Triggering Hope: Strengthening Social Resilience

1. Triggering Hope: Strengthening Social Resilience Helena Verdeli Assistant Professor of Clinical Psychology Columbia University Mara Russell Practice Manager: Food Security and Livelihoods Land O’Lakes Mary DeCoster Coordinator for Social and Behavioral Change Programs TOPS / Food for the Hungry

3. Treatment of depression and food security: a new frontier in Global Mental Health Lena Verdeli, Ph.D Teachers College, Columbia University & Columbia College of Physicians and Surgeons, Columbia University

5. 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 University Myrna Weissman, Lena Verdeli, Kathleen F. Clougherty, Priya Wickramaratne, Richard Neugebauer • World Vision Uganda Lincoln Ndogoni, Liesbeth Speelman

6. 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

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?

8. 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- Irritability - Bad, criminal or reckless behavior - Feeling sad - Feeling worthless - Not responding when greeted/withdrawn - Crying easily - Poor appetite - Feeling of severe suffering/pain • Okwekubagiza (self-pity) - Feeling sad - Feeling lonely - Worry too much about things -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

9. 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.

10. 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

11. Function Assessment Graphic

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. The Group Leaders

19. 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)

20. How the IPT Manual was Adapted • Sources of information: • trainees, and ethnographic study (interactive process) • Modifications of manual • General adaptations: • Simple language • More structure

21. 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)

22. How the IPT Manual was Adapted • Evidence for 3 Problem Areas • Grief: death of a loved one – multiple deaths - reconstruct the relationship while not being disrespectful to the dead loved one. • Role Disputes: disagreements - respect and work within the cultural code regarding power and intimacy. • 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?

23. 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

24. Study Population • Inclusion: • Over age 17, residing in Rakai and Masaka provinces • Identified by key community informants as suffering from Yo’kwekyawa and/or Okwekubagiza • Self-identified as suffering from Yo’kwekyawa and/or Okwekubagiza • Positive on both HSCL and function questionnaire • Consents to participate in the trial before randomization and consents after treatment allocation • Exclusion: • Actively suicidal

25. Flow Chart Intention to Treat Completers 163 randomized to IPT 139 approached 116 agreed to participate 107 completed IPT 631 identified 341 eligible 178 randomized to control 145 approached 132 agreed to participate 117 completed follow-up

26. Results for Intent-to-Treat Sample (N=248) Depression Scores (HSCL) P< .001 P< .001

27. Results for Intent-to-Treat Sample Functional impairment Scores P< .001 P< .001

28. 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). 1Bolton et al (2003) JAMA:289 (23), 3117-3124)

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

30. 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."

31. 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.

32. Some connections … Worldview / Mindset: Pessimistic attributional style & other fatalistic beliefs Gender- based Violence Lowered response to new opportunities / behavior change Learned Helplessness Difficult role Fulfillment (as parent, as farmer) Depression / Despair Maternal Distress: Depression / Anxiety More stunting & Underweight / Less program impact Negative attitudes (e.g., about child)

33. 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

34. 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.