Triggering Hope: Strengthening Social Resilience

Helena VerdeliAssistant Professor of Clinical Psychology

Columbia University

Mara RussellPractice Manager: Food Security and Livelihoods

Land O’Lakes

Mary DeCosterCoordinator for Social and Behavioral Change Programs

TOPS / Food for the Hungry

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LENA VERDELI, PH.D

TEACHERS COLLEGE,COLUMBIA UNIVERSITY

& COLUMBIA COLLEGE OF PHYSICIANS AND SURGEONS,

COLUMBIA UNIVERSITY

Treatment of depression and food

security: a new frontier in Global

Mental Health3

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Study #1 (2002-2003)Group IPT with Depressed Adults in Southern

Uganda

Johns Hopkins Bloomberg School of Public Health: Paul Bolton (PI), Judy Bass

NY State Psychiatric Institute, Columbia UniversityMyrna Weissman, Lena Verdeli, Kathleen F. Clougherty, Priya Wickramaratne, Richard Neugebauer

World Vision UgandaLincoln Ndogoni, Liesbeth Speelman

The Request

Qualitative mental health study by Bolton’s team (2002)1 found high prevalence of depression symptoms (21%) among adults in the southwest region of Uganda

Team in search of a psychotherapy which had shown efficacy, would have to be adapted for the local setting, and tested in a randomized controlled trial

1 Wilk CM, Bolton P. (2002)Local perceptions of the mental health effects of the Uganda acquired immunodeficiency syndrome epidemic. J Nerv Ment Dis,190:394-7

My Initial Reactions…

Why label human suffering “depression”?

Why intervene?

Is psychotherapy a luxury in these communities?

Should we use western-based psychotherapy concepts and techniques in these communities?

Would a rigorous clinical trial in such a resource-poor setting be possible?

Even if the intervention proved to be efficacious, would it be sustainable?

Local Syndromes of Depression

Yo’kwekyawa (self-loathing)- Feeling lonely- Feeling no interest in things- Worrying too much about things- Feeling hopeless about the

future- Hating the world- Thoughts of killing self- Irritability- Bad, criminal or reckless

behavior- Feeling sad- Feeling worthless- Not responding when

greeted/withdrawn- Crying easily- Poor appetite- Feeling of severe suffering/pain

Okwekubagiza (self-pity)- Feeling sad- Feeling lonely- Worry too much about things- Feeling worthless- Low energy, feeling slowed

down- Crying easily- Feeling fidgety- Feeling no interest in things- Feeling everything is an effort- Irritability- Unappreciative of assistance

Assessment of Depression and Functioning

Assessment of Depressive Symptoms: Hopkins Symptom Checklist (HSCL) validated against the local syndromes 1

Assessment of Functioning: Development of a Local Measure 2

Ethnographic methods derived gender-specific tasks viewed as essential elements of functioning (caring for self, family, community)

1Bolton P. (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument. Nerv Ment Dis. 189:238-242.

2 BoltonP, Tang AM. (2003). An alternative approach to cross-cultural function assessment. Soc Psychiatry Psychiatr Epidemiol. 37:537-543.

Items Comprising the Assessment of Functioning Scale

Males Personal Hygiene Farming Head the Home Manual Labor Plan for the Family Participate in

Community Development Activities

Attend Meetings Participate in Burial

Ceremonies Socialize

Females Personal Hygiene Caring for Children Cooking Washing

Clothes/Utensils Cleaning

House/Surroundings Growing Food Participate in

Community Development Activities

Attend Meetings Console and Assist the

Bereaved

Function Assessment Graphic

Rationale for Using Psychotherapy

Depression was recognized by the community as a major source of disability and needed to be addressed

Local traditional healers felt unable to treat depressive syndromes effectively

Medication not feasible, e.g., cost too high, few MDs

Selecting Psychotherapy

Psychotherapy had to be manualized, evidence-based and compatible with the local culture

Other instances of western psychotherapy that showed efficacy in developing countries (Arraya et al, 2003)

Psychotherapy delivery had to be feasible: use group format; implemented by non-mental health professionals

Selecting IPT

CBT and IPT were considered by local experts

Cultural attitude in Uganda: people see themselves as part of a family or group (“people are people within people”)

IPT seemed compatible with the Ugandan culture

Facts about IPT

Developed by Klerman, Weissman and colleagues in the 1970s

Time-limited psychotherapy (8 to 20 Sessions)

Focuses on improving symptoms and interpersonal functioning

Principles of IPT

Assumes that depression is triggered by interpersonal difficulties in one or more of the following problem areas:

GRIEF Death of a person significant to the patient

INTERPERSONAL DISPUTES Disagreements (overt and covert)

ROLE TRANSITIONS Life changes—negative and positive

INTERPERSONAL DEFICITS Loneliness, social isolation

Preliminary Work Before Departure

Preparation of a draft of the IPT manual, knowing it had to be modified on site (consulted with PI and local supervisor during development)

Manual specified 18 weekly sessions, 2 pre-group individual and 16 group sessions, 90 minutes duration

Single sex groups of 8, leaders’ sex matching that of the participants to facilitate disclosure

Project was sanctioned by local leaders and traditional healers

The Group Leaders

Group IPT Training in Rural Uganda

Problems Trainers were unaware of cultural

relevance of IPT concepts and techniques

The 10 trainees were non-mental health professionals (task shifting)

How the IPT Manual was Adapted

Sources of information: trainees, and ethnographic study

(interactive process)

Modifications of manual General adaptations:

Simple language More structure

How the IPT Manual was Adapted

Specific adaptations Pre-group meeting:

Local definition of depression (emphasize that it is not madness)

Role of leader: will not provide material goods Confidentiality (how much to disclose to the

community) Treatment contract (flexibility, schedule around

community events)

How the IPT Manual was Adapted

Evidence for 3 Problem Areas

1. Grief: death of a loved one – multiple deaths - reconstruct the relationship while not being disrespectful to the dead loved one.

