In Bangladesh and Pakistan, non-specialist health workers will deliver a simple psychological therapy called behavioural activation to people with both diabetes and depression, as part of a large clinical trial. This matters because people with diabetes are two to three times more likely to develop depression than the general population, and having both conditions makes each worse. South Asia now carries the world’s largest combined burden of depression and type 2 diabetes, yet health systems in low- and middle-income countries lack scalable treatments that address both together. Behavioural activation—a therapy that helps people re-engage with rewarding activities—is effective, culturally adaptable, and can be taught to non-specialists. If the trial succeeds, the intervention could be integrated into routine diabetes care across Bangladesh and Pakistan, improving both mental and physical health for hundreds of thousands of people. It would also reduce stigma around mental illness and lower out-of-pocket healthcare costs. The programme includes community panels and policy forums to plan for real-world rollout, and builds research capacity in multimorbidity for the region.
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Background Health care systems in low- and middle-income countries face the growth of mental and physical multimorbidity. People with long-term physical health conditions, such as diabetes, have a 2-3 fold increased risk of depression. Outcomes for comorbid depression and diabetes are significantly worse for both conditions. Diabetes is rapidly increasing, particularly in South Asia where depression in type 2 diabetes represents the largest combined mental and non-communicable disease burden. A joint approach to care is needed using a scalable intervention to recognise and treat depression, integrated with diabetes care. "Behavioural Activation" (BA) is a relatively simple, effective and culturally portable psychological therapy for depression, which can be delivered by non-specialists. Aims and objectives We aim to develop and test a culturally appropriate approach to the recognition and treatment of depression in people with diabetes in Bangladesh and Pakistan based on BA. In this 4-year programme, we will: Develop a culturally relevant, scalable intervention delivered by non-specialists, integrated within diabetes care (DiaDeM) Use decision modelling and value of information analysis to inform the design of a trial of DiaDeM Test the feasibility of DiaDeM, and develop procedures for a full trial evaluation Evaluate the clinical and cost-effectiveness of DiaDeM versus optimised usual care Estimate the economic impacts of depression and diabetes multimorbidity. Methods We will use interviews, literature review, consensus development and co-design to adapt BA for delivery alongside diabetes care in Bangladesh and Pakistan. A feasibility trial of DiaDeM will assess acceptability and whether proposed recruitment, randomisation and data collection procedures are feasible. We will conduct a multi-centre pragmatic individually randomised controlled trial with 294 participants in secondary care diabetes services from each country, comparing DiaDeM with optimised usual care for people with depression and type 2 diabetes. The primary outcome will be depression severity at 6 months (using PHQ-9); secondary outcomes include diabetes self-management, glycaemic control, health-related quality of life, and depression severity at 12 months. Cost-effectiveness will be assessed from alternative perspectives, reflecting the expenditure on public and private health care and out of pocket payments. We will analyse the data using linear regression, adjusting for baseline scores, stratification factors and other important covariables. A mixed methods process evaluation will aid understanding of the causal mechanisms, implementation and scale-up. Community Panels comprising people with mental-physical illness and organisations that advocate for them will be fully involved at all stages. We will also build capability in applied multimorbidity research and policymaking through experiential learning, doctoral fellowships, bespoke training and Research-Policy Forums . Anticipated impact and dissemination Potential impact will be maximised by an Impact Working Group including the Community Panels, healthcare practitioners and policy makers. If effective, it will plan the integration of the intervention into routine care and disseminate findings using social media, websites, reports, conferences and newspaper and journal articles. DiaDeM has potential to improve mental and physical health, reduce inequalities and stigma for vulnerable groups and provide economic benefit. Building on our existing collaborations, the programme will further enhance capacity in applied mental-physical multimorbidity research and policymaking.
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