• Users Online: 318
  • Print this page
  • Email this page

Table of Contents
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 75-83

Living Six Hours Away from Mental Health Specialists: Enabling Access to Psychosocial Mental Health Services Through the Implementation of Problem Management Plus Delivered by Community Health Workers in Rural Chiapas, Mexico

1 Compañeros En Salud Ángel Albino Corzo, Chiapas; London School of Hygiene and Tropical Medicine, London, UK, Mexico
2 Compañeros En Salud Ángel Albino Corzo, Chiapas; Universidad Iberoamericana, Mexico City, Mexico
3 Compañeros En Salud Ángel Albino Corzo, Chiapas, Mexico

Date of Submission29-Sep-2020
Date of Decision04-Dec-2020
Date of Acceptance01-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Fatima G Rodriguez-Cuevas
Primera Poniente Sur No. 25, Angel Albino Corzo, Chiapas
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_28_20

Rights and Permissions

Living with a mental health condition in rural Chiapas, the southernmost state of Mexico, where adversity, poverty and health in accessibility prevail, make it challenging to reach for mental health services since they are mostly centralised in urban settings, understaffed and underfunded. The Mexican sister organisation of the international non-profit, Partners In Health, has served in marginalised communities in collaboration with the Mexican Ministry of Health and has provided mental health services since 2014. In 2019, community mental health workers began delivering individual Problem Management Plus (PM+) sessions to people with mental health conditions through home visits. This field report aims to share implementation practice findings through the voice of four implementers, two of whom currently deliver PM+, and through two brief case reports. Results show PM+ has had a positive impact on patients’ symptoms and community health workers’ attitudes toward mental health and themselves. However, incompletion of sessions, appropriateness and acceptability of the intervention are issues that implementers still need to tailor to the context. Despite having made adaptations, complex problems such as intimate partner violence, stress due to structural adversity and grief related to the emerging COVID-19 pandemic represent challenges that the intervention needs to address to meet the needs of underserved areas.

Keywords: Chiapas, community mental health workers, COVID-19, Mexico, Problem Management Plus, psychosocial support, task sharing

How to cite this article:
Rodriguez-Cuevas FG, Valtierra-Gutiérrez ES, Roblero-Castro JL, Guzmán-Roblero C. Living Six Hours Away from Mental Health Specialists: Enabling Access to Psychosocial Mental Health Services Through the Implementation of Problem Management Plus Delivered by Community Health Workers in Rural Chiapas, Mexico. Intervention 2021;19:75-83

How to cite this URL:
Rodriguez-Cuevas FG, Valtierra-Gutiérrez ES, Roblero-Castro JL, Guzmán-Roblero C. Living Six Hours Away from Mental Health Specialists: Enabling Access to Psychosocial Mental Health Services Through the Implementation of Problem Management Plus Delivered by Community Health Workers in Rural Chiapas, Mexico. Intervention [serial online] 2021 [cited 2023 Jun 7];19:75-83. Available from: http://www.interventionjournal.org//text.asp?2021/19/1/75/312715

  Introduction Top

Background and Setting

Mental health conditions account for 14% of the Global Burden of Disease and represent a quarter of the disability adjusted life years (Prince et al., 2007). In remote places such as Chiapas, the southernmost state in Mexico, with over 70% of the population living with multidimensional poverty and 50% living in rural areas (INEGI, 2015), mental health conditions prevail. A local cross-sectional study performed in the mountainous region of Chiapas showed that the average depression prevalence amongst adults is 7.9%; according to a home-based survey (Elliott et al., 2019) whereas the Mexican national average remained at 4.0%–4.5% (Belló et al., 2005). Moreover, a study by Serván-Mori et al. (2020) in populations ranging from 14–20 years of age in the same rural context showed that 35.8% of adolescents suffered from depression or generalised anxiety disorder (GAD) symptoms, and 32.1% of people with both mental disorders reported having attempted suicide. Furthermore, a mixed methods study conducted in this region found that the lifetime prevalence of intimate partner violence (IPV) was 49.7% among young adult women and 54.7% among ever-partnered women, which was associated with depressive symptoms (Aguerrebere, 2018). Such data support previous findings that low quality of life within the family, lack of peer relationships, violence and problems arising from socioeconomic constraints and scarcity increase the risk of experiencing mental health disorders (Tsai et al., 2015). However, there is a shortage of resource allocation to address mental health conditions in Mexico. The rate of psychiatrists per population is only 0.67 per 100,000 inhabitants (World Health Organization, 2019), and the majority work in urban settings. Reaching them means travelling 6–9 hours from rural settings. Moreover, mental health services are underfunded; given only 2% of the health expenditure corresponds to mental health (Pan American Health Organization, 2011).

