, Professor Najma Siddiqi. Our team consists of:
- The University of York, UK
- The Initiative, Islamabad, Pakistan
- Institute of Psychiatry, Rawalpindi, Pakistan
- SINA Health Education & Welfare Trust, a not-for-profit organisation with a network of 40 primary care clinics in underserved areas of Karachi, Pakistan.
What will happen during the study?
The study is being carried out in 24 SINA clinics across Karachi. Based on random selection, half of the clinics will continue offering their regular (or “optimised usual care”) , while the other half will implement the Collaborative Care model .
In the Collaborative Care clinics there will be:
- Delivery of effective treatments: trained counsellors will deliver BA therapy and coordinate with doctors for antidepressant medication where needed.
- Regular monitoring: tracking progress regularly through a bespoke progress monitoring tool, using rating scales like the 9-item Patient Health Questionnaire (PHQ-9).
- Case review: Regular review of progress when mental health specialists provide supervision and guidance to clinic staff.
We will measure both health outcomes, such as improvements in depression and anxiety, and implementation outcomes, including the reach of the service, how well clinics adopt and maintain the new system. We are also looking at costs, because affordable care is essential for sustainability.
What do we want to find out?
Our main question is simple: Does Collaborative Care help people with depression in primary care settings?
Our primary measure of success is how much patients’ symptoms improve after six months. We are also tracking improvement in anxiety, quality of life, and the overall cost-effectiveness. We will also study how well the model fits into everyday clinic operations and whether staff and patients find it acceptable and useful.
By combining data and real-world experiences, we hope to understand not just if it works, but how and why it works, so others can learn from it too.
What happens after the study?
If the SPIRIT-D trial shows that Collaborative Care is effective and affordable, the results will provide a blueprint for integrating mental health into primary care across Pakistan and other resource-constrained settings.
The benefits would include:
- Better mental health outcomes for millions of people
- A trained primary care workforce
- Reduced stigma, since mental health care would be delivered in familiar, everyday settings
The project’s final phase will focus on scaling up and sustaining the model , working with health authorities, local policymakers and other stakeholders to embed it in public and private healthcare systems nationwide.
The SPIRIT-D project is funded by the UK National Institute for Health and Care Research (NIHR) Global Health Research Centre for Improving Mental and Physical Health Together. The views expressed here are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care