It has the feel of a bad movie.
When the BBC goes to interview psychiatrist Dr. Egip Bolsane in his native Chad, they find a man in a small office with a small wooden desk. Dr. Bolsane speaks enthusiastically about his work, wiping sweat from his forehead (he can’t afford an air conditioner) as he talks about the challenges of practice in a country where mental illness is often confused with possession.
Dr. Bolsane has his work cut out for him: he isn’t just Chad’s most famous psychiatrist, he’s Chad’s only psychiatrist.
No doubt there are deep problems with how we handle mental illness in Canada. But with the holiday season upon us, it’s nice to reflect on what we have. And compared to much of the world, our psychiatry cup runneth over.
And, with that in mind, I’ve chosen the following as the Reading of the Week:
(Because of firewall issues, this link may not work. The article follows.)
“Health care for all must include mental health care. It’s hard to believe but both Liberia and Sierra Leone have only a single psychiatrist. The Ebola crisis has exposed these countries’ malignant neglect of their health systems. People can’t get care for diarrhea and malaria. How will these countries take care of an epidemic of depression?
“This isn’t really a medical question. We know how to treat depression. What we don’t know yet is how to make effective treatment cheap, culturally appropriate, convenient and non-stigmatizing — all needed to get treatment out to millions and millions of people. But some researchers are finding out.”
And — again with the holiday season in mind — it’s nice to reflect on the good works of others.
In this New York Times’ article, Pulitzer-prize winning writer Tina Rosenberg explores ways that psychiatrists and not-for-profits are trying to bring evidence-based therapy to impoverished parts of the world.
· Uganda. Group IPT. Model: led by high school and college graduates with 2 weeks of training, with a reported 94% free of depression at 6 months.
· Rawalpindi, Pakistan. CBT. Model: led by female community health workers with 2 days of training, incorporated into pregnancy and newborn baby visits, with a reported 97% without depression at 6 months.
· Goa, India. IPT. Model: led by people with no health background and trained for 8 weeks, which was “very successful.”
According to Vikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine and the lead of the Goa study: “The idea is to really make it go viral.”
Dr. Patel and others are looking at tapping natural social networks that have been used to address issues of childbirth. These women are trained for a few days in the classroom, then out in the field. Clever.
A health care worker and a patient in Uganda
In fact, these efforts are very clever. Consider: in the west, labour is expensive — pushing therapies like CBT out of the reach of many people because of high cost; in much of the world, labour isn’t expensive — potentially meaning that therapies could be within reach, even of the poor. So training laypeople makes financial sense.
But does it work? The results are robust. In fact, maybe they are too robust. A 94% or 97% response rates makes me think that either we should be flying my patients to Uganda or Pakistan… or that some of the people diagnosed with depression are really going through an adjustment disorder.
Dr. Patel has published his data in The Lancet, and it’s less strong than the Uganda-Pakistan data, needless to say. His model is more complicated than described in this short NYT piece — it’s collaborative care work that is built on the efforts of trained laypeople, with stepped care, and involving primary care physicians. He doesn’t boast a 94% success rate; The Lancet data, though, is statistically significant over the usual care — suggesting that involving laypeople can work.
The subject is interesting and pushes into a larger topic: that of culturally specific depression care and the use of non-health care professionals, with implications there (outside the west) but also here (in the west). In a recent review paper published in Psychological Medicine, Chowdhary et al. considered such experiments in a variety of places, including, yes, Goa, but also in the United States.
They report (over the usual care):
This much is clear: in places where the reach of psychiatry is historically minimal, innovation is occurring, and occurring on the cheap.
For more on Dr. Bolsane and his work in Chad, see
For more on Dr. Patel and his work in Goa, see
And to read a paper on the Goa work, see The Lancet paper by Patel et al.
A Depression-Fighting Strategy That Could Go Viral
December 4, 2014 8:15 pm
Fixes looks at solutions to social problems and why they work.
When Ebola ends, the people who have suffered, who have lost loved ones, will need many things. They will need ways to rebuild their livelihoods. They will need a functioning health system, which can ensure that future outbreaks do not become catastrophes. And they will need mental health care.
Depression is the most important thief of productive life for women around the world, and the second-most important for men. We sometimes imagine it is a first-world problem, but depression is just as widespread, if not more so, in poor countries, where there is a good deal more to be depressed about. And it is more debilitating, as a vast majority of sufferers have no safety net.
