Where There is No Psychologist: Communitylevel Treatment of Depression using Interpersonal Group The

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Where There is No Psychologist Community-level
Treatment of Depression using Interpersonal Group
Therapy

• Tom Davis, MPH Gracia Blees, MEd, LPC, LMFT
• Director of Health Programs, Food for the Hungry
• Presentation for CCIH Conference,
• June 2006

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Depression in Developing Countries Your
Experiences

• Take five minutes to talk with your neighbor
  using the following questions

• How common a problem do you think depression is
  in developing countries and how does their rate
  compare with depression in industrialized
  countries?
• What types of mental illness have you seen in
  people working in developing countries?
• Is treatment of mental illness an area in which
  the Church and FBOs should lead the way?

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Some Causes of Depression

• Chronic illness (and the prolonged pain that
  often accompanies it)
• Loss of a friend or relative
• Disappointment and relationship problems at home,
  work, or school
• Alcohol or drug abuse
• Spousal abuse
• Chronic stress
• Childhood events like abuse or neglect
• Social isolation (common in the elderly)
• Nutritional deficiencies (e.g., folate, B12)
• How often do you see these precursors in
  developing countries??

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Leading Burden of Disease (Worldwide)1990
2020

• 1. Ischemic heart disease
• 2. Unipolar major depression
• 3. Road traffic accidents
• 4. Cerebrovascular disease
• 5. COPD
• 6. Lower resp infections
• 7. TB
• 8. War injuries
• 9. Diarrheal diseases
• 10. HIV

• 1. Lower resp. infections
• 2. Diarrheal diseases
• 3. Perinatal conditions
• 4. Unipolar major depression
• 5. Ischemic heart disease
• 6. Cerebrovascular disease
• 7. TB
• 8. Measles
• 9. Road traffic accidents
• 10. Congenital abnormalities

4 in terms of leading causes of
disability-adjusted life years (DALYs)
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Depression is now the 1 global cause of
disability

• 121 million people currently suffer from
  depression.
• 5.8 of men and 9.5 of women will experience a
  depressive episode in any given year.
• WHO fact sheet

1 leading cause of years of life lived with
disability (YLDs) WHO World Health Report 2001
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Depression throughout the world
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Depression and Abuse in Mozambique and Kenya

• 37 of all Mozambican mothers (Sofala province)
  felt depressed on half or more days of the week.
  
• 42 of the Kenyan women interviewed (Marsabit
  area) were depressed on half of the days of the
  week or more.
• 96 of Kenyan women interviewed said that it was
  okay for a man to hit a woman.
• (No relationship between material depression and
  childs malnutrition found but small sample)

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Group Interpersonal Psychotherapy for Depression
in Rural Uganda A Randomized Control Trial

• Paul Bolton, MBBS
• Judith Bass, MPH
• Richard Neugebauer, PhD, MPH
• Helen Verdeli, PhD
• Kathleen F. Clougherty, MSW
• Priya Wickramaratne, PhD
• Liesbeth Speelman, MA
• Lincoln Ndogoni, MA
• Myrna Weissman, PhD
• JAMA, June 18, 2003 Vol 289, No. 23, 3117-3124

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Adapting group interpersonal therapy for a
developing country experience in rural Uganda

• Verdeli et al.
• World Psychiatry, 22, June 2003, 114-123

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Context of the Rural Uganda Study on IPT-G for
Treatment of Depression

• World Vision project areas (Uganda)
• February June 2002
• 30 villages in Masaka and Rakai districts of
  Uganda (of 154 villages in all of Rakai province
  and contiguous half of Masaka province in SW
  Uganda).
• Three-stage screening process done by WV staff
  (explained later)

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Context of the Rural Uganda Study on IPT-G for
Treatment of Depression

• Studied men in 15 communities and women in 15
  communities (randomly assigned)
• Interviewed adult men or women who they or other
  villagers believed to have depression-like
  symptoms.
• (Feasibility and efficacy psychotherapy for
  depression never tested previously in Uganda.)

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Context of the Rural Uganda Program to Treat
Depression

• Interviewed using (1) a locally-adapted Hopkins
  Symptom Checklist and (2) an instrument assessing
  function.
• Created lists for each village 341 men/women who
  met DSM-IV criteria for major depression or
  subsyndromal depression.

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Context of the Rural Uganda Program to Treat
Depression

• Revisited in order of decreasing symptoms until
  they had 8-12 persons per village (working with
  the most depressed individuals).
• 248 (75) agreed to be in trial 9 refused
  remainder died/relocated.
• 108 men and 116 women completed the study (90).

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The InterventionInterpersonal Group Therapy

• 8/15 male villages and 7/15 female villages
  randomly assigned to the intervention arm.
  Remainder to control arm.