According to Rodríguez-Cuevas et al. (2020), strategies like task sharing have shown to be effective in similar settings and promising in mental health. A systematic review conducted by Van Ginneken et al. (2013) found that the use of nonspecialists may increase recovery for patients with depression or anxiety. Despite the scepticism around involving community health workers (CHWs) in mental health care, there is abundant evidence of their effectiveness in this area (Joshi et al., 2014; Singla et al., 2017).

Compañeros En Salud (CES) is the Mexican sister organisation of the international nonprofit organisation Partners In Health (PIH). Since 2012, CES has been working in marginalised communities in the Fraylesca and Sierra regions of Chiapas in collaboration with the Ministry of Health with the purpose to provide high-quality medical care. In February 2014, given the burden of mental conditions, CES launched its Mental Health Programme. The programme’s basis is both stepped care (Belkin et al., 2011) and collaborative care models (Acharya et al., 2017). The organisation facilitates the delivery of mental health by: (1) capacity building of nurses and physicians through high-intensity training and on-site supervision, (2) active case finding of people with mental conditions, (3) provision of community-based psychoeducation and accompaniment by five community mental health workers (CMHWs) and 92 CHWs, (4) procurement of a strong medication supply chain for pharmacological treatment delivery and (5) oversight of clinical assessment and patient-centred therapeutic plan by mental health specialists when needed.

This field report encompasses the results and analysis of the work performed from June 2019–September 2020, from the perspective of the authors. Two of them have lived in rural Chiapas for 1–6 years, and the remaining two are originally from Chiapas and work as frontline CMHWs themselves. The perspectives of the latter are crucial for a comprehensive report, especially in the fight for health equity.

  Implementation of PM+ in Mexico Project Top

In 2019, CES decided to recruit and hire five CMHWs, who thereafter received a training in the World Health Organization’s (WHO) low-intensity psychological intervention Problem Management Plus (PM+), to address common mental health conditions in people affected by adversity (Dawson et al., 2015). PIH’s partner site in Peru, Socios En Salud (SES), collaborated with CES in the training process, since SES implemented PM+ in 2017, and had already translated and implemented materials into Spanish (Socios en Salud, 2017; Coleman et al., 2021). Likewise, CES hired a case manager psychologist (CMP) to supervise CMHWs delivery of PM+. The PIH Cross-Site Mental Health Programme facilitated the implementation of the cross-site collaboration. The Cross-Site programme is a platform that addresses global mental health delivery challenges by sharing and improving practices in mental health care delivery across 10 PIH sites (Partners In Health, 2020; Coleman et al., 2021).

Following PM+ guidelines, CMHWs hold weekly sessions (mainly through home visits) with patients, on an individual basis. Each week, CMHWs work with a different PM+ session, which includes a brief review of the previous sessions. Along with the PM+ intervention, CMHWs provide a tailored psychoeducation component at every visit, focusing on what depression and anxiety are, their causes and their effects (mainly regarding thoughts, feelings and interpersonal relationships), resulting in 2–3 hour long sessions. Any patient should complete the programme within 5 weeks, with the opportunity to have additional sessions if they require them or if the CMHW and the CMP consider it appropriate (which they discuss during clinical supervision). Nevertheless, because of harvesting seasons, as well as other life circumstances that force patients to be far from their homes, the intervention can take several months.

Pathway of Mental Health Care

At CES, patients undergo a clinical assessment at the clinic by a physician trained in patient-centred care when they suspect a mental health condition. Physicians provide psychoeducation, evaluate the need for prescribing medication or not and refer cases of depression and GAD to CMHWs, who provide the PM+ intervention and facilitate psychoeducation open groups. For individual interventions, CMHWs do a home visit to explain what the PM+ intervention is, to obtain informed consent, and to schedule the first appointment. On the other hand, for group interventions, CMHWs create personalised invitations through letters or they visit homes to enrol possible participants. These groups, which CMHWs facilitate as well, are based on cognitive behavioural therapy basic skills, and their target is people living with depression, anxiety and/or adversity situations. The group curriculum is a contextual adaptation of Lewinsohn et al.’s (1984) Coping with Depression Course, and includes psychoeducation on mental health, problem solving, relaxation techniques, behavioural activation techniques and family support mobilisation. Patients can choose to attend either individual (PM+) or group (psychoeducation) sessions or to be part of both.

