Community-based interventions for mental health: Bridging primary care and community approaches

 Corresponding author: Dian Mustikarini Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Community-based interventions for mental health: Bridging primary care and community approaches Dian Mustikarini 1, *, Dyahati Wahyurini 2 and Dwiretno Pangastuti 3 1 Medical Doctor, Amarta Medika Clinic, Sleman, Yogyakarta, Indonesia. 2 Clinical Research Unit, Dr. Cipto Mangunkusumo National General Hospital, Central Jakarta, Indonesia. 3 Department of Medical Education, Faculty of Medicine, Brawijaya University, Malang, Indonesia. World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 Publication history: Received on 18 March 2025; revised on 26 April 2025; accepted on 29 April 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.1.1565 Abstract Mental health is one of the important factor for human well-being and their productivity in society. However, the prevalence of mental illness in Indonesia is slightly high, due to increasingly stigma about mental disorders and lacking of mental health professional. In order to resolve these challenges, the role of general practitioners as a community leader in primary care is needed. This study aims to summarize various interventions in primary level, their procedure and the outcome for mental health in communities. This study used a literature review design based on secondary data from electronic database, such as PubMed, Cochrane Library, and ScienceDirect. There are 16 articles required after screening by PRISMA 2020 and met the inclusion criteria. The results of this study is community-based program for mental health could be conducted in three ways: mental health programs such as Mindfulness-Based Program, Family intervention, Emotional Resilience Skills Training, and School-based intervention; mental health tools using chatbot AI; and the combined of both programs and tools: SMART Mental Health. Some of these interventions proved effective to reduce sign and symptoms of mental illness, especially depression and anxiety disorder. Further research is needed to analyze mental health outcome of each interventions and to improve the applicability of those programs in Indonesia with various challenges like cultural diversity, stigma and limited mental health resources. Keywords: Community-based; Community health; Intervention; Mental health; Primary care 1. Introduction Mental health is crucial to personal health and well-being. Despite the global burden of mental disorders, many primary healthcare systems predominantly focused on physical health, ignoring the critical need for mental health care [1, 2].. Mental disorders are widespread across nations and contribute significantly to suffering, reduced quality of life, and elevated mortality rate [2]. According to Indonesia-National Adolescent Mental Health Survey (I-NAMHS) 2022, 1:20 of the population experienced mental disorders, with 1 in 3 teenagers have it [3,9]. The majority of individuals with mental illness do not seek treatment due to concerns such as damaging their family’s reputation, diminishing marriage prospects, facing discrimination, social exclusion, and stigma [3]. The stigma against mental illness is one of the global issue that hurts individuals who experienced it. This stigma can manifest at various levels, including structural, societal (interpersonal stigma), and individual (internalized stigma) [4]. Mental health stigma is linked to more severe psychological issues, reduced access to mental health care, poor treatment adherence, and adverse outcomes [4]. While anti-stigma programs in high-income countries well-established and have shown positive results, there is a lack of comprehensive literature from low and middle income countries, including Indonesia [4].. One of the worst forms of discrimination caused by mental health stigma is “pasung”, the physical restraint of individuals suffering from mental World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4076 disorders [5]. The National Basic Health Research documented 1,655 cases of pasung against people with mental disorder in Indonesia [6]. The other challenges to improved mental health among worldwide stigma is the lack of mental health professionals. The ratio of psychiatrists in Indonesia is 1:200,000 population, that each one of psychiatrist must serve 200,000 people [7]. This ratio is inadequate based on WHO standard that requires 1:30,000 for an ideal ratio of psychiatrists to a population [1]. However, WHO estimates that one in every eight individuals worldwide is suffered with mental illness [1]. In this situation, Integrating mental health into primary healthcare is more significant in resolving the gap between resources and needs, to reduce stigma and to improve better mental health outcomes. Primary healthcare not associated with any specific health condition, thus the fear of being stigmatized or marginalized from the community is reduced, making this primary level more acceptable and accessible for most patients and their families [2]. Furthermore, because primary healthcare are in or near people’s communities, many indirect health expenditures associated with seeking care further afield (e.g. transportation to facilities located in urban areas, loss of productivity related to the time spent in accompanying the patient to hospital, etc) are avoided, making