Treating Depression, Unprofessionally

Some people doubt that necessity really is the mother of invention, but necessity can produce conditions where we can test out different unprofessional treatments for depression.

Writing in the New York Times, Tina Rosenberg explains how necessity has forced people to improvise in providing treatment for depression in Africa.

Those who engage in this work want to provide low-cost, effective treatment to the largest number of patients. Fair enough. And yet, they must do wo without being able to rely on an army of psychiatrists and psychologists.

Apparently, it is more than possible to do so. Peer counselors with minimal training can work effectively with depressed patients.

Psychiatrists and psychologists will not embrace the good news. What is the value of all those years of study when someone who has been trained for a few weeks can do similar work effectively?

One suspects that the mania for credentialing mental health providers derives as much from a desire to restrain trade as from a wish to ensure the best treatment.

It ought not to be news. Rosenberg reminds us that previous studies showed that peer counselors who underwent brief training in group therapy or cognitive behavioral therapy worked well with patients.

The results were striking:

Two years ago, I wrote about a research study in 2002 that provided group interpersonal therapy, led by college students and high school graduates with two weeks’ training, to depressed women in Ugandan villages. The treatment was so effective that six months after starting this therapy, only 6 percent of those treated still had major depression.

More recently, similar work has gone on in South Asia. In rural Rawalpindi, Pakistan, the Thinking Healthy Program taught basic cognitive behavioral therapy for only two days to female community health workers with a high school education. The trainees, called Lady Health Workers, then integrated the therapy into their regular visits with pregnant women and new mothers. (Studies often focus on women, especially new mothers, because they suffer depression more than men and their mental health is crucial to their children’s development. It allows health workers to paint the program — truthfully — as a way to help the baby, which is more socially acceptable than treating depression in the mother.) Six months later, only 3 percent of those treated were still depressed. The largest study was in Goa, India, where local people with no health background were given an eight-week course in interpersonal psychotherapy and worked with physicians to treat patients with mental health disorders. This, too, was very successful.

Rosenberg offers the only reasonable conclusion:

These studies were proof that depression could be treated in poor countries by lay people. Now these researchers are trying to figure out how to streamline these interventions to the minimum outlay of resources needed to maintain excellent results. 

Of course, a study is only as good as its control group. Can we compare patients who received no treatment with those who received the group therapy or cognitive therapy provided by peers?

Previous outcome studies in America compared patients who received treatment with those who had had their names put on a waiting list. The latter group often did better than the former.

Rosenberg explains what happened in a control experiment in Uganda:

Helena Verdeli, who ran the first Uganda study, is collaborating with a new organization, Strong Minds, to use the same group interpersonal therapy to treat women with moderately severe or severe depression in the slums of Kampala. Strong Minds’ idea is to rapidly test round after round of treatment, each round cutting something off the intervention to make it cheaper or faster.

The first 26 therapy groups, which started in May, treated 244 women for 16 weeks using only four very busy facilitators — two nurses and two college graduates with degrees in community psychology. There was also a control group of 36 women.

A week after the sessions ended, 94 percent (pdf) of the women no longer had depression. Oddly, the control group also improved, although by far less — 33 percent no longer were depressed. But Strong Minds’ goal of eliminating depression in 75 percent of patients was achieved earlier, in week 12.

Does this mean that there is no place for credentialed mental health professionals?

Rosenberg explains that they still have a place, albeit a lesser place:

Peers cannot do everything in mental health. Patel warns that peers are valuable but must complement professionals, who are needed to diagnose and treat more serious illnesses and, in many cases, depression. It may be that the job of spreading the word, recruiting and organizing therapy groups can’t be done by peers — Strong Minds is testing this.

But peers can do a lot. The therapy groups offer confidential social support — a place for women to understand they have a disease shared by many others, and to talk about their problems without fear of gossip.

And peers can provide practical help. In their initial interviews, most of the women reported that their depression was triggered by a specific crisis. Most likely, others in the group are dealing with or have dealt with it, too.

It is important to emphasize that the women who were suffering depression in these communities belonged to coherent, cohesive communities. They did not belong to diverse communities where people did not know the rules and did not know how to interact.

As Rosenberg knows well, peer group counseling is not new. It forms the basis for AA.

I have often noted how important the AA treatment model is. There, those who sponsor recovering alcoholics or who lead group meetings are unlicensed:

The best example of true virality in a peer support group is Alcoholics Anonymous, which is run by its members. AA may already be treating depression. In a paper to be published by the journal Psychology of Addictive Behaviors, researchers at the University of New Mexico found that AA attendance was associated with relief from depression — and not simply because members are drinking less.

AA encourages members to replace the bad habit of hanging around in bars with the good habit of going to meetings. It appears that socialization provides a therapeutic benefit, one that, I imagine, supports and sustains the benefits of drinking less.