Physicians, CMHWs and CMPs have monthly meetings to comment on cases and to elaborate follow-up plans, both at the primary care clinic and within the community. Simultaneously, physicians oversee the medical follow-up, including pharmacological treatment when patients require it ([Figure 1]).
Figure 1 Pathway of Mental Health Care

Click here to view

  Adaptation of PM+ According to Context Specific Needs Top

CMHWs provided oral and written feedback on the PM+ visit forms and paper-based materials during the 5-day PM+ course, after the training team gave them the pilot versions. Such feedback guided the thorough adaptation process ([Table 1]).
Table 1 Adaptation of PM+ Tools to Chiapas Context

Click here to view

The CMHWs carry out the same series of tests before, during and after the PM+ programme, for continuing symptoms assessment, data analysis and for clinical scores comparison even if patients drop the programme prematurely.

Psychological Outcome Profiles

This is a four-item, self-administered subjective mental health outcome measure (Ashworth et al., 2005). CES adapted the test by translating the measure to the local language and shortening the instructions for CMHWs to read and administer to patients. Using CMHWs’ feedback, and implementers’ observations from previous survey applications, we replaced Psychological Outcome Profiles’ numbered mood scale with a visual analogue one, since locals prefer the latter rather than the former.

Generalised Anxiety Disorder Scale

This is a seven-item, self-administered questionnaire that focuses on anxiety symptoms. The Generalised Anxiety Disorder Scale (GAD-7) score cut points indicate severity of anxiety as follows: zero to four points (minimal), five to nine points (mild), 10–14 (moderate) and 15–21 (severe). A GAD-7 score of 10 points or more makes the diagnosis of GAD more likely (Spitzer et al., 2006). The physician uses the Spanish and culturally adapted version of the scale in the primary care clinic as well, which has sensibility and specificity of 87% and 93%, respectively (Garcia-Campayo et al., 2010).

Patient Health Questionnaire and Suicide Risk Assessment

This is a nine-item, self-administered test that focuses on the major depressive disorder symptoms (Kroenke et al., 2001). Severity of depression symptoms is indicated by the following cut points: zero to four (minimal), five to nine (mild), 10–14 (moderate), 15–19 (moderately severe) and 20–27 (severe). Arrieta et al. (2017) adapted and validated this scale to the Fraylesca and Sierra context (sensibility and specificity of 88%), which both CMHWs and physicians use at the primary care clinics. Question number nine inquires about suicidal thoughts. If positive, CMHWs proceed to do a risk assessment and a safety plan in collaboration with the patient. When suicide risk is high, CMHWs refer patients to the physician at the primary care clinic for a more advanced intervention.

  Adaptations to PM+ Due to COVID-19 Top

The growing number of people facing stress and anxiety due to COVID-19 led to the expansion of the PM+ intervention to reach those cases as well. However, to decrease the risk of acquiring COVID-19 during encounters, CMHWs began to do home visits considering the following measures:
  • Use of personal protection equipment. For regular sessions, such equipment consisted of a three-layered fabric mask and hand sanitizer; when visiting someone who possibly had COVID-19, the equipment comprised an N95 or KN95 respirator mask, face shield, isolation gown and gloves.
  • Keeping 1.5 metres of distance between the patient and themselves.
  • Meeting at a private ventilated area other than inside the house (e.g. a garden, patio or clinic’s backyard).

CMHWs also needed to adapt some PM+ aspects to fit the pandemic preventative measures. For example, to maintain safe distancing they modified their teaching of relaxation techniques (which normally requires proximity to patients and a low soothing volume of voice) by making larger body movements, providing more constant verbal feedback to patients and by increasing the volume of their voices. They also provided a greater emphasis on family support mobilisation, as some patients in panic would say, “I’d rather leave this world than acquiring COVID-19”. To elicit useful thoughts and feelings through the PM+ behavioural activation component (Get Going, Keep Doing), CMHWs prioritised both pleasurable indoor activities and activities that did not implicate gatherings, including reading and studying Bible passages on their own, gardening and individual walks in open spaces, instead of joining sports teams or attending their church more often.