primary healthcare the most affordable option both for patients, the community and the country [2]. As the first level of contact of patients, General practitioners playing an essential role in early prevention and identification, the prompt interventions, and maintain open communication and normalizing mental health discussions even in someone with physical health problem only [2]. Indeed, general practitioner in the unique position of providing care throughout people’s life cycle, from birth until elderly [2]. Not only being care providers who treat individuals personal health, but also general practitioners being a community leader, according to the 5-star doctors by WHO. In this case, general practitioner becomes the decision maker to provide more comprehensive and applicable of community-based solutions to deal with the stigma and the limited mental health professionals in Indonesia. The tasksharing approach from specialists to primary care and community health workers, has been increasingly implemented in many countries over the past decade [8]. Therefore, to bridge the gap in the existing literature, current review aims to highlight the characteristics of community-based program to improve mental health in primary care settings and their communities. Additionally, we intend to emphasize crucial aspects of each programs, including their procedure and the most effective components of those interventions based on their mental health outcome. 2. Material and methods The design of this study is a literature review, included several journals, articles, and research findings published in electronic databases such as PubMed, ScienceDirect, Cochrane Library, and Google Scholar. Five keywords were combined in order to found relevant literature: “Community-based” OR “Community health” AND “mental health” OR “mental illness” AND “intervention”. Data collection was conducted on February until March, 2025. The Literature filtered using PRISMA format (Preferred Reporting Items for Systematic Reviews and Meta-analyses) and 50 articles were obtained. Screening based on duplication or similarity of articles, and eligibility based on the title, abstract, and free full text; there are 30 remaining articles. Furthermore, articles that not have enough data and overly specific to a minor particular population were excluded. The inclusion criteria were articles or journals relevant to the research topic, available in free full text, written in English, and published within the last five years (2020–2025). After filtering by inclusion and exclusion criteria, 16 articles were met the requirements. 3. Results and discussion Although mental health services continue to expand, the prevalence of depression and anxiety disorders remains increasing [2]. The findings of this review are discussed narratively below. Mental health and Psychosocial support intervention can described under three ways: 1) Mental Health Program, 2) Mental Health Tools, and 3) Combined Intervention: Program and Tools. Besides the program, the tools or instrument can be a supporting factor for clinicians to improve mental health through a community approach. 3.1. Mental Health Program Mental Health and Psychosocial Support (MHPSS) encompasses a comprehensive range of strategies and interventions aimed not only at treating mental disorders but also at preventing the development of poor mental health (e.g., by strengthening coping mechanisms and social support) and promoting overall psychological and social well-being (e.g., through family support, community engagement, and recreational activities) for individuals, families, and communities [10]. The most effective MHPSS strategies include fast and flexible community-based interventions, psychosocial support integrated with other health response systems, involvement of vulnerable groups and the use of lived experiences, community-based approaches such as healing dialogues and peer support to increase social cohesion and World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4077 reduce stigma, and technology-based interventions (e.g., hotlines, online counseling) [11]. They were very effective but had limitations in areas with low access to technology. MHPSS best practices are not solely about delivering mental health interventions; they also involve broader approaches to how we connect with and assist people facing crisis. MHPSS should be systematically integrated into clinical services, public health initiatives, and social welfare responses, including programs that promote financial security [12,13]. Besides in normal state, MHPSS should be institutionalized as a critical clinical and frontline capacity within epidemic preparedness frameworks too. Even though epidemics are uncommon occurrences, some aspects of them can be predicted. The necessity of understanding mental health, psychological first aid, bereavement counseling, and social support should not come as a surprise to physicians, nurses, clinicians, public health specialists, and community health workers. In fact, these topics should ideally be incorporated into the majority of public health models [14]. The COVID19 pandemic 5 years ago, along with other public health emergencies, demonstrated the crucial role of strong interpersonal and community networks in ensuring effective responses [15]. Trained peers from affected populations can build trust and diminish stigma by