Originally published by Foreign Affairs on April 21, 2015.
By: Catherine Thomas and Johannes Haushofer
Depression, which the World Health Organization calls “the leading cause of disability worldwide,” affects 350
million, but it strikes the poor the hardest. A meta-analysis of 56 epidemiologic studies by researchers at the
Catholic University of Louvain in Belgium found that those who fell in the lowest socioeconomic group within any
given population were several times more likely to suffer from major depression than those in the highest group. In
developing countries, depression and mental illness are exacerbated by conflict, extreme poverty, and other
calamities. For example, in Uganda, a country disproportionately affected by civil unrest and the HIV epidemic,
rates of depression hover between 21 percent and 25 percent. Globally, depression affects 10 percent of the
Sadly, the vast majority of the mentally ill do not receive any care—over 80 percent are left untreated in
developing countries. There are two problems when it comes to treatment. First, mental illness manifests itself
differently across cultures, which means that addressing it will require a different methodology in Kampala, Uganda,
from what is practiced in, say, Princeton, New Jersey. The second looming issue is the extreme shortage of mental
health professionals in developing countries. High-income countries have 10.5 psychiatrists per 100,000 people;
the average among low-income countries is 0.06 . Rwanda, for example, has only six psychiatrists throughout
the entire country (for a population of almost 12 million), and Ghana has only 12 nationwide (for a population of
almost 26 million). Even fewer psychiatrists work in the public sector or in rural areas.
The good news is that in recent years, mental health researchers around the world have begun to design care
packages that tackle these two challenges in delivering treatment in developing countries: making remedies culturally
appropriate and operating in low-resource environments.
Just as doctors craft a personalized treatment plan for each of their patients, mental health researchers are now
tailoring their screening tools and evidence-based therapies to specific cultural contexts and socioeconomic risk
factors. For instance, a program called the Friendship Bench in Zimbabwe treats Kufungisisa, which means “thinking
too much” in the Shona language, a condition that in the West would be considered depression. Through six sessions
of therapy, health workers help patients generate solutions to their psychosocial and financial problems, develop
coping skills to reduce anxiety, and engage in activities that will assist them in recovering.
Those suffering from Kufungisisa differ from patients in the West in that they rarely present emotional symptoms but
rather exhibit somatic ones (such as fatigue and headache) and often attribute their symptoms to supernatural factors
as well as social and economic stressors. Such cultural concepts have been incorporated into a symptom
questionnaire for patients in Zimbabwe, enabling health practitioners to more accurately detect depression in clinical
settings. For example, between 2002 and 2003, a team of health-care providers and interdisciplinary researchers from
Columbia University and Johns Hopkins University conducted extensive ethnographic research in Uganda on the
manifestations of depressive symptoms. They sought to build a foundation for adapting and testing evidence-based
therapy for mental health and conducted one of the first treatment trials in a developing country. They found that
depressive symptoms were described locally as y’okwetchawa and okwekubaziga, akin to “self-loathing” and “selfpity”
in the local language of Luganda.
Their research revealed that particular triggers of depression in these communities involved interpersonal problems,
especially ones related to the HIV epidemic—losing loved ones to AIDS, losing social support from friends and
family, and losing a job. Patients noted that the most problematic consequences of depressive symptoms revolved
around their inability to engage with their community and in economic activities, as well as care for others. The
research team decided accordingly to adapt and implement therapy that addresses interpersonal issues, as opposed to
cognitive behavioral therapy, which focuses on altering negative thinking and habits. In this way, health-care
workers could directly address the local understandings, triggers, and consequences of mental illness. Relying on
Western diagnostic criteria alone would result in overlooking or dismissing many of these patients in Uganda.
In addition to culture, mental health treatment programs must consider local risk factors. Through decades of
extensive research in Zimbabwe, researchers have found that patients experiencing financial insecurity and
hunger are not only more likely to develop depression, but to experience it more persistently. Furthermore, many
Kufungisisa patients also have HIV/AIDS, which adds another level of social and economic stressors to their
depression. The research team that developed the Friendship Bench program thus enhanced treatment with a
“behavioral activation activity” that enables HIV-positive female patients to participate in an income-generating
project, such as manufacturing and selling handbags. This therapeutic component serves the dual purpose of
reducing financial stressors that may prevent recovery and of providing an empowering and uplifting activity to
reinforce the cognitive elements of recovery. This program is but one example of a new, rigorous, thoughtful, and
multidisciplinary approach to treating mental disorders in developing countries—one that is designed by mental
health professionals with the help of public health practitioners, anthropologists, and other social scientists.
When it comes to delivering care in resource-poor settings, however, the challenge is finding enough practitioners to
counsel and treat patients. Twelve psychiatrists in Ghana cannot possibly provide adequate care for a country of
nearly 26 million. The answer to the problem may lie in using well-trained laymen. A number of studies show
that this approach works. In practice, specialist and nonspecialist health workers “task share” and are assigned a
portion of the treatment based on their specific knowledge and skill set; for example, anyone can be trained in basic
counseling, although drugs can be prescribed only by licensed professionals.
A number of randomized controlled trials have now proven the effectiveness of this multitiered approach to the
delivery of mental health care in developing countries. In fact, the Friendship Bench program is primarily
implemented by peer health workers, although it is overseen by psychiatrists and/or psychologists. Friendship Bench
is based upon the success of the programs evaluated in the MANAS trial in India. MANAS was one of the largest
mental health trials in a low-income country to date. This study evaluated a treatment program where lay health
workers were trained to manage cases and educate patients about anxiety, depression, and psychotherapy while
primary care physicians and mental health specialists focused on diagnosis and drug prescription, particularly in
patients with more severe illness. The study revealed that the intervention was effective both in treating depression
and, notably, in increasing productivity: patients in the treatment group suffered four to five fewer “disability days”
per month or days of work lost because of their illness. Another program in Uganda, StrongMinds, uses lay
health workers to deliver therapy in groups and has produced striking results, including increased self-employment,
lower unemployment, and increases in savings.
Currently, a majority of the developing world remains woefully underserved in mental health care. Thus, the next
step is to determine how to rapidly scale up these services to reach not thousands but millions of people. In addition
to employing lay health workers in the clinical setting, many community-based solutions hold promise. For example,
StrongMinds ultimately intends to teach laypeople to then teach others in basic counseling techniques. In this way,
the program empowers communities by giving them the skills to address their own needs. Such treatment models do
not suggest that mental health professionals are superfluous—they are sorely needed, especially in the poorest parts
of the world—but this model can expand their reach.
Whether mental illness is tackled through community-based approaches or more formalized health-care systems,
prioritizing mental health care in developing countries promises to reap large returns: improving individual wellbeing
and socioeconomic outcomes. Given the large returns to treating mental illness, it is not just a humanitarian
issue but also a crucial factor when it comes to boosting a country’s economic development.
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