  Training of CMHWs Top

The training process was a partnership between SES and CES. CES selected five out of the 10 communities where they work to implement the intervention to match the budget, to pilot the project first and learn from the implementation, and thereafter expand the project if appropriate. The selection of the five pilot communities included places with a high burden of mental health disorders, level of development of other CES’ programmes, high marginalisation with limited social or mental health services. During CMHWs recruitment, community members helped to design the inclusion criteria for the CMHW profile. Inclusion criteria strongly focused on including women, since they are a vulnerable population with limited economic and social capital, and because most patients with common mental conditions are women. Criteria also comprised 18–50 years of age, will to serve others, empathy, sense of responsibility, availability of time, tolerance to different mindsets, creativity, trustworthiness, openness to walking long distances and good communication and teaching skills. Based on such criteria, CES recruited three candidates per community (for a total of 15 candidates) to receive an initial training that comprised mental health specific topics ([Table 2]). After the training, the team selected a CMHW out of the three candidates. The five CMHWs participated in a 5-day-long PM+ training. Veteran CMHWs, who had previously worked for 2 years with CES by facilitating the psychoeducation groups, facilitated some topics during the training; moreover, it was a good opportunity for peer-to-peer case discussion and learning.
Table 2 Training Contents for CMHWs

Click here to view

The PM+ training mainly comprised the use of digital slides, role plays, interactive simulation stations and case vignettes. Training sessions were facilitated primarily by SES staff and co-designed by CES staff. Following the initial training, CES has conducted ongoing trainings due to an increasing demand for health care workers trained in mental health for specialised interventions for specific case subjects. The selection of these topics is collaborative, leading to a selection of grief and bereavement care, psychological first aid and trauma desensitisation. The 2021 training lesson plans include development psychology topics and addiction counselling techniques.

  Supervision of CMHWs Top

The CMP provides supervision from a developmental perspective, in which the supervisor adjusts the methods “to fit the confidence and skill level of supervisees as they develop and grow professionally” (Haynes et al., 2002). In order to maintain continual supervision, CMHW receive monthly in person (or field) supervision in their respective communities, as well as weekly telesupervision.

Field supervision consists of a monthly 2–3 day visit to each community. It comprises the following:
  • case consultations (case follow-up, questions, difficulties with case management);
  • live observation of at least one PM+ session;
  • role plays and
  • discussion of issues regarding countertransference (linking their cases to their own problems and learning how to cope better with mixed feelings elicited in them).

There is also an assessment of self-care strategies and a space for self-disclosure, in which CMHWs can share personal difficulties with their supervisor. Supervision includes the evaluation of written case notes and assessments, and a follow-up meeting with the community physician.

Due to COVID-19, some communities closed their doors to foreign people and transit through them became limited. Therefore, over the last months, we have relied more on remote supervision, which consists of 1-hour-long weekly video calls that focus exclusively on case consultation. CMHWs get mentored around emergency cases, mainly regarding suicide risk and/or violence, through instant messaging. CMHWs have a cell phone of their own (for personal purposes, but that is also used for work-related situations), as well as bandwidth access at their clinics, provided by CES’ IT team. However, connectivity issues, such as electricity blackouts due to weather and limited local infrastructure, are common. CMHWs also have a headset (provided by CES), access to a private room inside the clinic for telesupervision and use code names for their patients to decrease breaches of confidentiality.

  Evaluation and Results Top

To date, three supervisors and six CMHWs have been trained in PM+ and 71 patients have enrolled since the beginning of the intervention.

General Impact in Clinical Symptoms

Data from 71 patients, obtained from the primary care clinic’s electronic medical record and the CMP’s database showed that over 95% of patients who have tried PM+ initially underwent an assessment and diagnosis process at the clinic, after which CMHWs began PM+ sessions. About 88.7% of them were women (n = 63) and 11.27% (n = 8) were men. Around 65% of the cases showed with depression symptoms (n = 46), 21% with anxiety (n = 15) and 14%with psychosomatic complaints (n = 10; [Figure 2]). According to the 71 patients’ Patient Health Questionnaire (PHQ-9) scores from their initial visit: 15 presented with mild symptoms, 29 with moderate, 17 with moderately severe and eight with severe.
Figure 2 Patients’ Symptoms Before PM+ Sessions

Click here to view

Moreover, around 42.2%% of enrolled patients (n = 30) disclosed to have suffered violence in the past or were currently living IPV. The forms of violence ranged from controlling behaviours, which was the most common, to physical and sexual violence.

