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.
I don't know if the models in the post below are mental health professionals or not but after taking a good look at them I definitely feel less depressed.
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