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Busting the myth that depression doesn’t affect people in poor countries (Guardian)

12 May 2019


The Guardian title: Busting the myth that depression doesn’t affect people in poor countries

Guardian subtitle: For decades, many psychiatrists believed depression was a uniquely western phenomenon. But in the last few years, a new movement has turned this thinking on its head.

Published on: 30 April 2019

When Vikram Patel first began to study mental health, he believed depression only existed in rich nations. But today, he is the single most influential figure in the growing global movement to treat mental illness in poor countries, especially the most common disorder, depression.

In 1993, Patel, who was born in Mumbai, finished his training as a psychiatrist in London and moved with his wife to Harare, the capital of Zimbabwe, to begin a two-year research fellowship at the national university. His purpose was to find evidence for the view, then widespread among psychiatrists, that what looked like depression in poor countries was actually a response to deprivation and injustice – conditions stemming from colonisation. The remedy in such cases, he believed, was not psychotherapy, but social justice.

Patel began his work by holding focus-group interviews with traditional healers and others who cared for patients with mental illness, and then by interviewing patients. He asked them what mental illness was, what caused it, and how to treat it. The most common illness had a name: kufungisisa, a word in Shona, the local language, which means excessive worry about a problem. Many of the healers said kufungisisa was not an illness, but a reaction to the stresses of life, such as poverty or illness. Aha! Patel thought. It was as he expected: in Zimbabwe, mental suffering was being caused by social injustice.

But when Patel asked patients how kufungisisa felt, the answers were familiar. No matter what they called it, no matter what they held to be the reason or the cure, they cited hopelessness, exhaustion, inability to confront their problems and a lack of interest in life – classic signs of depression. “They were identifying the same symptoms as people I would treat in a clinic in south London,” Patel said.

Far from exposing depression as a uniquely western phenomenon, Patel’s research in Zimbabwe led him to conclude that depression is a fundamental human experience. “The basic nature of emotional pain is no different than physical pain,” he said. “The way they seek help may be different, but human beings feel it in the same way.”

While Patel was in Zimbabwe, the World Bank in Washington was conducting a landmark project that would transform global health. For the first time, data was being used to make decisions about preventing and treating illnesses around the world. In order to know how best to allocate international aid, bank officials decided they needed to know what humans suffer from. What kills us? Sickens us? Causes us to live less than fully? Analysing data that had been gathered from around the world three years earlier, researchers published a study called The Global Burden of Disease, 1990. (Such mapping now happens continuously, involving thousands of researchers.)

The results shocked doctors and policymakers. Earlier such projects had tracked only deaths, not disease. While mental illness is a factor in many deaths, it is almost never listed on death certificates, so it barely even registered in previous reports. Now, for the first time, researchers went beyond deaths to examine the global causes of illness and disability. They found that the single largest cause of disability worldwide was mental disorders – largely, the common illnesses of depression and anxiety. They caused a seventh of all the disability in the world. In the poorest countries as well as the richest, and at every socioeconomic level in between, mental disorders were the greatest thief of productive life.

The consequences of this were catastrophic. Patients in south London had a shot at seeing any number of psychologists or psychiatrists. But the treatment typically given to sufferers of depression in wealthier countries was completely out of reach for hundreds of millions of people who needed it. Poor countries spent virtually no money on mental health.

“I was astonished to find that there were just 10 psychiatrists in Zimbabwe,” said Patel, who is now Pershing Square professor of global health at Harvard Medical school. “Eight of them were in Harare. And of the 10, eight were foreigners like me.” Those psychiatrists spent their time treating the few patients wealthy enough to pay. The situation was similar in other poor countries. In 2005, the World Health Organization reported that a number of countries – including Afghanistan, Rwanda, Chad, Eritrea and Liberia – had just one or two psychiatrists in the whole country.

Training the tens of thousands of traditional mental health professionals that countries such as Afghanistan and Zimbabwe needed was impossible, Patel feared. But there was a more radical solution.

For most of the 20th century, the view that “mental health” was exclusively a problem of the wealthier west was widely held by doctors, mental health professionals and cultural theorists. JC Carothers, a psychiatrist and consultant to the WHO, represented one typical branch of this belief. In 1953, he published an influential paper on the “African mind”, in which he argued that the continent’s inhabitants lacked the psychological development and sense of personal responsibility necessary to experience depression.