CMHWs have delivered 250 sessions overall; however, only 43.6% of patients (n = 31) completed all five sessions. Reasons for incompletion of PM+ treatment included referral of complex cases to a psychologist, abandonment of programme, impossibility to locate patients and patient’s change in address. Around 28% (n = 20), who completed PM+, continue to receive care by CMHWs during home visits for complementary support and psychosocial accompaniment (e.g. elderly that are isolated, patients with persistent somatic symptoms, lack of social support, etc.). Refer to [Figure 3] to see patients’ distribution per community.
Figure 3 Distribution of Type of Patients’ Treatment Per Rural Community

Click here to view

According to an internal analysis of 66 patients’ outcomes, there was significant improvement in the clinical symptoms of those who completed PM+ treatment (five sessions). Basal PHQ-9 and follow-up scores were collated at the primary care clinic by the physician and during PM+ sessions by the CMHW, respectively. For PHQ-9 average obtention, the score was measured at each patient’s initial and their final visit. Around 31 patients completed at least five PM+ sessions and were included in the Average Percent Change in PHQ-9 compared to baseline calculation. Each patient’s individual percent change in PHQ-9 was calculated by subtracting their initial PHQ-9 score from their final PHQ-9 score, and then dividing it by their initial PHQ-9 score and multiplying it by 100. The individual percent changes were added and then divided by the total number of patients. All 31 patients had a negative individual percent change ([Figure 4]).
Figure 4 Formula to calculate PHQ-9 Percent Change

Click here to view

Our results showed that 68% (n = 45) of patients reached remission with a PHQ-9 score <5 after completion of PM+ sessions. There was a 69.9% average change in PHQ-9 scores after completion of PM+ compared to baseline. Furthermore, as the number of sessions increases, there is a drop in average PHQ-9 scores with an average score of 13.8 at baseline and 3.9 at fifth session. Nevertheless, as number of sessions increase, the number of patients enrolled decrease ([Figure 5]).
Figure 5 Average PHQ-9 Drop Throughout PM+ Sessions

Click here to view

During final sessions, patients mentioned that they appreciated having someone’s company during difficult times, the communication skills that CMHWs had, and doing activities along with them such as gardening or going for a walk.

Impact in CMHWs and Community Care

CMHWS value the empowerment and noticeable changes in self-confidence that came with the process of becoming a CMHW, and by learning a strategy that could help people living with mental health conditions:

I live with my mom, and I used to fear making my own decisions before (becoming a CMHW). I would expect others to decide on my behalf, but not anymore. Now I make my own decisions and my mother and family respect them… I only studied until middle school, but now I am determined to major in psychology. I know this (job) made me fall for psychology, and I would not like to stop doing my work. You can help people not only by being a doctor or a nurse, but by being like me, some sort of a psychologist.

Moreover, having a psychosocial treatment option to deliver within the community has meant an epistemological rupture in mental health care in the communities where CMHWs live and serve, as expressed by a fellow CMHW:

People bear their mental health complaints, because they go to doctors that make them spend a fair amount of money without them giving a real solution or a diagnosis, in plain 2020! But here, within the community, a lot of people have benefited from the clinic and are content because they are able to move forward, in comparison to before, when they did not know where they could go to, and would just endure, because that is how it was supposed to be. Husbands used to mistreat women instead of supporting them: they would say they were lazy, that they just wanted to sleep, but now we know it’s due to a health condition.

In the words of a fellow CMHW, capacity building is an aspect that has the potential for knowledge to prevail within community members:

If they (CES) told me that the CMHW role has ended, I would continue helping, I don’t care if the group ends. Thank God we have learnt, and what we have learnt is for something: for our community and our people.

Furthermore, CMHWs consider that guiding their patients to “get distracted” from cognitive distortions, reviewing their social support network and focusing on problem solving skills help patients the most.

Case Presentations

The following cases depict strengths and challenges in the implementation of this low-intensity intervention.

Case 1: When adaptations are made to fit the context needs:

I had the case of a 64-year-old woman that attended the clinic with depressive symptoms. The physician referred her to me, so I went to her home to introduce her to the PM+ programme. She had an overly complicated case; she was a lonely woman, almost socially abandoned. She was living with diabetes and hypertension, both treated at her local clinic, and had lost most of her visual capacity. Hence, I had to adapt some of PM+ activities, such as the calendar for (the behavioural activation component) Get Going, Keep Doing, which I had to draw on a bigger scale in a flip chart sheet. She would place it on her walls and remember what we had agreed on doing. She also had some anxiety symptoms, such as fatigue and worrying too much. It was hard to see that she had several incurable diseases; however, depression had a cure. Over time, she started getting out of her house, she got closer to her family, with whom I also had the chance to speak to (to explain to them what depression and anxiety were and how they could help). Once, we went for a walk together and there was another time when we planted flowers together. We managed to get her a radio where she could listen to music. She was very content when we finished PM+ sessions. Afterwards, I would continue visiting her every once in a while (as part of the psychosocial accompaniment visits), because we are also part of the community and our patients will always be regarded as our patients, so we will never abandon them. Whenever I found her listening to the radio, I would feel very joyful.