Intervention Group

• Group Interpersonal Therapy for depression as
  weekly 90-minute sessions for 16 weeks.
• IPT-G carried out by WV staff members who
  received a two-week training in IPT-G by authors
  of study

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The InterventionInterpersonal Group Therapy

• IPT-G process
• Facilitator reviews each persons depressive
  symptoms
• Asks person to describe past weeks events and to
  link events to his/her mood
• Facilitates support and suggestions for change
  from other group members
• Attendance was moderate 54 attended 14
  sessions.
• Dropout rate was 7.8
• (More later)

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The InterventionInterpersonal Group Therapy
Control Group

• Control Group No IPT-G. (free to seek other
  interventions.)
• Told all that if the intervention worked, it
  would be made available to controls eventually.
  (WV is doing this presently.)

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Measurement of Program Results

• Examined depression and dysfunction scores
• Scales adapted and validated for local use.
• Measured proportion of persons meeting DSM-IV
  major depression diagnostic criteria.

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Measurement of Program ResultsDysfunction Scale

• Dysfunction Scale
• Looked at 9 individual tasks for men and 9
  individual tasks for women (some overlap)
• For each, participant rated them based on scale,
  comparing themselves to other people their age
  and gender

0 No more difficulty (than others) 1 a
little more difficulty 2 a moderate amount more
difficulty 3 a lot more difficulty 4
frequently unable to do the task

• Total dysfunction score Total of scores for all
  nine tasks (e.g., 41312). (Low
  functional High dysfunctional)

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Measurement of Program ResultsDysfunction
Depression Scale

• Depression score -- Done in a similar fashion
  (Adding responses to each of 25 (?) questions on
  Hopkins Symptom Checklist).1

1 More on HSC-25 http//www.hprt-cambridge.org/L
ayer3.asp?page_id10
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How persistent is this?
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74 decrease
16 decrease
16 decrease
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How much did function vary?

• At baseline, both groups had an average of about
  1.4 for each task ( A little / moderate amount
  more difficult in completing the task than other
  people but its an average).
• At follow-up, the intervention group had an
  average of 0.47 (no more difficulty) and the
  control group had an average of 0.96 (a little
  more difficulty than most people).
• BUT, some differences were greater than others

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0.77
0.16
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(No Transcript)
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So what effect does Depression have on Food
Security?

• Largely unexamined question BUT, we know that
  anemia affects productivity. For example
• Hookworm infection in adults is associated with a
  diminished capacity to carry out physical work1
• Productivity of Kenyan workers with moderate
  anemia was 24 below non-anemic workers (34 less
  for severely anemic workers)2

1 Latham, Michael C. (1983). Dietary and
Health Interventions to Improve Worker
Productivity in Kenya. Tropical Doctor, 13
34-38. 2 Latham, M. and Stephenson, L. (1981).
Kenya Health, Nutrition, and Worker Productivity
Studies. World Bank, Washington, D.C.
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Review of Results

• Average (mean) reduction in depression severity
  was 17.47 points for the intervention group
• 3.55 point reduction for controls.
• Mean reduction in dysfunction was 8.08 points for
  the intervention group
• 3.76 point reduction for controls.

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Review of Results

• Following the intervention, depression dropped
  from 86 to 6.5 (-92) in the intervention group
• Depression dropped 94 to 54.7 in the control
  group (42)
• Six month follow-up Groups still meeting (?)

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Review of Results

• Odds of post-intervention depression among
  controls was 17.31 compared to the odds of
  depression in the intervention group (CI
  7.63-39.27) that is, controls were 17.3 times
  more likely to be depressed at follow-up (four
  months later) than those who received IPT-G.
• IPT-G was found to be highly efficacious in
  reducing depression and dysfunction.

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Background on Interpersonal Group Therapy (IPT-G)

• Brief, time-limited psychotherapy developed for
  treatment of non-bipolar, nonpsychotic depressed
  patients.
• IPT based on work of Adolf Myer Psychological
  problems are a result of maladaptive adjustment
  to ones social environment
• Adapted for use with groups by Denise Wilfley and
  others in 1989.

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Background on Interpersonal Group Therapy (IPT-G)

• Assumes the development of depression occurs in a
  social and interpersonal context and that onset,
  response to tx, and outcomes are influenced by
  interpersonal relations
• Bolton et al felt it was more similar to
  problem-solving approach used in SSA cultures
  (part of family/community).