Even by the late 1990s, versions of this thinking survived. There was a heated debate going on in the US about whether the triggers for depression in wealthier countries could possibly have the same effect among the world’s poor, recalled Melanie Abas, a reader in global mental health at the Institute of Psychiatry, Psychology & Neuroscience at King’s College London. Abas characterised the sceptics’ position as: “If your baby died and you had seven already, you didn’t experience it in the same way.”

Curiously, many people with leftist views arrived at the same dismissal of the need for mental health care, although via different routes. Critics of colonialism argued that calling what looked like depression an illness needing treatment was an act of western cultural hegemony: it medicalised experiences that were not considered illnesses and were dealt with perfectly well by the local culture. Others believed that the more communal nature of society and the stronger family ties in poor countries inoculated people against depression, which was linked to the loneliness, stress and materialistic culture of western life. Still others acknowledged the existence of depression, but argued that treating it was a luxury: surely people with no food or shelter have more important things to worry about. The implication of all of these views was that people in poor countries didn’t need the sort of counselling often prescribed for sufferers of depression in the west.

We now know that they need it desperately. Abas has spent much of her career in Zimbabwe; in the 1990s, she treated patients at Harare Psychiatric hospital and, even before Patel did, documented extensive depression. Some of her research looked at the relationship between depression and life’s tragedies. She found that severe events, such as the death of a child, were as likely to cause depression in a poor woman in Harare as they were in an affluent Londoner. “But women in Zimbabwe faced many more such events in a year,” Abas said.

Before working in Zimbabwe, Patel had believed that depression was simply an appropriate response to adversity. Your husband drinks and beats you. Your crop failed. Your family is homeless. Your children are hungry. Of course you are sad. You and your family need treatment for alcoholism, fertiliser subsidies, stable employment. What does psychotherapy have to do with it?

Sadness is an appropriate response to adversity. But depression is not the same. (While the poor are more likely to be depressed, the vast majority of the poor are not, so poverty alone does not lead to depression.) Depression is a fog of negative thoughts that debilitate and paralyse the sufferer so she cannot respond to terrible events. “The question is how quickly you are able to get past distressing emotions so they don’t themselves acquire an independent effect on your life, and become a problem in themselves,” Patel said. “If your negative thoughts are coming in the way of solving a problem, if your sleeplessness affects work – that is compounding whatever triggered it.”

The disability caused by depression is actually much wider-ranging than the data from World Bank’s 1993 report suggested, because the numbers only measured depression’s direct effect on health. But depression also takes a huge indirect toll. It makes other diseases much worse. People who are depressed are more likely to get other illnesses, and less likely to be treated successfully. Depressed patients, for example, do not take their HIV medicine, and are less able to support their families or take care of others: babies of depressed mothers often aren’t well nurtured and fail to thrive.

Far from a luxury, treating depression is often a necessary first step towards solving other problems. Addressing poverty sometimes brings about a small improvement in people’s mental health, said Kari Frame, the programme director at Strong Minds, an organisation that helps depressed women in Uganda treat their illness by forming self-help groups. But addressing mental health very often leads to a big decrease in poverty.

In 2007, Patel and several other experts published a series of articles on global mental health that inaugurated a profound change in approaches to treatment worlwide. The series, in the prominent British medical journal The Lancet, warned that mental health disorders are neglected and stigmatised, and pointed to the critical shortage in mental health care. This was – and still is – true in rich countries: more than half of Americans who need treatment don’t get it, for example. But in poor countries, virtually no one was getting the care they needed.

In low- and low-middle-income countries, budgets for mental health treatment were less than 3% of an already meagre health provision. Most of that went to institutions housing people with severe mental illnesses such as schizophrenia. Such institutions were almost always understaffed, manned by poorly trained workers and dedicated to containing rather than treating their patients, using methods that often amounted to torture. Depression and anxiety got no treatment at all.

The Lancet articles proposed a massive expansion of mental health treatment worldwide. Richard Horton, the Lancet’s editor, urged people to join a new social movement to provide effective care for the world’s neediest populations. “The time to act is now,” the authors wrote.

Psychiatrists and psychologists were costly to train and pay. And how would poor countries keep them? Medical professionals often studied at their government’s expense – and then emigrated, to practise in North America or Europe.