Case 2: When the implementation process differs from the book:

I had the case of a 50-year-old woman whom the physician diagnosed with depression, so he referred her to me. During the first visit I made her, she shared that she had had suicidal ideation accompanied by low energy and negative thoughts. She told me that she missed her dead father, as well as her sons when they were away; she also had a difficult relationship with her husband, who had a heavy alcohol use. The patient kept talking and seemed to want to spill everything she had had to endure. I remember that during our training, we learnt how to obtain information from patients through the forms and get the clinical scores (PHQ-9 and GAD-7), but I couldn’t do it during the first session, as I didn’t want to interrupt her story, so I just let her talk. The same happened during the following sessions, in which I couldn’t do the questionnaires, but showed her the relaxation techniques and activities to get distracted from “thinking too much”. A safety plan was done too. I commented this case with my case supervisor and she told me that catharsis was important for this patient even if that meant not fully adhering to PM+ sessions, and that I could continue visiting her, because it helped her. Had I followed PM+ sessions’ structure by the book, I would have lost this patient, since she would have felt unheard and pressured by the questionnaires. Having patience with her helped her to feel free to express everything she wanted whenever she wanted to. She finished her PM+ sessions and now she enjoys visiting the village and talking with friends as part of her support network.

  Discussion Top

Challenges and Recommendations

There were certain cases in which PM+ helped but was not the most appropriate strategy with which to start. For people living with depression who disclosed traumatic experiences (including violence and adverse childhood experiences), CMHWs and their supervisor (through technical training, ongoing supervision and co-therapy sessions) provided complementary sessions of emotion regulation skills, trauma desensitisation and/or violence safety planning before delivering PM+ sessions. Besides, it was necessary to have flexibility with the structure of sessions as patients appreciate having enough time to disclose personal stories, rather than just answering questions. Adaptations to fit the preventative measures due to COVID-19 also helped to ensure safety for CMHWs while continuing to provide care for people in need.

Furthermore, a myriad of challenges was present for keeping patients’ permanence throughout the programme, as about half of them dropped out due to clinic’s remoteness, change in address to look for job opportunities abroad and referral due to complexity of cases. Hence, it is necessary to establish the infrastructure to address complex clinical cases with accessible mental health services and build structures that offer community financial security.

Regarding supervision, the three main challenges that arose with telesupervision were confidentiality, communication and infrastructure. To maintain confidentiality, many aspects had to be put in place for protecting patients’ information such as the establishment of private spaces, provision of supplies and an emphasis on keeping confidentiality with patients. In terms of communication, the lack of nonverbal cues led to difficulties at specific moments of the supervision. As for infrastructure, the unsteady internet connection and constant power outages have also decreased the frequency of sessions.

As we have seen in our practice, PM+ is helpful for people when they have a specific problem, however, when the complexity of cases and the structural adversity increase, limitations come. From our perspective, PM+ helps people become resilient, by using more inner resources and coping better with adversity, and makes people feel cared by somebody that accompany them constantly.

Lessons Learned

During our practice we valued the inclusion of community members as reference points to know best what the local needs are and how to approach them. Community authorities and members buying in of CMHWs role and of PM+ were crucial in maintaining a harmonic relationship. When gaps in communication arise, rumours and critiques can be deleterious on the programme and on the personnel too, impairing access of people to these services. Hence, there is value in collaborative decision-making with all stakeholders.

There is also a perceived feeling of increased self-efficacy amongst CMHWs. By being frontline providers of PM+, they have identified benefits for themselves in giving the sessions, including finding a professional calling. In addition to this, the gender sensitive curriculum has demonstrated to impact CMHWs by adopting an active position against all forms of violence and by contributing to their household incomes.

  Limitations Top

Although this field report offers quantitative data and cases presentation depicting the work performed and its impact, there is the need for a rigorous methodology to improve data analysis, as well as formal qualitative assessments from patients and other CMHW to have a better sense of the impact of PM+ sessions in community context. Furthermore, medications use data was missing, hence its analysis, effect on the clinical results and comparison among groups of patients receiving PM+ with or without pharmacological treatment was not possible. This is an opportunity field for further research.

