Upload
amena
View
39
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Triggering Hope: Strengthening Social Resilience. Helena Verdeli Assistant Professor of Clinical Psychology Columbia University Mara Russell Practice Manager: Food Security and Livelihoods Land O’Lakes Mary DeCoster Coordinator for Social and Behavioral Change Programs - PowerPoint PPT Presentation
Citation preview
Triggering Hope: Strengthening Social Resilience
Helena VerdeliAssistant Professor of Clinical Psychology
Columbia University
Mara RussellPractice Manager: Food Security and Livelihoods
Land O’Lakes
Mary DeCosterCoordinator for Social and Behavioral Change Programs
TOPS / Food for the Hungry
2
LENA VERDELI, PH.D
TEACHERS COLLEGE,COLUMBIA UNIVERSITY
& COLUMBIA COLLEGE OF PHYSICIANS AND SURGEONS,
COLUMBIA UNIVERSITY
Treatment of depression and food
security: a new frontier in Global
Mental Health3
4
Study #1 (2002-2003)Group IPT with Depressed Adults in Southern
Uganda
Johns Hopkins Bloomberg School of Public Health: Paul Bolton (PI), Judy Bass
NY State Psychiatric Institute, Columbia UniversityMyrna Weissman, Lena Verdeli, Kathleen F. Clougherty, Priya Wickramaratne, Richard Neugebauer
World Vision UgandaLincoln Ndogoni, Liesbeth Speelman
The Request
Qualitative mental health study by Bolton’s team (2002)1 found high prevalence of depression symptoms (21%) among adults in the southwest region of Uganda
Team in search of a psychotherapy which had shown efficacy, would have to be adapted for the local setting, and tested in a randomized controlled trial
1 Wilk CM, Bolton P. (2002)Local perceptions of the mental health effects of the Uganda acquired immunodeficiency syndrome epidemic. J Nerv Ment Dis,190:394-7
My Initial Reactions…
Why label human suffering “depression”?
Why intervene?
Is psychotherapy a luxury in these communities?
Should we use western-based psychotherapy concepts and techniques in these communities?
Would a rigorous clinical trial in such a resource-poor setting be possible?
Even if the intervention proved to be efficacious, would it be sustainable?
Local Syndromes of Depression
Yo’kwekyawa (self-loathing)- Feeling lonely- Feeling no interest in things- Worrying too much about things- Feeling hopeless about the
future- Hating the world- Thoughts of killing self- Irritability- Bad, criminal or reckless
behavior- Feeling sad- Feeling worthless- Not responding when
greeted/withdrawn- Crying easily- Poor appetite- Feeling of severe suffering/pain
Okwekubagiza (self-pity)- Feeling sad- Feeling lonely- Worry too much about things- Feeling worthless- Low energy, feeling slowed
down- Crying easily- Feeling fidgety- Feeling no interest in things- Feeling everything is an effort- Irritability- Unappreciative of assistance
Assessment of Depression and Functioning
Assessment of Depressive Symptoms: Hopkins Symptom Checklist (HSCL) validated against the local syndromes 1
Assessment of Functioning: Development of a Local Measure 2
Ethnographic methods derived gender-specific tasks viewed as essential elements of functioning (caring for self, family, community)
1Bolton P. (2001) Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument. Nerv Ment Dis. 189:238-242.
2 BoltonP, Tang AM. (2003). An alternative approach to cross-cultural function assessment. Soc Psychiatry Psychiatr Epidemiol. 37:537-543.
