Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study

The Healthy China 2030 Plan [1] outlines China’s 21st Century vision for healthcare and creates a favorable policy environment for mental health system reform of both national and global significance [2, 3]. At its core, it acknowledges the symbiotic relationship between a healthy working population and economic success [4]. It embodies key values of the United Nations’ Sustainability agenda [2, 5] and aligns with the latest global thinking on “person-centered, integrated care” [6‐9]. Importantly, for a country with a sizable mental health treatment gap, where the vast majority of those with an identifiable mental health condition do not receive care [10, 11], the plan prioritizes the need to improve mental health awareness and prevention along with ready access to mental health services [12].

Shenzhen is a thriving metropolitan city located in Guangdong Province of China, just across the causeway from Hong Kong. Its population has rapidly expanded from 10.42 million people in 2010 to 17.56 million in 2020 with an average annual growth rate of 5.36% [13]. It was one of China’s first special economic zones and is nationally renowned for its progressive socioeconomic reforms [14, 15] which has transformed the region into a global commercial hub. Aware of increasing rates of mental disorders overall [16‐18] and above national levels of prevalence for depressive disorder in key working and vulnerable populations [17, 19‐23] (i.e. above 7.4%) [24], the local health authority committed to improving the recognition and prevention of common mental disorders within its developing primary healthcare sector[25]. Importantly, they invested in the upskilling of the GP workforce [26‐28] and sought to implement the service of at least one doctor with a mental health certification in each community health centre (CHC) by 2020 [29]. Findings from qualitative research conducted with primary healthcare leaders in Shenzhen [30], however, found that along with improved professional development, doctors at CHCs also needed better access to diagnostic guidelines and protocols for depression care.

Guidelines can be considered as a “synthesis of evidence” that have been shaped into “practice-oriented recommendations” and represent the “highest quality opportunity” for patient care [31]. The sharing of guideline information, from one setting to another, avoids duplication of research efforts and optimizes on resource in underfunded settings [32, 33] and, as such, has become a widely accepted approach for global progress in healthcare [34]. One such guideline, the World Health Organization (WHO), Mental Health Gap Intervention Guide (mhGAP-IG) [35] offers community health care centers in Shenzhen a rigorously developed and internationally approved resource [36, 37] with which to train doctors on the assessment, management and follow-up of depression patients and other priority mental health conditions [38, 39]. Now freely available in its second edition (although not in Mandarin Chinese), mhGAP-IG.v2 [40] incorporates both evidence-based and financially affordable treatment options suitable for use in community and resource-poor settings.

mhGAP-IG.v2, however, is a generic tool and adoption needs to be accompanied by prior consideration of its context of use: “the physical, organizational, institutional and legislative structures that enable and constrain, resource and realize, people and procedures” [41, 42]. Whilst a universal approach to the adaptation of mhGAP-IG is still evolving [43], it is generally agreed upon that the consultation of end-users is integral for the appropriate adaptation and enhancement of future implementation [38, 44, 45]. These pre-requisites are particularly relevant to China, where substantive organizational and operational change to the national healthcare system have produced a model of primary healthcare delivery unique to its developmental context.

For example, mhGAP-IG embodies aspirational global standards in mental health practice which have been shaped by an established acceptance and confidence for the close involvement of primary healthcare in the diagnosis and management of mental health conditions in upper income countries [7, 46‐48]. In contrast, primary healthcare doctors in China administer care without the legal authority to diagnose severe mental health conditions [30, 49]. Neither do CHCs experience the operational autonomy of western clinics. Instead, they are tied into the management system of their district hospital which controls both their budget and drug formulary [50]. Whilst Chinese psychiatrists were involved in the drafting of the initial mhGAP-IG, primary care representatives were not included in the consultation process and the guide may omit vital procedural or referral information in keeping with the realities of primary care prescribing practice.

Nor can the impact of culture on how different countries perceive, realise and respond to mental disorders at both a personal and system level, be ignored [51]. Socio-political events in China’s past have conditioned current-day attitudes and behaviors that can act as barriers to the expression of, and health seeking for, depression [52‐54]. mhGAP-IG.v2 is closely aligned to international classification systems (e.g. ICD 10, DSM-IV) which were originally developed according to western presentation of disease in hospital settings and may not be sensitive enough to pick up cultural subtleties of disease presentation in community-based settings.