  Conclusions Top

In low resource settings such as rural Chiapas, where the burden of mental health conditions is high and mental health services nonexisting, task sharing strategies can fill this gap. In such places, CMHWs, who are mentored and trained in WHO PM+, offer a treatment option for people living with common mental conditions. From the lens of CMHWs, the embedding of PM+ into a reliable pathway of care, that offers the space, the staff, supplies and the system, allows for clinical improvement in people that face adversity on a daily basis, and even for community workers themselves. For tailoring the appropriateness and acceptability of the intervention, we made proper adaptations to the context, the providers’ and people’s needs. Nevertheless, in complex cases there is still a need for using complementary strategies that PM+ lack and for which PM+ was not intended for, such as violence, alcohol use and trauma. Addressing these is necessary for providing equitable mental health services in marginalised areas.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Acharya B., Ekstrand M., Rimal P., Ali M. K., Swar S., Srinivasan K., Mohan V., Unützer J., Chwastiak L. A. (2017). Collaborative care for mental health in low- and middle-income countries: A WHO health systems framework assessment of three programs. Psychiatric Services, 68 (9), 870-872. https://doi.org/10.1176/appi.ps.201700232  Back to cited text no. 1
Aguerrebere M. (2018). Understanding intimate partner violence, sexual abuse, and mental health in non-indigenous rural Chiapas: Implications for Global Mental Health Practice. Master’s thesis, Harvard Medical School. https://nrs.harvard.edu/URN-3:HUL.INSTREPOS: 37365183  Back to cited text no. 2
Arrieta J., Aguerrebere M., Raviola G., Flores H., Elliott P., Espinosa A., Reyes A., Ortiz-Panozo E., Rodriguez-Gutierrez E. G., Mukherjee J., Palazuelos D., Franke M. F. (2017). Validity and utility of the Patient Health Questionnaire (PHQ)-2 and PHQ-9 for screening and diagnosis of depression in rural Chiapas, Mexico: A cross-sectional study. Journal of Clinical Psychology, 73 (9), 1076-1090. https://doi.org/10.1002/jclp.22390  Back to cited text no. 3
Ashworth M., Robinson S. I., Godfrey E., Parmentier H., Shepherd M., Christey J., Wright K., Matthews V. (2005). The experiences of therapists using a new client-centred psychometric instrument, PSYCHLOPS (Psychological Outcome Profiles). Counselling and Psychotherapy Research, 5 (1), 37-42. https://doi.org/10.1080/14733140512331343886  Back to cited text no. 4
Belkin G. S., Unützer J., Kessler R. C., Verdeli H., Raviola G. J., Sachs K., Oswald C., Eustache E. (2011). Scaling up for the “bottom billion”: “5×5” implementation of community mental health care in low-income regions. Psychiatric Services, 62 (12), 1494-1502. https://doi.org/10.1176/appi.ps.000012011  Back to cited text no. 5
Belló M., Puentes-Rosas E., Medina-Mora ME. (2005). Prevalence and diagnosis of depression in the adult population in Mexico. Salud Publica Mexico, 47(Suppl 1), s6-s8. [in Spanish] https://www.saludpublica.mx/index.php/spm/article/view/4683  Back to cited text no. 6
Coleman S. F., Mukasakindi H., Rose A. L., Galea J. T., Nyirandagijimana B., Hakizimana J., Bienvenue R., Kundu P., Uwimana E., Uwamwezi A., Contreras C., Rodríguez-Cuevas F. G., Maza J., Ruderman T., Connolly E., Chalamanda M., Kayira W., Kazoole K., Kelly K. K., Smith S. L. (2021). Adapting Problem Management Plus for implementation: Lessons learned from public sector settings across Rwanda, Peru, Mexico and Malawi. Intervention, 18 (1), 58-66.  Back to cited text no. 7
Dawson K. S., Bryant R. A., Harper M., Tay A. K., Rahman A., Schafer A., van Ommeren M. (2015). Problem Management Plus (PM+): A WHO transdiagnostic psychological intervention for common mental health problems. World Psychiatry, 14 (3), 354-357. https://doi.org/10.1002/wps.20255  Back to cited text no. 8
Elliott M. L., Aguerrebere M., Elliott P. F. (2019). Depression in rural communities and primary care clinics in Chiapas, Mexico. Journal of Epidemiology and Global Health, 9, 103-106. https://doi.org/10.2991/jegh.k.181128.001  Back to cited text no. 9
