Mental health disorders are a leading cause of disability worldwide, yet access to care remains limited, especially in low- and middle-income countries (LMICs). In India, the National Mental Health Survey estimated that nearly 150 million people require mental health services, with treatment gaps ranging from 75% to 95%. Only around 4% of individuals with major depressive disorder receive minimally adequate care. These gaps are often more pronounced in rural areas due to stigma, lack of trained professionals, and limited health infrastructure.
To address these challenges, the SMART Mental Health project was conceived as a scalable, community-based intervention to improve the identification, referral, and management of common mental disorders (CMDs) including depression, anxiety, and suicide risk. The project was implemented within the existing Indian government healthcare system, with government-contracted community health workers known as Accredited Social Health Activists (ASHAs) playing a pivotal role.
The intervention combined a community-led anti-stigma campaign with a mobile-based electronic decision support system (EDSS) for ASHAs and primary health care (PHC) physicians.
The interlinked EDSS enabled ASHAs to screen and refer individuals at high risk of CMDs while physicians used the system to diagnose and manage cases in line with WHO’s mhGAP guidelines. A built-in priority list supported ASHAs in tracking follow-ups and ensuring adherence to recommended care. The project was implemented across 44 primary health care centres (PHCs) and 133 villages in Haryana and Andhra Pradesh, targeting adults aged 18 and above.
The research was conducted between 2020 and 2023, building on formative work initiated in 2018 and earlier pilot studies conducted in another region of India. The intervention was evaluated through a cluster randomized controlled trial (cRCT) by The George Institute for Global Health India, in collaboration with AIIMS New Delhi, University of Hyderabad, and international partners.
Policy engagement was embedded throughout the project lifecycle. A policy symposium was held in Andhra Pradesh in 2019, before the project started, to align the intervention with local priorities and gather input from government and civil society stakeholders. Throughout the project, policymakers at the state and district levels were regularly updated on trial progress and engaged in discussions on barriers and facilitators to implementation. Dissemination meetings were conducted in 2022 in both states, engaging officials from the National Mental Health Programme (NMHP), District Mental Health Programme (DMHP), and other key actors. These meetings explored pathways for integration of SMART Mental Health components into existing health systems. Tele-consultation services that were provided during the project (as the intervention was rolled out during COVID) complemented the existing government initiative to provide mental health care using teleconsultation.
The results showed significant reduction in depression risk among participants receiving the intervention over one year.
The cure rate, measured by remission, was significantly higher in the intervention group, with 75% achieving full recovery, compared to just 50% in the control group. The study also reported improvements in knowledge and attitudes related to mental health, accompanied by a notable reduction in the stigma associated with seeking help. While behavioural changes related to mental health were not significant at one-year , positive effects emerged as early as three months into the programme. ASHAs checked in with nearly all people identified as at risk, most of whom consulted a doctor at least once. More than half accessed care through local health camps, which made it easier and cheaper. The digital tools supported coordination between ASHAs and doctors and were used to send reminders, and keep track of people’s progress in real time.
Nationally, the project aligns with India’s Mental Health Policy and the Comprehensive Mental Health Action Plan 2013–2030 and was implemented within the existing government healthcare system. Doctors who received training reported that they continue to apply those skills to manage CMDs. The ASHAs also continue to use their training in identifying individuals showing symptoms of CMDs and refer them to doctors for further assessment. Integration of SMART Mental Health was most successful in the state of Andhra Pradesh where the District Mental Health Program (DMHP) is relatively well established and additional doctors and ASHAs have been trained. The project team continues to engage with the government and is hopeful that the trial will contribute to national efforts to reduce the mental health treatment gap by strengthening local health systems.
Internationally, SMART Mental Health has contributed to the development of the WHO Mosaic Toolkit to End Stigma and Discrimination in Mental Health and was featured as one of twelve global case studies that exemplify core evidence-based principles in action, particularly through its community-led anti-stigma campaign and integration of lived experience into intervention design and delivery. The project contributes to the evidence base for task-sharing and digital health interventions in LMICs, with findings published in JAMA Psychiatry (2024) and cited in the Lancet Commission on ending stigma and discrimination in mental health (2022).
Several factors enabled the SMART Mental Health project to achieve impact:
Programme monitoring: Project staff continuously monitored progress of project activities and provided support to ASHAs and PHC physicians.
Task-sharing model: Leveraging ASHAs and PHC physicians ensured community ownership and sustainability.
Digital innovation: The EDSS streamlined workflows, improved data quality, and supported clinical decision-making.
Cultural adaptation: Anti-stigma materials were tailored to local languages and contexts, including the use of local celebrities and community drama.
Stakeholder engagement: Early and continuous involvement of government, civil society, and service users built trust and relevance.
Evidence generation: The rigorous trial design and high follow-up rates provided robust data to inform policy.
The SMART Mental Health project offers a scalable, evidence-based model for integrating mental health into primary care in LMICs. It demonstrates that community health workers, supported by digital tools and stigma reduction strategies, can effectively manage CMDs in resource-constrained settings. The project’s success has generated interest in replication and scale-up, with potential applications in adolescent mental health, urban slums, and vulnerable populations such as transgender communities and waste pickers. By bridging the gap between research and policy, SMART Mental Health contributes to India’s efforts to transform mental health care and serves as a model for global mental health equity.
Watch a video about the SMART Mental Health project: A smart way to tackle mental health
This research was funded by the National Health and Medical Research Council (NHMRC), Australia, under the Global Alliance for Chronic Diseases (GACD) Mental Health Research Programme.
To access publications relating to this project, see GACD’s publications webpage (filter by project MH16 – SMART Mental Health: Systematic Medical Appraisal, Referral and Treatment for Common Mental Disorders in India)
For more information about this project, please see the project webpage or contact Pallab Maulik, The George Institute for Global Health, India.
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