Health care for all must include mental health care. It’s hard to believe but both Liberia and Sierra Leone have only a single psychiatrist. The Ebola crisis has exposed these countries’ malignant neglect of their health systems. People can’t get care for diarrhea and malaria. How will these countries take care of an epidemic of depression?
This isn’t really a medical question. We know how to treat depression. What we don’t know yet is how to make effective treatment cheap, culturally appropriate, convenient and non-stigmatizing — all needed to get treatment out to millions and millions of people. But some researchers are finding out.
They are doing so despite the fact that growing attention to this issue hasn’t been accompanied by money. The U.S. National Institute of Mental Health last year provided just $24.5 million for global mental health efforts, and the Canadian government’s Grand Challenges Canada, which is said to have the largest portfolio of mental health innovation in developing countries, has spent only $28 million on them since it began in 2010.
Two years ago, I wrote about a research study in 2002 that provided group interpersonal therapy, led by college students and high school graduates with two weeks’ training, to depressed women in Ugandan villages. The treatment was so effective that six months after starting this therapy, only 6 percent of those treated still had major depression.
More recently, similar work has gone on in South Asia. In rural Rawalpindi, Pakistan, the Thinking Healthy Program taught basic cognitive behavioral therapy for only two days to female community health workers with a high school education. The trainees, called Lady Health Workers, then integrated the therapy into their regular visits with pregnant women and new mothers. (Studies often focus on women, especially new mothers, because they suffer depression more than men and their mental health is crucial to their children’s development. It allows health workers to paint the program — truthfully — as a way to help the baby, which is more socially acceptable than treating depression in the mother.) Six months later, only 3 percent of those treated were still depressed. The largest study was in Goa, India, where local people with no health background were given an eight-week course in interpersonal psychotherapy and worked with physicians to treat patients with mental health disorders. This, too, was very successful.
These studies were proof that depression could be treated in poor countries by lay people. Now these researchers are trying to figure out how to streamline these interventions to the minimum outlay of resources needed to maintain excellent results. Many models are being tried, which integrate mental health care into primary care, employ community health workers or piggyback therapy on to other kinds of services. But one very promising strategy is to rely on peers as therapists. “The idea is to really make it go viral,” said Vikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine and the leader of the Goa study.
In Rawalpindi and Goa, researchers are shifting the Thinking Healthy Program from community health workers to minimally trained peers. These projects are part of the South Asia hub of a major project financed by the N.I.M.H. to support and link global research on delivering mental health care in poor countries. The study is in its early days — results won’t come out for several years.
In both places, mental health professionals are recruiting and training local women with levels of education similar to those of the depressed mothers they will work with. The training is only a few days in the classroom and a few days in the field. Most of their work will be one-on-one, although in Pakistan the peers will bring patients to some groups.
“This is a human resource widely available in every population,” said Patel. “These are natural social networks women have traditionally used to address issues of childbirth. These are not alien ideas — that’s why we chose them.”
Atif Rahman, a professor of child psychiatry at the University of Liverpool and the designer of Thinking Healthy, said that they hoped to be able to train people using lessons on a tablet or phone someday — this is being tested elsewhere in Pakistan. Or they may train families, using the power of family networks. But for now, while the Thinking Healthy counseling is done by peers, those peers are organized, recruited, trained and supervised by more highly educated workers, including some psychologists.
In Uganda, researchers are aiming to be more viral still.
Helena Verdeli, who ran the first Uganda study, is collaborating with a new organization, Strong Minds, to use the same group interpersonal therapy to treat women with moderately severe or severe depression in the slums of Kampala. Strong Minds’ idea is to rapidly test round after round of treatment, each round cutting something off the intervention to make it cheaper or faster.
The first 26 therapy groups, which started in May, treated 244 women for 16 weeks using only four very busy facilitators — two nurses and two college graduates with degrees in community psychology. There was also a control group of 36 women.
A week after the sessions ended, 94 percent of the women no longer had depression. Oddly, the control group also improved, although by far less — 33 percent no longer were depressed. But Strong Minds’ goal of eliminating depression in 75 percent of patients was achieved earlier, in week 12.
Five weeks ago, round two started — identical treatment, except that the groups will meet for only 12 weeks. If this works just as well, subsequent rounds will make further changes. (If there is money, that is — so far, Strong Minds’ funding for 2015 falls far short of supporting all this.) Sessions could be even shorter: 10 weeks, or even eight, which interests the World Health Organization. Another way to streamline is to use Verdeli’s earlier strategy of having high school graduates with two weeks’ training replace the professionals.