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IPT-Gs Successes

• IPT-G has demonstrated success
• Major depression (including treatment-resistant
  depression)
• Recurrent depression
• Bipolar mood disorders
• Bulimia
• Binge eating
• Abused women with acute PTSD
• Used with
• Adolescents
• Couples
• Patients with co-morbid medical conditions (e.g.,
  HIV, recent cancer diagnosis)
• Others

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Differences between IPT-G and other Therapies

• IPT-G is
• Time limited, not long term
• Focused, not open-ended
• Addresses current relationships, not past ones
• Interpersonal rather than intrapsychic or taking
  a CBT approach
• Semi-structured (strategies, but no established
  agenda for meetings or thematic discussions)
• Very action-oriented person is expected to put
  what they learn in the group into practice
  outside the group.

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Principles of Interpersonal Group Therapy

• Most groups have 12-24, 90-minute weekly
  sessions. (In Uganda, used 16 weekly sessions.)
• Aimed at resolving problems (depression triggers)
  in four areas
• Book Grief Uganda Death of a loved one
• Interpersonal role disputes (Disputes). Work
  Communicating directly/effectively find solutions
  to conflict.
• Role transitions (life changes e.g., loss of
  job, becoming HIV) Usual work Identify /-
  aspects of the old and new role. Uganda
  Identify areas you can control, skills-building,
  and identification of options. Goal ?
  powerlessness
• Interpersonal deficits ? lead to problems in
  initiating or maintaining health relationships.
  (Loneliness/shyness) Can include binge eating,
  promiscuity, excessive anger, excessive
  passivity, other social skills deficits).

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Principles of Interpersonal Group Therapy

• Groups should be homogenous (e.g., having the
  same target problem, like grief).
• Book says Do not include people with suicidal
  ideation, antisocial, psychopathic, highly
  defensive, or have extremely low or no motivation
  to change.
• If gender is an issue Consider one male one
  female facilitator

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Modifications to Approach in Uganda

• Changed names of four problem areas
• Created detailed scripts in simple language for
  use in trainings
• Modifications based on trainee group members
  ideas

• Trainees asked to describe depressed person they
  know discuss behavior. Added some symptoms
  recognized locally (no info)
• Challenge How to reconstruct relationship with
  the dead person where no one speaks ill of the
  dead. The dead are living amongst us. Could
  ask Were there times in your life together
  when you felt disappointed by (the dead)?
• Challenge Getting your point across without
  being direct. (An IPT task To get a person to
  say exactly and directly what they expect.)
• Challenge Finding culturally appropriate
  options for resolving a dispute
• Debated poverty as a trigger for depression
  Decided it was a risk factor, but not a
  trigger.

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Training of Facilitators

• Facilitators were WV non-clinical, college-level
  educated employees (not psychologists, and not
  CHWs)
• Emphasize no handouts.
• Group is for mutual support to find out which
  situations contribute to their depression and
  what to do to feel better.
• Discuss confidentiality.
• Explore triggers for depression.
• Dydactic experiential group process Role
  plays and practice on each stage of treatment.
  Used trainees as a group to talk about loss,
  disputes, etc.

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What happens in group Phases of IPT-G

• Initial Phase (Sessions 1 -5)
• Create cohesive group atmosphere and positive
  group norms
• Promote active member-to-member interactions.
• Understand each members focal issues.
• Most learning is between group members.
• Intermediate Phase (Sessions 6-13)
• Group members provide support and challenges to
  other group members
• Apply group learning to current life situation.
• Facilitator encourages/models enthusiasm for each
  members work and curiosity regarding how they
  are applying what they have learned.
• Focus on current rather than past events.
• Termination Phase (Sessions 14-16)
• Confine new issues.
• Explore feelings about the group ending.
• Make plans to maintain gains.

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Last thoughts. Depression also affects treatment
compliance

• Depression has been associated with poor ART
  adherence in several studies (e.g., Safren et
  al., 2001 Catz et al., 2000 Patterson et al.,
  2000).

Correlations of PTSD and Depression with
Adherence1
1. http//www.fenwayhealth.org/site/DocServer/safr
en_to_signs_dot_com_sbm_map_ptsd_poster.ppt?docID
263256,1,Slide 1
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Why else is this important?

• Screening for depressive symptoms in sexually
  active adolescents, particularly boys, may
  identify those at risk for STDs.
• Temporal Associations Between Depressive Symptoms
  and Self-reported STDs in Adolescents. Shrier
  et al. Arch Pediatr Adolesc Med. 2002 156
  599-606

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What can the Church add?

• Taken together, these findings show a protective
  effect on depression of intrinsic religiosity
  of roughly the same magnitude as that of selected
  serotonin reuptake inhibitors."
• Religiosity as a Protective Factor in Depressive
  Disorders (Miller et al., Am J Psychiatry, 1999)

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A practical manual for mental health care aimed
at community health workers, primary care nurses,
social workers and primary care doctors.
Describes more than 30 clinical problems
associated with mental illness.
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Questions and (Possibly!) Answers