Garcia-Campayo J., Zamorano E., Ruiz M. A., Pardo A., Perez-Paramo M., Lopez-Gomez V., Freire O., Rejas J. (2010). Cultural adaptation into Spanish of the generalized anxiety disorder-7 (GAD-7) scale as a screening tool. Health and Quality of Life Outcomes, 8 (1), 8. https://doi.org/10.1186/1477-7525- 8-8  Back to cited text no. 10
Haynes R., Corey G., Moulton P. (2002). Clinical supervision in the helping professions: A practical guide (1st ed.). Brooks Cole.  Back to cited text no. 11
INEGI. (2015). Number of inhabitants. [in Spanish]. http://www.cuentame.inegi.org.mx/monografias/informacion/chis/poblacion/  Back to cited text no. 12
Joshi R., Alim M., Kengne A.P., Jan S., Maulik P.K., Peiris D., Patel A.A. (2014). Task shifting for non-communicable disease management in low and middle income countries-a systematic review. PLoS ONE, 9(8), 1-8. https://doi.org/10.1371/journal.pone.0103754  Back to cited text no. 13
Kroenke K., Spitzer R. L., Williams J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16 (9), 606-613. https://doi.org/10.1046/j. 1525-1497. 2001.016009606.x  Back to cited text no. 14
Lewinsohn P. M., Antonuccio D. O., Breckenridge J. S., Teri L. (1984). The coping with depression course. International Journal of Mental Health, 13 (3/4), 8-33. http://www.jstor.otg/stable/41344359?seq=1  Back to cited text no. 15
Partners In Health. (2020). Mental Health at Partners in Health. https://www.pih.org/mental-health-partners-health  Back to cited text no. 16
Pan American Health Organization. (2011). Informe Sobre Sistema De Salud Mental En Mexico. https://www.who.int/mental_health/who_aims_country_reports/who_aims_report_mexico_es.pdf?ua=1  Back to cited text no. 17
Prince M., Patel V., Saxena S., Maj M., Maselko J., Phillips M. R., Rahman A. (2007). No health without mental health. The Lancet, 370 (9590), 859-877. https://doi.org/10.1016/s0140-6736(07) 61238-0  Back to cited text no. 18
Rodríguez-Cuevas F. G., Hartman S., Aguerrebere-Gómez-Urquiza M., Palazuelos D. (2020). Accompanying people with mental illnesses: The role of CHWs in mental health care services in Chiapas, Mexico [E-book]. In Innovations in global mental health (1st ed., pp. 1-22). Springer Publishing. https://link.springer.com/referenceworkentry/10.1007/978-3-319-70134-9_101-1  Back to cited text no. 19
Serván-Mori E., Gonzalez-Robledo L. M., Nigenda G., Quezada A. D., González-Robledo M. C., Rodríguez-Cuevas F. G. (2020). Prevalence of depression and generalized anxiety disorder among Mexican indigenous adolescents and young adults: Challenges for healthcare. Child Psychiatry & Human Development, 52, 179-189 https://doi.org/10.1007/s10578-020- 01001-9  Back to cited text no. 20
Singla D. R., Kohrt B. A., Murray L. K., Anand A., Chorpita B. F., Patel V. (2017). Psychological treatments for the world: Lessons from low- and middle-income countries. Annual Review of Clinical Psychology, 13 (1), 149-181. https://doi.org/10.1146/annurev-clinpsy- 032816-045217  Back to cited text no. 21
Socios en Salud. (2017). Initiative: Facing Problems Plus (EP +) in Peru. [in Spanish]. https://sociosensalud.org.pe/iniciativa-enfrentando-problemas-plus-ep-en-el-peru/  Back to cited text no. 22
Spitzer R. L., Kroenke K., Williams J. B. W., Löwe B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166 (10), 1092. https://doi.org/10.1001/archinte.166.10.1092  Back to cited text no. 23
Tsai M. C., Hsieh Y. P., Strong C., Lin C. Y. (2015). Effects of pubertal timing on alcohol and tobacco use in the early adulthood: A longitudinal cohort study in Taiwan. Research in Developmental Disabilities, 36, 376-383. https://doi.org/10.1016/j.ridd.2014.10.026  Back to cited text no. 24
Van Ginneken N., Tharyan P., Lewin S., Rao G. N., Meera S. M., Pian J., Chandrashekar S., Patel V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database of Systematic Reviews, 11, 1-366. https://doi.org/10.1002/14651858.cd009149.pub2  Back to cited text no. 25
World Health Organization. (2019). Human resources Data by country. Global Health Observatory Data Repository. https://apps.who.int/gho/data/node.main.MHHR?lang=en  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Implementation o...
Adaptation of PM...
Adaptations to P...
Training of CMHWs
Supervision of CMHWs
Evaluation and R...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded343    
    Comments [Add]    

Recommend this journal