Treating depression

In the past 50 years there has been a rapid growth in the development and application of effective treatments for many child and adult psychiatric disorders in developed countries. However, the real challenge is to find how these treatments can best be adopted by developing countries with limited resources. Evidence from Uganda, Chile and India shows how low cost community-based mental health treatments can be successful and sustainable.

Interpersonal Psychotherapy (IPT), a psychotherapy for non-psychotic depression produced in the developed world and conducted with individuals and groups, has been effectively adapted for use in rural south-west Uganda. As well as being the most cost-effective treatment, IPT was chosen because it focuses on and views interpersonal crises, such as the death of a close family member, as triggers of depression. This is a technique culturally compatible with the communities in that part of Uganda.

Group leaders with no mental health care background were chosen from local communities to run the IPT programme. To make learning easier, an accessible easy-to-read IPT procedures manual was developed for the leaders. In addition, significant adaptations were made to the training process, and to the final content and implementation of the treatment. These adaptations included culturally sensitive ways of helping people mourn and handle disputes by assisting the person to get their point across whilst respecting the community's power hierarchy and code of communication. In a randomised clinical trial of 248 depressed people in south-west Uganda, IPT was found to be significantly more effective in reducing depression and improving the daily lives of people in comparison to those whose conditions were only assessed.

A common problem facing all community-based projects is that they may come to an abrupt end when studies assessing their effectiveness conclude, so that communities lose out. The Uganda project, however, has the continued support of its main sponsor, World Vision, and is still thriving after being accepted by the local community.

Two other clinical trials of depression treatments conducted in developing countries have demonstrated the feasibility and significance of interventions. A trial in India showed that low cost antidepressants were not only effective, but also reduced health care costs. In Chile, dramatic benefits were achieved with a 'stepped care' model for depression in women in primary care clinics.

For a treatment to be acceptable and effective in a community with limited resources it must address:

• how mental illness is expressed and understood by community members
• how mental illness affects people's ability to function in their communities
• where people seek help and who from
• how the community reacts to mental illness and those seeking help.

In addition, a number of significant differences in the effects and working of treatments across populations need to be taken into account. For example, how different drugs such as lithium or antipsychotics work in the body over a period of time.

Effective and sustainable treatment to alleviate mental suffering in poor communities does exist and the costs involved are relatively low. However, more support and funding are needed to help poor communities to adapt and use such treatment successfully.

Helena Verdeli
Columbia College of Physicians and Surgeons
Columbia University
Unit 24, NYSPI,
1051 Riverside Dr.
New York, NY 10032
USA
T +1 (212) 543 5262
VERDELIH@childpsych.columbia.edu

See also

'A clinical trial of group interpersonal psychotherapy for depression in rural Uganda', The Journal of the American Medical Association 289: 3117-3124 by P. Bolton et al, 2003

'Interpersonal psychotherapy for a group in Uganda (IPT-GU)', by K.F. Clougherty et al, 2003 (Contact kfcipt88@aol.com or mmw3@columbia.edu for a copy)

'Treating depression in the developing world', Tropical Medicine and International Health (9): 539-541 by V. Patel et al, 2004

'Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda', World Psychiatry 2(2): 114-120 by H. Verdeli et al, 2003

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