Whilst over 90 countries have seen the uptake of mhGAP-IG [39], publications focusing on its adaptation for country-specific needs are in short supply. The Programme for Improving Mental Health Care (PRIME) initiated investigations into the use, adaptation and integration of mhGAP-IG resources into the primary care systems across low and middle income countries [55, 56]. Since then, researchers based in Africa [38, 57‐59] and Nepal [45] have endeavored to either contextualize or provide a culturally sensitive translation [59] of the guide. This was commonly achieved by engaging key stakeholders in a multi-stepped review, generally led by mental health specialists or a discrete research team [38, 57, 58] and including Primary care representatives in at least one stage of the adaptation process (i.e. as participants of preliminary qualitative focus groups [38, 57] for prototype testing of a training program [58].

This research uses the Delphi Approach, an established consensus methodology (see methods section for more details), to adapt the depression component of the mhGAP-IG.v2 for use by doctors working in community healthcare centres in Shenzhen, to take into account local culture and health system structure and reform. It signifies the completion of three phases of research, all of which have been conducted “with primary care, for primary care”: from its conception with primary care leaders to explore the current needs for the improved management of depressive disorder in CHCs [30]; to immersive workshops with primary care leaders to compare the depression guidelines with current conceptualisations of depression and clinical practice (awaiting publication); through to this Delphi study with the broader primary care community in Shenzhen.

It is unique amongst these adaptation studies by its intentional focus on the depression component only (i.e. one chapter of the guide). With the exception of one study in Nepal [45], which focused on dementia, other key studies in this field were directed at reviewing the whole guide [38, 57‐59]. The advantage of this depression-only approach is the breadth and depth of items, generated from highly focused preliminary research that can be put forward for consensus testing. As such, there is potential to obtain the systematic consensus on guideline adaptations across a range of topical mental health system, depression symptom presentation and other complex care-related concepts, which have not been previously explored in this way. Importantly, it seeks to support local and global aspirations of reducing the mental health treatment gap in China.

In summary, this study occupies a vital bridge between international guidance on best practice for depression care and making knowledge relevant and acceptable for the end-user of the guide. To the best of our knowledge, it is the only mhGAP-IG.v2 adaptation study initiated in China within the primary healthcare sector.

Several limitations of this study are closely related to the COVID-19 pandemic, which spanned the duration of research and directly impacted research feasibility. Wave 1 research coincided with the national call to action for GP panelists to conduct COVID testing and contact tracing of approximately 1 million people who had travelled between Wuhan (the geographic source of the epidemic) and Shenzhen prior to Wuhan’s lockdown [92‐95]. Throughout 2020 healthcare services were heavily in demand (to administer care and support vaccine roll-out) and international relations between China and Australia deteriorated [96‐99] with the following consequences:

This research was designed to obtain the perspectives of primary care physicians only. However, depression care cannot be provided in isolation and further development of the guide would ideally seek advice from multiple stakeholders including the specialist team that receive the referrals, the local services which strive to rehabilitate patients back into the community and, most importantly, persons who live with the day-to-day reality of the condition.

Finally, translation of some concepts/items from the source workshops may have been difficult for primary care doctors to understand. To minimise translation concerns, however, all items were back-translated by an experienced translator and tested prior to fieldwork by two bilingual doctors, working in CHCs in Shenzhen.

This research asserts that adaptation to mhGAP-IG.v2 is needed in order to align the content and algorithmic flow of decision making for CHC doctors in Shenzhen, China. Panelists gave their consent to diverge from the progenitor guide to accommodate for differences in the context-specific presentation of depression, health system organisation, primary care treatment prioritisation and access, as well as China’s overall person-centered aspirations for twenty-first century care. Uniquely, they assert their preference for a guide that reflects the life course of disease and one that documents the scope of the wider mental healthcare team and family involvement. Equally panelists chose to adopt key measures already contained within the guide for the diagnosis and treatment of bipolar patients, which are outside their current standards of practice. The updating of mhGAP-IG.v2 for the Shenzhen context provides not only a contemporary training tool of local relevance for community healthcare centres but also offers other nations an additional resource to consider in the global advancement of improved treatment and care for depression.