The end goal is to have members themselves facilitate the groups. “Ideally, we’d get groups to diagnose, recruit and treat almost by themselves,” said Sean Mayberry, Strong Minds’ founder.
Next year the organization plans to work with selected graduates of the program, showing them how to teach it to others and diagnose depression. “We want to devolve it down to the community level. That’s the key to scale — not us maintaining and operating groups for the next 20 years,” Mayberry said. The organization is also forming partnerships with development and refugee relief groups in Uganda to help them integrate mental health care into their work.
So far, the experience of Strong Minds illustrates how desperately these groups are needed — and how difficult it might be to get them to sustain themselves without outside help.
Before they started recruiting members, the facilitators went into their target communities to meet with local leaders and introduce the concept of depression. “People tell us someone is sad, has lost interest, and cannot concentrate,” said Christine Nanyondo, who supervises the facilitators (as a high school graduate, she ran groups in Verdeli’s 2002 study). “But they say it’s because of witchcraft, or laziness. In all the villages we’ve been in, we’ve met only two women who went somewhere for counseling for their depression. Others buy pills. They think maybe they have malaria.”
Stress, of course, is overwhelming for these women, but they have little sense they should or could seek relief. Women in Africa and South Asia care for others. They do not spend valuable time taking care of themselves.
Peers cannot do everything in mental health. Patel warns that peers are valuable but must complement professionals, who are needed to diagnose and treat more serious illnesses and, in many cases, depression. It may be that the job of spreading the word, recruiting and organizing therapy groups can’t be done by peers — Strong Minds is testing this.
But peers can do a lot. The therapy groups offer confidential social support — a place for women to understand they have a disease shared by many others, and to talk about their problems without fear of gossip.
And peers can provide practical help. In their initial interviews, most of the women reported that their depression was triggered by a specific crisis. Most likely, others in the group are dealing with or have dealt with it, too.
Kristin Ssumbe, a 55-year-old small-businesswoman who was a group member, said her depression started after a diagnosis of cancer. “I could not eat, could not sleep,” she said. “I had a family to look after — five kids. I had to pay school fees and feed them — but I thought I was going to die, and when I die, who will take over?”
She stopped working and spent her days sitting at home. Her businesses collapsed.
When she started group therapy, she didn’t want to talk. “I thought people would laugh at me,” she said. “People were talking about me around the village. I hated everybody — people were backbiting me.”
After a few sessions, she opened up. “I thought everybody was against me, but I found out that I had some people who cared. I started getting new friends and talking business. I had a problem getting medicine — cancer medicine is very expensive. They comforted me and asked, ‘Why don’t you talk to your family?’ ”
She had considered this, and discarded it. “I feared to tell my family I had no money,” she said. “I thought it was too much to ask — nobody has money in the drawer for me.”
But, urged by the group, she asked — successfully. “What I was feeling was not what my family was feeling,” she said. And the medicine has worked — she is better. Such advice seems elementary, but depression paralyzes. It robs people of their ability to respond to their troubles.
The best example of true virality in a peer support group is Alcoholics Anonymous, which is run by its members. AA may already be treating depression. In a paper to be published by the journal Psychology of Addictive Behaviors, researchers at the University of New Mexico found that AA attendance was associated with relief from depression — and not simply because members are drinking less.
But AA is viral because people show up on their own. Depressed women in Kampala’s slums are unlikely to seek out an interpersonal therapy group. Strong Minds’ challenge, then, is to find and test ways to get them to do exactly this.
There is precedent: some similar therapy groups run by World Vision in Uganda continued to meet for years after the formal sessions ended. Angela Nakakto, a 60-year-old patient who said that her Strong Minds group rescued her from suicide and helped her deal with an enormous debt, still brings her group together to talk and do cash rounds — a scheme in which every woman puts in a little money every week, and the pool is given to the member who needs it the most.
And peers are natural recruiters. The women in Strong Minds’ second round of therapy sessions were almost entirely recruited by women in the first round, who brought in friends, family or acquaintances who had symptoms they now recognize as depression. Strong Minds has powerful entrenched beliefs and customs surrounding depression that it must overcome to succeed. But it also has women who can tell a friend: I got better. You can, too.
Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.” She is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.