providing culturally sensitive mental health support [11,33]. In addition, the digital tools must be addressed to ensure technology-based services are widely accessible, even in remote areas [11]. Besides the programs that focused on patient with mental disorder, the intervention should be targeted to clinician, other health workers at the community level and all level of stakeholders. It can be training or workshop to increase the capacity of them to provide psychosocial support together during normal condition, health emergencies and prepare for unexpected disease outbreaks in the future. Some of intervention programs to improved mental health outcome are described below: 3.1.1. Mindfulness-Based Program Mindfulness-Based Programs (MBPs) have become a popular method for mental health prevention and used in various institutions such as workplaces and schools [16]. This led to the development of three Mindfulness-Based Programs, each aimed at alleviating depression, anxiety, or psychological distress within targeted populations. These approaches have been widely adopted in both physical health and mental health contexts. A notable example is Mindfulness-Based Stress Reduction (MBSR), an intensive eight-week program focused on mindfulness meditation training. MBSR was created in 1979 to help reduce stress, emotional distress like anxiety and depression, and the pain that often comes with chronic illnesses [17,18]. Derived from MBSR, Mindfulness-Based Cognitive Therapy (MBCT) is an eight-week, evidence-based program that integrates Cognitive Behavioral Therapy (CBT) techniques for treating depression with mindfulness meditation practices. Originally, MBCT developed to prevent recurrent depression, but it has been adapted for various range of other mental disorders too [18-20]. Mindfulness-Based Relapse Prevention (MBRP) is a program that blends mindfulness meditation with techniques from cognitive behavioral therapy to help prevent relapse. It's designed to help individuals manage negative emotions, cravings, and prevent substance use relapse [18,21]. Many studies have shown that MBPs can reduce stress and anxiety, but there is a significant variation in their effectiveness. The study of Galante et al [16] described the effects of MBPs and its individual factors such as baseline stress level, gender, age, and education influence the effectiveness of MBPs in non-clinical settings. The analysis used a random-effects, two-stage IPD meta-analysis approach with a primary focus on the impact of MBPs on psychological distress within 1 to 6 months after the intervention. The study showed that MBPs reduced psychological distress with minor to moderate effects. No evidence was found that such variables as gender, age, education level, or level of dispositional mindfulness modify the effects of MBPs on psychological distress. MBPs did not demonstrate significant superiority over other active interventions such as physical exercise or stress management programs. MBPs persisted up to 6 months after the intervention, but there was insufficient data to assess long-term impact beyond 6 months. Therefore, more research is needed to understand the factors that influence the effectiveness of MBPs at the individual level and explore ways to increase their impact in actual practice [16]. Furthermore, one of mindfulness-based program is mindfulness-based Stress Reduction (MBSR). According to the findings of the Sercekman, 2024 study [22], MBSR programs seem to be most successful at lowering stress levels soon after they are finished. Participants reported immediate benefits in stress reduction and increased consciousness. They described an increased relaxation and enhanced capacity to handle with the stressors they face on daily basis. The program has equipped them with effective stress management tools and strategies, resulting in an overall improved mental wellbeing. These MBSR programs were researched by 8 key themes on either meditation or yoga routinity. A year after completing the program, participants continued to experience positive effects on their inner calm, coping mechanisms, and interpersonal relationships. Three years later, the long-term impact was evident in the adoption of a mindful lifestyle, enhanced compassion, and sustained personal development [22]. World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4078 3.1.2. Family-Based Intervention Children of mentally ill parents have a three to seven times higher risk of developing mental disorders compared to the general population. The children’s mental health problems along with the risk and protective factors associated with the parental disorder can be described on multiple levels, such as the child, parental, family, and society level [23]. Risk factors on the parental level are the specific psychiatric diagnosis, inappropriate coping strategies and poor emotional availability. Family-related risk factors include violence, the lack of communications, and social isolation. At the child level, risk factors include the child’s temperament, cognitive and social abilities, and the phenomenon of parentification. From a psychosocial perspective, insufficient social support and the absence of attachment figures outside the family are also significant risks to the child’s development. Conversely, a range of protective factors have been identified, including positive relationships both within and