The Lancet writers noted that one of the most important trends in global health was shifting tasks from professionals to lay people. Community health workers, who offer basic health information and services in the communities where they live, were not new – China’s “barefoot doctors” programme of the late 1960s was one example – but they had fallen out of favour. In the early 2000s, however, there was a resurgence of interest. Developing countries were training and paying (albeit poorly) millions of community health workers to teach nutrition, weigh babies, treat pneumonia and organise campaigns to clean up standing water.

Lay health workers didn’t deal with depression, but there was no reason they couldn’t, Patel and his colleagues argued. For all the suffering it causes, it turns out that diagnosing and treating many episodes of depression is actually not that complex.

To see the role that a lay person could play in addressing depression, I visited Santa Cruz high school in the Indian state of Goa. In September 2016, Mamta Verma set up a table and two plastic chairs in a crammed storeroom, and installed herself there on Monday and Wednesday mornings. For the first time, the school could offer its students counselling.

Verma exudes gentleness and warmth. She had studied psychology in college, and was getting her master’s degree through distance learning. But she was not a psychologist yet – and that was the whole point. If she were, she wouldn’t be working in a storeroom at a high school. She was testing a new programme created by Sangath, a Goa-based organisation founded by Patel and six colleagues in 1996.

Sangath – the name means “together” in Konkani, the official language of Goa – designs and studies ways to make mental health care as cheap and accessible as possible. When a programme works, Sangath then chips away at it to see how much it can shed without sacrificing results. If eight weeks of counselling bring success, how about six weeks? Could group therapy leaders get two weeks’ training instead of four? If someone with a high school education is leading the group, what about a community health worker with less education – or none? If the patient is a child, can his parents learn to deliver the therapy?

While I sat in her storeroom, a steady stream of students visited Verma to talk about parents who fight, classmates who bully, anger management, boy trouble, their weight, their skin, their concentration, their difficulties in Hindi or maths. Verma uses a workbook featuring Priyanka and Ajay, two fictional teenagers with typical teenage issues. Verma asked students to analyse what Priyanka and Ajay were facing and come up with solutions for them to try. Then the students applied these techniques to their own problems. This method is called problem-solving therapy.

Sangath is by far the most influential research organisation on mental health care in poor countries. It has 300 employees and fellows, and has published dozens of studies, many of which describe real breakthroughs in care. People visit from around the world to learn Sangath’s strategies for preventing or treating conditions such as postnatal depression, problem drinking, schizophrenia, depression in the elderly, stress in people with HIV and their caregivers, and teen depression and behaviour problems. All of these strategies involve lay therapists like Verma, and many use a version of the sort of problem-solving therapy she applies.

One example is Sangath’s health activity programme. The organisation trained lay people to give around eight weekly sessions of counselling to patients suffering from severe depression. The focus is helping patients stop doing things that make them feel bad – staying in bed, neglecting personal hygiene – and start doing healthy activities, such as talking to friends, engaging in hobbies or taking a walk. Counsellors also ask patients to brainstorm possible solutions to their problems, pick the best one and try it. It seems absurdly simple, but three months later, the patients who had been through just that brief programme were 64% more likely to be in remission than those that hadn’t.

Abas, the Institute for Psychiatry reader, said that although Sangath has been seminal, its approach to depression focuses too narrowly on single episodes. “Depression for most people is really a chronic illness,” she said. “I don’t think they’ve done enough to emphasise that. It’s important to get treatment when you’re really low, but if this relapses, what next?”

For most patients in wealthy countries, what’s next – or often what’s first – is an antidepressant. Abas points out that medicines are curiously absent from the global mental health movement. “It’s become very fashionable to talk about talk therapy,” she said. “A lot of people do really well with it. But some are too unwell to even start. If you are very depressed and your brain is shutting down, are you even able to talk?”

In the 12 years since Patel and his colleagues published their groundbreaking series of articles, global mental health has become a movement. When they were drafted in 2000, the UN’s millennium development goals for 2015 made no mention of mental health. Now, “mental health care for all” is a pillar of the UN sustainable development goals for 2030. Dozens of low-cost mental health care projects have sprung up around the world. Various networks, including the Mental Health Innovation Network, help them share information and ideas.

