Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT Director of Health Programs, Food for the Hungry

1. 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

2. Depression in Developing Countries: Your Experiences • 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? Take five minutes to talk with your neighbor using the following questions:

3. 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??

4. 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 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 Leading Burden of Disease (Worldwide)1990 2020 #4 in terms of leading causes of disability-adjusted life years (DALYs)

5. 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]

6. Depression throughout the world…

7. 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 child’s malnutrition found [but small sample])

8. 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

9. Adapting group interpersonal therapy for a developing country: experience in rural Uganda • Verdeli et al. • World Psychiatry, 2:2, June 2003, 114-123

10. 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…)

11. 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.)

12. 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.

13. 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%).

14. The Intervention:Interpersonal Group Therapy 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 8/15 male villages and 7/15 female villages randomly assigned to the intervention arm. Remainder to control arm.

15. The Intervention:Interpersonal Group Therapy IPT-G process: Facilitator reviews each person’s depressive symptoms Asks person to describe past week’s 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…)

16. Control Group The Intervention:Interpersonal Group Therapy • 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.)

17. 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.

18. 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: Measurement of Program Results:Dysfunction Scale 0 = No more difficulty (than others) 1 = a littlemore 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., 4+1+3+1+2…). (Low = functional; High = dysfunctional)

19. Measurement of Program Results:Dysfunction & 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/Layer3.asp?page_id=10

20. ` How persistent is this?

21. 74% decrease 16% decrease 16% decrease

23. 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 it’s 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 …

24. 0.77 0.16

26. … 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.

27. 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.

28. 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 (?)

29. 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.

30. 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 one’s social environment Adapted for use with groups by Denise Wilfley and others in 1989.

31. 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).

32. IPT-G’s 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

33. 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.

34. 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).

35. 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

36. Modifications to Approach in Uganda • 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. Changed names of four problem areas Created detailed scripts in simple language for use in trainings Modifications based on trainee group members ideas:

37. 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.

38. 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 member’s 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.

39. Last thoughts…. Depression also affects treatment compliance… Correlations of PTSD and Depression with Adherence1 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). 1. http://www.fenwayhealth.org/site/DocServer/safren_to_signs_dot_com_sbm_map_ptsd_poster.ppt?docID=263#256,1,Slide 1

40. 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

41. 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)

42. 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.

43. Questions and (Possibly!) Answers