outside the family, effective individual and family coping strategies, and supportive family dynamics [23, 24]. The systematic review from Bosque et al., 2023 [25] described that 43 of the 64 family or parenting interventions had positive and effective results for the mental health of children and adolescents 0-24 years. Some successful strategies involve non-specialist facilitators (an effective and sustainable strategy, especially in a country with limited mental health professionals), involving fathers in the program, and an integrated or multi-sector service approach. Most interventions use CBT, family systems theory, and social-ecological approaches to influence parent-child relationships and the family environment. Integrating mental health interventions with general health and social services is the key to sustainability and effectiveness [25]. For family-based intervention, Clinicians and psychologists must consider family background in diagnosis and intervention. Parent's mental health needs to be evaluated for every child with signs and symptoms of mental disorders [26]. Parents who experience Adverse Childhood Experiences (ACEs) have a higher risk of having children with mental health problems. Adverse Childhood Experiences are negative experiences in childhood, such as domestic violence, abuse, or family dysfunction, that can hurt a person's mental and physical health well into adulthood. A cross-sectional quantitative study by Buchanan G.J.R. et al., 2023 [26] assessed the parental ACEs, parental mental health (Kessler-6, GAD-7, and Brief Resilience Scale, parenting style (Authoritarian, authoritative, and permissive), and child mental health (with the Strengths and Difficulties Questionnaire / SDQ). The study concluded that parental ACEs have a direct impact on children's mental health problems (β = 0.189, p < 0.001). The higher the parent's ACEs, the worse the child's mental health. However, this impact is entirely mediated by parental mental health and parenting patterns. Parents' ACEs also hurt their mental health. Poor parental mental health leads to poor parenting patterns, which hurts children's mental health. If the parents have good mental health and positive parenting styles, the impact of ACEs on children can be significantly reduced. This can stop the cycle of intergenerational transmission of ACEs. One of the factors that can reduce the negative impact of ACEs on children is the stable mental health of parents, thereby forming children's psychological resilience. Positive parenting that is loving and supportive can also reduce ACEs. Parenting patterns can be trained with a Parenting education program that strengthens parenting skills. The final supporting factor is social and community support, such as parent support groups, family therapy services, and mental health education in schools [26]. 3.1.3. Emotional Resilience Skills Training Public Safety Personnel (PSP) Public Safety Personnel (PSP) such as police, firefighters, paramedics, and communications staff often exposed to psychologically traumatic events, which can lead to post-traumatic stress disorder (PTSD) and post-traumatic stress injury (PTSI). Carleton’s research [27] has evaluated the effectiveness of Emotional Resilience Skills Training (ERST) in reducing symptoms of mental health disorders among PSPs. ERST is designed to increase emotional awareness and emotional regulation skills to reduce the impact of PTSI. The study design was a 16-month longitudinal study with 119 PSPs. Participants with active psychosis, high risk of suicide, or severe alcohol/drug dependence were excluded. The intervention was conducted as Unified Protocol-based ERST training in 13 weeks through group sessions lasting 1 hour/week. The process was assessed at three stages: (pre-training), (post-training), and (1-year follow-up). Measurement with validated questionnaires such as the PTSD Checklist for DSM-5 (PCL-5), GAD-7, (PHQ-9), and others. From this study, there was a significant reduction in symptoms of PTSD, depression (MDD), anxiety (GAD), and social anxiety disorder (SAD) from before to after training. This reduction remained visible at follow-up 1 year after intervention. Organizational support influences the success rate of interventions, with sectors that devote paid time to training showing better results. Further research needs to explore moderating factors such as organizational culture and individual influence on ERST effectiveness. [27] World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4079 Prospective University Students Students in modern higher education face high academic and emotional burdens, including complex curriculum demands, long study hours, and pressure to succeed. This requires strong emotional resilience to adapt, complete their studies well, and maintain their mental health. The study by Moroz, 2021 [28] analyzed the impact of emotional overload with a study to how students improve emotional resilience. Emotional resilience helps students to remain calm when facing difficulties, absorb material efficiently, deal with criticism constructively, and make self-corrections in a timely manner. The main components of emotional resilience include: positive response to criticism, ability to adapt to exam pressure, ability to find and apply information, ability to develop learning strategies and deal with failure, social skills, including communication and building relationships. Students with high emotional resilience are more resistant to mental fatigue and burnout, and are better able to develop intrinsic motivation and focus on academic and professional success. Inhibiting factors include the lack of psychological services in higher education institutions, minimal attention to students' psychosocial needs, and uneven interpersonal competence. The study concluded that Emotional resilience is an important element in maintaining students' mental health and academic success [28]. 