Sunday, July 22, 2012

Treating Depression for the World's Victims of War and Disaster

What is the most burdensome disease in the world today? According to the World Health Organization, the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression.

The disease is not merely a bourgeois problem. It is especially prevalent in places that have experienced war, disaster or crushing deprivation. Yes, in many poor countries the bonds between people are much stronger than they are in wealthier, more individualistic societies, and this is a good thing for mental health.

But it can hardly counteract the fact that a lot of people have an awful lot to be depressed about. War and high rates of crime produce widespread post-traumatic stress. The constant worry that a crop failure or serious illness will throw a family into poverty is a source of extreme anxiety. Seeing your children go hungry creates paralyzing guilt.

In troubled places, depression’s impact is more severe. Most families have no cushion or safety net — they are running very hard just to stay in one place. A parent who is too depressed to work can bring a family to ruin.

Yet attention to mental health care in low-income countries has been close to zero. The conventional wisdom is that treating depression in countries where there are myriad other problems is a luxury. Besides, how could it be done? Drugs are expensive, and a vast majority of poor countries have virtually no psychiatrists or psychologists outside of private clinics.

Today, however, not only is mental health getting global attention, but mental health care is also successfully expanding. The strategy is the same one that employs nurses and clinical officers to do the work of doctors in treating AIDS in Africa and that relies on barely literate women to improve the health of their villages.

“It became very clear it was possible to train lay members of the community to do fairly specific things and do them well,” said Harry Minas, a psychiatrist who directs the Center for International Mental Health at the University of Melbourne.

Amadi was inside her hut, sitting in the semidarkness, when a local woman named Christina Nanyondo came to her door to invite her to do something that would have been unheard-of in her Ugandan village before: Join a therapy group for depression.

Amadi (a pseudonym) was 59, and had lost five of her nine children in the last 10 years, three of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden or do her mat-weaving. “All the treatment in the world won’t bring my children back,” Amadi told Nanyondo.

But at Nanyondo’s urging, she joined the group of eight women. The sessions, part of a study designed to test whether interpersonal psychotherapy could work in 30 rural villages, began with Nanyondo as facilitator. They met weekly, first spending their time describing their problems, later comforting one another and suggesting steps to take. Together they held a formal mourning service at the graves of their loved ones.

All the women, including Amadi, got better. Eighteen weeks after starting therapy, Amadi had no more symptoms of depression. Her husband said she had been a fierce, strong, loving woman. Now she was again.

Amadi’s story was described by one of the organizers of the study, Lena Verdeli, an assistant professor of clinical psychology and director of the Global Mental Health Lab at Columbia University’s Teachers College. By accident, the study did something unexpected and significant.

The researchers had intended for the groups to be led by trained health workers from the Christian humanitarian group World Vision. “But they couldn’t spare any,” Verdeli said. “They said, ‘don’t worry, we’re going to hire their younger brothers and sisters.’” Some, including Nanyondo, had only a high school degree. They received only two weeks of training.

Yet the treatment was overwhelmingly successful: Six months after beginning therapy, only 6.5 percent of the people treated still had major depression. It was proof that effective therapy for depression could be delivered in the poorest of settings, by lay people.

Other studies have confirmed this. In Goa, India, young local women took an eight-week course in interpersonal psychotherapy and proved very effective at treating depression. Even more impressive was a project in Pakistan. It gave community health workers — women who had completed secondary school — a two-day course in listening and basic cognitive behavioral therapy.

They were shown how to integrate these things into their regular visits to pregnant women and new mothers. Even that brief training made a huge difference: A year later, only a quarter of their depressed patients were still depressed, compared with 59 percent of the control group.

Health systems are now starting to use task shifting for mental health. At the end of June, for example, India announced a new national mental health care plan, which will train a cadre of community mental health workers.

Several places that have expanded mental health care have done it by taking advantage of crisis. Sri Lanka and Indonesia’s province of Aceh both had long-running civil conflicts that traumatized much of the population. But they started getting access to treatment for that trauma only after the tsunami of 2004. War had damaged far more people, but it was the tsunami that brought in money for mental health care.

In the past, perhaps, international aid might have been used to enable doctors from outside to treat patients for a few months. Now, instead, most of the money was employed to build mental health care into the government’s health system, using task shifting. The visiting psychologists and psychiatrists were there to train locals.

Lay people in Aceh learned to work with patients and their families in the community. Nurses were trained in psychotherapy. Doctors learned how to treat patients with a limited number of psychiatric drugs.

This time nearly 85 percent of health centers in Aceh have some staff with mental health training, Miller wrote. Sri Lanka, which has a similar system, is now expanding it beyond zones hit by the tsunami.

If depression can paralyze people who have everything, how could we ever have thought that it didn’t affect people who have nothing? “There’s an assumption that after you bury five of your kids you get used to it, and it doesn’t hurt as much,” Verdeli said. “People don’t realize you don’t get used to it. You just give up.”

The New York Times

Tina Rosenberg is the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World.”

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