News & Updates
healthcare in developing countries
January 5, 2014
A Community Approach to Mental Health
Building Back Better, a recent report by the the World Health Organization (WHO), outlines a new, community oriented approach to providing mental health care in developing countries that have experienced devastating emergencies. The report describes how, in the aftermath of wars and natural disasters, ambitious mental health reforms have been instituted and are starting to make a difference. One of the most striking characteristics of these reforms is their focus on creating mental health care systems that put trained nonprofessionals on the front line of treatment. According to Mark van Ommeren, a psychiatric epidemiologist at WHO in Geneva, talk therapies adapted to specific cultures show promise in easing these problems.
Eleven countries and territories contributed to the report including Afghanistan, Burundi, Indonesia (Aceh Province), Iraq, Jordan, Kosovo, Somalia, Sri Lanka, Timor-Leste, and West Bank and Gaza Strip. These participants described their major achievements and most difficult challenges and shared how those challenges were overcome, in part by using community-based strategies.
For example, in Goa, India, an investigation called MANAS (an acronym meaning “Project to Promote Mental Health” in India’s Konkani language) documented the effectiveness of group therapy led by non-medical people local to the area. In the study, which encompassed 2,800 individuals being treated for common mental health problems, interpersonal psychotherapy and other interventions delivered by health counselors substantially relieved patients’ depression and improved their work and home lives well after treatment ended.
In the Democratic Republic of the Congo, another study conducted by Johns Hopkins University provided evidence for the healing power of group therapy administered by trained nonprofessionals. The project involved the treatment of 405 women from 15 villages, many of whom were suffering symptoms of post traumatic stress syndrome (PTSD), the emotional aftereffect of rape and other conflict-related ordeals in the war-torn country. They were divided into groups of six to eight women and received up to 12 sessions of cognitive processing therapy administered by lay counselors supervised by a Congolese social worker trained in the therapy. The number of women suffering from PTSD was reduced from 60% to 9% after 12 sessions.
The Limits of “Medication Only” Mental Health Strategies
The key to any of these approaches is that they are sustainable. The treatments highlighted in the WHO report not only meet the primary need to relieve the patient’s anguish and inability to live a depression-free life, but do so at a much lower cost. The results achieved also indicate that it is a false economy to medicate without talk therapy support, either individually or in a group setting, because patients may experience no effect or a slew of very bad effects, from unmonitored medication for mental health issues. To date, studies done on “medication only” versus “talk therapy” (alone or with some medication) show that roughly two-thirds of patients prefer talk therapy, seeing better long-term results.
Policymakers around the world now have over a decade of data on what works well and what works less well in the design of mental health programs in developing countries. And what they have learned points to the need to review the current state of mental health care both in developing and developed countries, particularly with regard to including various forms of talk therapy in their programs.
Ironically, in the U.S., the birthplace of interpersonal psychotherapy, this type of therapy is on the decline. Patients seeking help for depression in the U.S. are consistently shown in surveys to prefer psychotherapy to drug therapy. The power of the pharmaceutical industry is generally pointed to as the reason why “talk therapy” practitioners are harder and harder to find. U.S. health providers and insurers realize immediate savings from having a patient’s Primary Care Physician (not a therapist) write a prescription for an antidepressant and promote this as the preferred treatment for a patient’s depression. This seemingly cheaper treatment outweighs the strength of studies showing that longer term “talk therapy” with or without medication results in patients being able to sustain progress made in treatment. But there are long term, hidden costs to the medication-only approach.
After years of medication-only treatment with no measurable improvement, patients remain saddled with ongoing depression that can make them less productive. It can also results in the inappropriate use of medical resources. For example, seeing physicians who are not mental health care specialists for health complaints that, in actuality, arise from untreated depression. The cost of tests and other diagnostic efforts in pursuit of a diagnosis by physicians who are not mental health care specialists can be substantial.
Neighbors Healing Neighbors
Building Back Better is a hopeful window on how people who live in some of the most conflict-ridden areas of the world are getting effective mental health care from the members of their community to heal the deep wounds they bear after generations of war and poverty. But it offers a lesson for policymakers of all nations to consider talk therapy, guided by trained community-based nonprofessionals, to tackle their mental health challenges.