3.1.4. SME-ZTEs program Sun Y et al, 2024 [29] provided other effective interventions for mental well-being using the Sharing, Mind, Enjoyment (SME) and Zero-time Exercises (ZTEx) approach. The research discussed an intervention in primary care to improve physical activity and mental well-being in Hong Kong. This intervention used a Sharing method (Encourage the involvement of family and friends in physical activity, Mind (Emphasizing positive emotions and mindfulness during activities), and Enjoyment (Assess engagement and enjoyment in activities), as well as ZTEx (Light exercises that can be done at any time without equipment, such as simple stretches while watching TV or waiting for transportation). The intervention consisted of two sessions of 2 hours each. The control group received social activities unrelated to SME or AF, such as table games and garden tours. [29] The main results described significant improvements at 3 months post-intervention in the group of SME engagement compared to the control group. The huge impact also occurred in perceived personal health at 1 month. About the acceptance and satisfaction, 97% of participants disposed to share their ZTEx experience with others. Many participants reported improved family relationships and decreased stress through participation in activities. Some participants suggested extending the duration of the program and adding follow-up sessions to maintain positive effects. Community collaborators suggested wider distribution at other service centers. [29] 3.1.5. School-based mental health literacy for child and adolescent Adolescent is one of the most vulnerable mental health populations, with the main obstacle is low levels of mental health literacy among educators, parents, and teenagers themselves. The program "Go-To Educator" was developed to increase the capacity of teaching staff in Early identification of adolescents at risk of mental health disorders, facilitate more effective referrals system and Reducing the stigma at school environment. The intervention was a "Go-To Educator" program in the form of 6 hours of intensive training for school staff (teachers, counselors, and support staff) [30]. Baxter’s research [30] concluded that School-based mental health literacy training improves the frequency, quality, and effectiveness of referrals to mental health services. The students' age is younger, indicating that the problem was identified early. More students from single-parent families received referrals, indicating increased sensitivity to socioeconomic factors. Decreased referrals due to suicide risk suggest that intervention is provided early before the condition worsens. Students referred from schools who have been trained have a higher level of case severity, including more comorbid diagnoses. Upon discharge from mental health services, students who receive treatment significantly improve their condition. Educators have an essential role in the early detection of mental disorders. This program strengthens the link between schools and mental health services, ensuring that students who need help. This collaboration is urgently needed to improve overall adolescent mental health. [30] 3.2. Mental Health Tools: Chatbot AI Nowadays, AI-based chatbot used increasingly in mental health interventions. The systematic review from Harris et al., 2023 [31] evaluated existing evidence of chatbot AI based on the 31 articles that were eligible for analysis, published between 2010-2023 in peer-reviewed journals. It described the increasing factors for chatbot engagement such as automatic reminders and shorter session times. The average interaction varies from a few minutes to weeks. It explained more frequent interactions are associated with better psychological outcomes, especially for anxiety and mild-moderate depression. Technical issues and lack of personalization of content were the main reasons for low engagement in several studies. Most users have a positive attitude towards chatbots due to the nature of chatbots that are easy to access, responsive, and able to provide non-judgmental emotional support. The main factors influencing it World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4080 are the chatbot's empathetic personality, ease of access, and flexibility of use. However, chatbots also have limitations, specifically in understanding complex conversations, repetitive responses, and technical discomfort. Age and level of digital literacy also influence perceptions of chatbots, with older people tend to be more skeptical. [31] Cognitive Behavioral Therapy (CBT)-based chatbots are effective in reducing depressive symptoms, especially in nonclinical and mild clinical populations. Some studies showed significant reductions in anxiety disorders, while others showed minimal improvements or no differences compared to control groups. Chatbots