2. Role Disputes: disagreements - respect and work within the cultural code regarding power and intimacy.

3. Role Transitions: life changes - when dealing with devastating life changes (AIDS, famine), focus on the elements under the individual’s control.

*Poverty: is this a separate problem area?

The IPT Training (workshop, manual, supervision)

Extensive didactic workshop (2 weeks) of lay community members

During training: modified manual; conducted workshop; assessed preliminary therapist competence

Used trainee group as an experiential group to demonstrate problem areas and group process

Study Population

Inclusion: o Over age 17, residing in Rakai and Masaka provinceso Identified by key community informants as suffering

from Yo’kwekyawa and/or Okwekubagiza o Self-identified as suffering from Yo’kwekyawa and/or

Okwekubagizao Positive on both HSCL and function questionnaireo Consents to participate in the trial before

randomization and consents after treatment allocation

Exclusion: Actively suicidal

Flow Chart

631identified

341 eligible

163 randomized

to IPT

178 randomizedto control

139 approached

145 approached

116 agreed to participate

132 agreed to participate

107 completed

IPT

117 completedfollow-up

Intention to Treat

Completers

Results for Intent-to-Treat Sample (N=248)

0

5

10

15

20

25

30

Baseline Termination 6-MonthFollow-Up

IPT Mean

Control Mean

26

De

pre

ssio

n S

co

res

(H

SC

L)

P< .001 P< .001

Results for Intent-to-Treat Sample

-1

1

3

5

7

9

11

13

15

Baseline Termination 6-MonthFollow-Up

IPT Mean

Control Mean

Fu

nct

ion

al i

mp

airm

ent

Sco

res

P< .001 P< .001

Results

At termination, 6.5% and 54.7% of the IPT and TAU groups respectively still met criteria for Major Depression compared with 86% (IPT) and 94% (TAU) at baseline1

Ethnographic assessment in study communities on intended and unintended consequences of the IPT program (positive and negative) showed as the most frequently endorsed outcomes: (Lewandowski, et al, in preparation).

1 Bolton et al (2003) JAMA:289 (23), 3117-3124)

What are all the changes that happened for people who participated in the IPT groups?

Change in community (60 respondents): Number of respondents who mentioned change:People pay school fees for children to go to school. 34

They are active in agriculture and animal husbandry.Cleanliness in families has improved (sanitation in family compound including toilets, keeping rubbish away).

33

28

We get enough food (from farming, aka, farms produce more now). 26People are working harder. 21

We received knowledge and skills in modern farming, agriculture and animal husbandry. 21Cleanliness in the community has improved (there are better sanitation facilities and practices). 20

Children now go to school (due to changed attitudes and motivation in children). 19

Parents learn to behave well (to respect other family members). 18Behaviors in homes have improved. 16

We get counseling and advice concerning our problems from our fellow members. 16

We behave in a way that society expects us. (aka, people behave well). 14There is peace in families. 13We still lack some support (financial). 13

We give each other advice about animal and crop husbandry and how to overcome problems. 13There is unity (and cooperation). 12We dig/cultivate crops together. 11We consider working very important because it is the means through which we get some money. 10There is no more depression. 10We now get some happiness (we have pleasant times). 10Children now get involved in working. 9They save some money in their groups. 9

Collective Resilience

Michael Ungar, Co-Director of the Resilience Research Center in Halifax, has suggested that resilience is better understood as follows:

"In the context of exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being, and their capacity individually and collectively to negotiate for these resources to be provided in culturally meaningful ways."

No health without mental health. No development either.

Depression is a condition of hopelessness and helplessness

By assisting depressed community members to break the social isolation, generate options, identify advocates when powerless, and have more hope, we can help communities find greater access to resources available

We now have feasible, inexpensive, culturally acceptable, and highly effective tools to treat depression

Lets do it.

Learned Helplessness

Worldview / Mindset: Pessimistic attributional style & other

fatalistic beliefs

Depression / Despair

Difficult roleFulfillment (as

parent, as farmer)

Gender-based

Violence

Maternal Distress:Depression /

Anxiety

Negative attitudes(e.g., about child)

More stunting & Underweight / Less

programimpact

Lowered responseto new opportunities /

behavior change

Some connections …

My hope is that mental health interventions will increasingly be included in food security programs.  But first we need to make the case that they could be effective and that it's something that implementers could do with the proper training.” Tom Davis

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Food for the Hungry and do not necessarily reflect the views of USAID or the United States Government.