But an archipelago of small programmes is far from a global solution. China and India are trying to expand mental health care in rural areas, but it will be a long time coming. More than a decade after the articles that changed the debate on global mental health, there has been no real growth in access to treatment, in poor countries’ spending on mental health care, or in mental health care funding from wealthy countries.

There is one place, however, where mental health care has become a routine part of medical care, and that is Harare, Zimbabwe. The nation that proved to Patel that depression was universal has come up with a form of psychotherapy accessible to all – one that is effective, easy to duplicate and cheap.

When Patel taught psychiatry at Harare Central hospital in the early 1990s, Dixon Chibanda was one of his students. After graduation, the other five psychiatry students in Chibanda’s class all left Zimbabwe for richer countries. Chibanda stayed. He treated private patients to make money, but also worked in the psychiatric hospital, where much of his work consisted of prescribing medicine and trying to make sure people took it. “I got into psychiatry to connect with people and nurture the human spirit,” he told me. “But I was beginning to feel increasingly disconnected from the people I was trying to help.”

One night in 2005, Chibanda got a call from a doctor in Mutare, a city south-east of Harare. One of Chibanda’s former patients, a 24-year-old named Erica, had tried to kill herself with rat poison. Chibanda asked the doctor to tell Erica’s mother to bring her to see him as soon as possible. He heard nothing for three weeks, then one day the mother called to tell him that Erica had hanged herself from a mango tree in the family garden.

“Why didn’t you bring her to see me as we planned?” Chibanda asked.

“We didn’t have bus fare,” the mother said.

“I started to realise that psychiatry in an institution is not the way to go,” Chibanda recalled. “We have to take it to the community.”

He conducted a survey in 12 clinics around Harare, and found that the clinic with the highest rate of depression was in the slum of Mbare, where one in three people was affected. In 2006, he told the city health department he wanted to start a mental health programme there.

Neither the department nor the clinic staff were enthusiastic. “The clinic told me the nurses were too busy,” Chibanda said. “And there was no space for me to work inside the building.” So he set up a bench in the yard.

Grudgingly, the clinic lent Chibanda the services of its “Grannies” – middle-aged or older women with little education, who earn a small stipend doing community health work. The Grannies were given two weeks to learn what depression is, how to diagnose it using a simple questionnaire adapted for Zimbabwe by Patel, and how to do a form of problem-solving therapy modelled on an approach Abas had used in Harare in the early 90s.

To be able to treat large numbers of depressed or anxious people, any solution has to be cheap and easy to spread. It can’t depend on having an office or trained professionals. The goal, said Abas, was to teach people who are already working with the community how to treat depression. Grannies on a bench turned out to be perfect.

By 2015, every health clinic in Harare had a group of sturdy red wood benches in its yard, known as friendship benches, and grannies in brown uniforms who sat on them talking to patients each morning. The grannies use standard problem-solving therapy, but put it into terms people can relate to. They use Shona phrases for opening up the mind and strengthening the spirit. If patients want to pray with their granny, they pray. “We try to avoid dismissing what people believe in,” Chibanda said. “We say, pray, but in a way that encourages problem-solving: ‘God, help this person to identify which problem to focus on.’”

Israel Makwara, Harare’s chief health promotion officer, told me that the grannies made every other health programme in Harare go better. The clinics’ HIV programmes were one example. “If somebody’s frame of mind is now solid, they are likely to adhere to their medications,” Makwara said. “They’ll do a whole lot better than someone who has given up the will to live.”

At the Hatcliffe Polyclinic, in the north of Harare, very few people come to the clinic for mental health care, but the protocol is to offer everyone a questionnaire to screen them for depression. If they score high, they get an appointment on the friendship bench in the front yard.

In Zimbabwe, elders are used to simply dispensing advice, said Vongai Muchengeti, a granny at the Hatcliffe clinic. But encouraging patients to come up with their own solutions is an important part of the therapy; it teaches patients to think more critically, assess alternatives and gain confidence.

“How do you think you can resolve this?” Muchengeti kept asking one patient.

“I’ve come here for you to tell me how,” the patient replied. “You’re supposed to help me.”

“This is how I’m helping you,” Muchengeti said.