have also shown positive results on insomnia, eating disorders, and ADHD symptoms, although the effects vary depending on the chatbot design and target population. The effectiveness of chatbots varies depending on factors such as the type of intervention, technological features, and user demographics. Larger studies are needed for further validation and development. In the future, chatbots are expected to be able to integrate with conventional mental health services. [31] 3.3. Combined intervention: mental health program and assessment tools The research by Mukherjee A. et al. 2022 [32] studied on SMART Mental Health, a combined intervention of a community-based stigma reduction campaign and a technology-based approach with an Electronic Decision Support System (EDSS) for primary health workers. The study used mixed methods (quantitative & qualitative) to evaluate 144 primary health centers (PHC), six intervention groups and two control group. The first intervention is Anti-Stigma Campaign, which is community-based, with audiovisual and printed materials to raise awareness about mental health and reduce stigma. In the next step, Community health workers (ASHAs - Accredited Social Health Activists) are trained to use EDSS. EDSS helped in screening, diagnosis, referral, and management of CMDs. This intervention also used a TaskSharing approach that after initial digital screening (with PHQ-9 for depression, GAD-7 for anxiety), High-risk patients will be referred to a doctor at the primary health center. The fourth component is the reminder and Priority System. ASHAs use a color-based algorithm (red-yellow-green) to identify priority patients who require immediate follow-up. [32] Success is measured by adopting the Medical Research Council (MRC) Framework and the RE-AIM Framework, which includes five components. First, Reach, namely how wide the coverage of campaigns and services is. Second, Effectiveness: Do interventions increase access and reduce mental health burden. Then, about Adoption: The extent to which ASHAs and doctors accept and use this technology. Implementation: Barriers and supporting factors in implementation. The final component, Maintenance, is the potential for post-trial sustainability of the intervention. The implementation barriers include technological infrastructure, such as problems with internet connectivity and electricity, which hinder the optimal use of EDSS. Besides that, the excessive workload of ASHAs lead to their needs of motivation influenced by financial incentives and community support. Mental health stigma is also an obstacle, where there is community resistance to mental health services. It was found that men are more reluctant to seek care than women. Despite facing various challenges, there still supporting factors such as involvement of village and religious leaders, to increase community acceptance. Community-based educational sessions increase community participation, and mHealth helps reduce the long time and distances that patients needed to reach health facilities. Community-based screening also allows early detection of mental disorders. [32] 4. Conclusion These review concluded that community-based approach in primary care and their communities can be a pragmatic solution and practical approach to prevent and treat the mental disorders, also to improve access mental health services in Low-Middle Income Countries, including Indonesia. Community-based intervention for mental health could be implemented in three ways: programs, tools, and the combination both of them. Program interventions included MHPSS, MBP, family interventions, school based training, and emotional resilience training. For the supporting factors to mental health care, the tools of chatbot AI is one of choice. Both of programs and tools could be combined to make better mental health outcome, such as SMART Mental Health program. Multi-modal intervention and multi-sectoral coordination are needed to increase the quality and quantity of community-based mental health program, either in primary care or advance health facilities, to make these programs widely implemented on any level of age, from birth, adolescent, parents and elderly with or without physical comorbid disease. While community-based screening is effective, stigma and structural barriers remain significant challenges in implementing mental health services. Community-based strategies to reduce stigma should be strengthened to increase help-seeking people with mental health disorders. These interventions should be supported by adequate training for primary and public health workers, a strong supervision system by each level of stakeholders, and the development of policies that integrate advanced mental health services with primary health services. Although some of those interventions have been implemented in Indonesia, research about the outcomes, the cultural adjustment for increasing World Journal of Advanced Research and Reviews, 2025, 26(01), 4075-4083 4081 their applicability, and the strategies to resolve specific mental health challenges is required in the future. Hopefully the effective program can be sustainable and well-established to accomplish problem of stigma, high prevalence mental illness and limited mental health professionals in Indonesia Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. 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