Remimazolam versus propofol on seizure adequacy in electroconvulsive therapy: a retrospective cohort study.

In response to the severe shortage of mental health specialists in low- and middle-income countries (LMICs), the WHO and national governments have promoted task-shifting, delegating psychological care to trained non-specialist providers, including lay health workers (LHWs). These workers are often community members without formal specialist mental health qualifications who deliver brief psychological interventions for depression and anxiety with focused training and supervision. Most research on task-shifting in LMICs has focused on intervention effectiveness and implementation, with far less attention to how LHWs themselves experience delivering care. Our systematic review and meta-ethnography synthesise qualitative evidence from multiple LMICs and show that this work depends not only on technical competence, but also on substantial relational and emotional labour. LHWs often move beyond manuals to respond to poverty, family conflict, stigma and risk, while managing their own distress, boundaries and safety. These hidden costs of care are not only emotional but also structural, shaped by working conditions, weak recognition, limited resources, supervision and organisational support. Efforts to scale up lay-delivered mental healthcare should therefore go beyond strengthening training and supervision alone. They should also recognise relational and emotional labour as core components of service delivery and embed this recognition in fairer remuneration, role clarity, protected time, safeguarding, supportive supervision and stronger organisational support. Depression and anxiety are major global health concerns and disproportionately affect low- and middle-income countries (LMICs), as classified by the World Bank based on gross national income per capita (World Bank, ). An estimated 5.53% of adults in LMICs live with depression and 4.52% with anxiety, conditions that frequently co-occur (Saha et al., ; WHO, ). Despite the burden, many people in LMICs face substantial barriers to accessing care, including limited mental health literacy, stigma, poor availability of services and lack of perceived need for therapy (Andrade et al., ; Saha et al., ; Roberts et al., ). These challenges are exacerbated by a severe shortage of mental health professionals (Eaton et al., ; Patel et al., ; WHO, ). LMICs have only 3.8 mental health workers per 100,000 population compared with 72.7 in high-income countries (WHO, ), and just 13.7% of people with depression and anxiety receive condition-appropriate care (Evans-Lacko et al., ). In response, WHO has promoted task-shifting, which involves transferring routine tasks from specialists to trained non-specialists, including lay health workers (LHWs) (Liu et al., ; WHO, ). When supported by structured training and supervision, task-shifting can improve health outcomes, reduce specialist workload and expand access to early psychological care, which can prevent more severe illness and costly hospital care (Kakuma et al., ; Seidman and Atun, ; Heller et al., ). The WHO’s Mental Health Gap Action Programme (mhGAP) provides guidance and training materials to support these roles (Kohrt et al., ; WHO, ).