The ideas the patients do come up with – I could look for work, I could talk to my husband – might seem obvious, but they’re not to people with depression. “You have HIV, your teenage daughter is pregnant, your husband is abusive, you’re about to be evicted,” said Ruth Verhey, a German-born clinical psychologist who runs the programme with Chibanda. “That buildup leads to a sense of helplessness.”

The grannies help people overcome that. At the end of 2016, Chibanda published the results of a randomised control study in which he assigned 573 patients either to a bench or to a better version of usual care, including antidepressants when necessary. After six months, 50% of patients in the non-bench group were still depressed, while only 14% of friendship bench patients were.

Today, Zimbabwe has friendship benches at 72 health clinics in three cities. Verhey estimated that about 40,000 patients have been treated in the last two or three years, most of them women. Chibanda has also launched benches in rural areas, and one for adolescents, which will be staffed by their peers. The model is also being adapted in other places, from Malawi and Zanzibar to New York.

Verhey said people write from all over the world. “We get so many people saying: ‘I want to do this with my NGO, with my church group,’” she said. “My standard reply is that we like to work inside the health system. That way you have accessibility and sustainability.”

For all its profile, however, the programme has next to no money. Neither Chibanda nor Verhey are paid. The programme has funding for specific research projects – including, recently, a much-needed study of how grannies were actually delivering therapy. But there are no funds to spread the programme.

Even before the friendship bench programme was fully underway, Chibanda knew it also had to offer some solutions to patients’ most important problem: desperate poverty. He consulted an expert on how women in slums or villages could make money: his own grandmother, who lived in Mbare, where the programme began. She said many women make money by crocheting sleeping mats – could they crochet other things?

Verhey began collecting plastic destined for landfills, such as grocery bags and old videotapes, that could be shredded or unspooled and turned into yarn. Women visiting the benches used the yarn to crochet bags, purses, laptop cases and other items. They then sold the bags in local markets, while Verhey sold some in Zimbabwe’s high-end tourists shops and to other parents at Harare’s international school. A bag could sell for as much as $10 – more than three times the average daily income in Zimbabwe.

The crocheting project had a second purpose: treatment on the bench usually lasts for about six sessions. But the need for solidarity and companionship does not go away. Meeting to turn in their bags and get new materials gave women a reason to congregate. The programme created a support system for the women, called Circle Kubatana Tose, which means “hold hands together”. There was a circle in nearly every clinic.

I went to one circle in a small red building on the campus of the psychiatric unit at Harare Central hospital. Women came in with their latest crochet work and there was soon a heap of brightly coloured bags on the floor. They prayed, drummed, sang and shared their news. Their problems – domestic violence, alcoholic partners, HIV, hunger – were common in their neighbourhoods. But because of stigma, they were rarely discussed outside the circle. Neighbourhood life can be supportive and warm, rich with human connection. But it can also be dominated by gossip and judgment.

A woman named Tackla told me that when she was diagnosed with HIV, she was desperate to talk about it. “But I was frightened to talk to people because they might laugh at me,” she said. “And if you talk to a neighbour, they could tell everybody. So I kept it to myself.” The circle was the only place she could talk freely, she said. In her circle, she was the first to volunteer that she was infected. “When I did, another woman said she was, too. We talk to each other,” she said. “We are friends.”

The collapse of Zimbabwe’s economy is accelerating, and Verhey’s bag programme collapsed a year ago for lack of buyers. But the circles refused to fail. Women still gather at their health clinic or village well and sit and talk in a group they trust, and while they talk, they still crochet, or make shoes from rubber tyres.

Vikram Patel had gone to Zimbabwe in 1993 seeking to show that depression was a social and political condition, and that no clinical intervention was necessary. He convinced himself of the opposite: psychotherapy or medicine were all that was needed to cure it.

Now he has come halfway back around: you need both. About 80% of depressed people everywhere, Patel said, need only what he called a “hope intervention” – someone to guide them through self-help. That could be as little as a single session of counselling with a lay health worker. But it is also necessary to sit and talk to trusted friends in a circle. It is necessary to take a crochet hook and fashion old videotape into something that can allow you to feed your children.

“We have to redefine what is a psychological intervention, recognising that for many people, their psychological well-being is embedded in their social world,” Patel said. “It would be almost unreal for a psychological worker in India to say to a woman whose husband beats her: ‘That is not my concern. I’m only concerned with your negative thoughts.’” ”



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