Items Comprising the Assessment of Functioning Scale
Males Personal Hygiene Farming Head the Home Manual Labor Plan for the Family Participate in
Community Development Activities
Attend Meetings Participate in Burial
Ceremonies Socialize
Females Personal Hygiene Caring for Children Cooking Washing
Clothes/Utensils Cleaning
House/Surroundings Growing Food Participate in
Community Development Activities
Attend Meetings Console and Assist the
Bereaved
Function Assessment Graphic
Rationale for Using Psychotherapy
Depression was recognized by the community as a major source of disability and needed to be addressed
Local traditional healers felt unable to treat depressive syndromes effectively
Medication not feasible, e.g., cost too high, few MDs
Selecting Psychotherapy
Psychotherapy had to be manualized, evidence-based and compatible with the local culture
Other instances of western psychotherapy that showed efficacy in developing countries (Arraya et al, 2003)
Psychotherapy delivery had to be feasible: use group format; implemented by non-mental health professionals
Selecting IPT
CBT and IPT were considered by local experts
Cultural attitude in Uganda: people see themselves as part of a family or group (“people are people within people”)
IPT seemed compatible with the Ugandan culture
Facts about IPT
Developed by Klerman, Weissman and colleagues in the 1970s
Time-limited psychotherapy (8 to 20 Sessions)
Focuses on improving symptoms and interpersonal functioning
Principles of IPT
Assumes that depression is triggered by interpersonal difficulties in one or more of the following problem areas:
GRIEF Death of a person significant to the patient
INTERPERSONAL DISPUTES Disagreements (overt and covert)
ROLE TRANSITIONS Life changes—negative and positive
INTERPERSONAL DEFICITS Loneliness, social isolation
Preliminary Work Before Departure
Preparation of a draft of the IPT manual, knowing it had to be modified on site (consulted with PI and local supervisor during development)
Manual specified 18 weekly sessions, 2 pre-group individual and 16 group sessions, 90 minutes duration
Single sex groups of 8, leaders’ sex matching that of the participants to facilitate disclosure
Project was sanctioned by local leaders and traditional healers
The Group Leaders
Group IPT Training in Rural Uganda
Problems Trainers were unaware of cultural
relevance of IPT concepts and techniques
The 10 trainees were non-mental health professionals (task shifting)
How the IPT Manual was Adapted
Sources of information: trainees, and ethnographic study
(interactive process)
Modifications of manual General adaptations:
Simple language More structure
How the IPT Manual was Adapted
Specific adaptations Pre-group meeting:
Local definition of depression (emphasize that it is not madness)
Role of leader: will not provide material goods Confidentiality (how much to disclose to the
community) Treatment contract (flexibility, schedule around
community events)
How the IPT Manual was Adapted
Evidence for 3 Problem Areas
1. Grief: death of a loved one – multiple deaths - reconstruct the relationship while not being disrespectful to the dead loved one.
2. Role Disputes: disagreements - respect and work within the cultural code regarding power and intimacy.
3. Role Transitions: life changes - when dealing with devastating life changes (AIDS, famine), focus on the elements under the individual’s control.
*Poverty: is this a separate problem area?
The IPT Training (workshop, manual, supervision)
Extensive didactic workshop (2 weeks) of lay community members
During training: modified manual; conducted workshop; assessed preliminary therapist competence
Used trainee group as an experiential group to demonstrate problem areas and group process
Study Population
Inclusion: o Over age 17, residing in Rakai and Masaka provinceso Identified by key community informants as suffering
from Yo’kwekyawa and/or Okwekubagiza o Self-identified as suffering from Yo’kwekyawa and/or
Okwekubagizao Positive on both HSCL and function questionnaireo Consents to participate in the trial before
randomization and consents after treatment allocation
Exclusion: Actively suicidal
Flow Chart
631identified
341 eligible
163 randomized
to IPT
178 randomizedto control
139 approached
145 approached
116 agreed to participate
132 agreed to participate
107 completed
IPT
117 completedfollow-up
Intention to Treat
Completers
Results for Intent-to-Treat Sample (N=248)
0
5
10
15
20
25
30
Baseline Termination 6-MonthFollow-Up
IPT Mean
Control Mean
26
De
pre
ssio
n S
co
res
(H
SC
L)
P< .001 P< .001
Results for Intent-to-Treat Sample
-1
1
3
5
7
9
11
13
15
Baseline Termination 6-MonthFollow-Up
IPT Mean
Control Mean
Fu
nct
ion
al i
mp
airm
ent
Sco
res
P< .001 P< .001
Results
At termination, 6.5% and 54.7% of the IPT and TAU groups respectively still met criteria for Major Depression compared with 86% (IPT) and 94% (TAU) at baseline1
Ethnographic assessment in study communities on intended and unintended consequences of the IPT program (positive and negative) showed as the most frequently endorsed outcomes: (Lewandowski, et al, in preparation).
1 Bolton et al (2003) JAMA:289 (23), 3117-3124)
What are all the changes that happened for people who participated in the IPT groups?
Change in community (60 respondents): Number of respondents who mentioned change:People pay school fees for children to go to school. 34
They are active in agriculture and animal husbandry.Cleanliness in families has improved (sanitation in family compound including toilets, keeping rubbish away).
33
28
We get enough food (from farming, aka, farms produce more now). 26People are working harder. 21
We received knowledge and skills in modern farming, agriculture and animal husbandry. 21Cleanliness in the community has improved (there are better sanitation facilities and practices). 20
Children now go to school (due to changed attitudes and motivation in children). 19
Parents learn to behave well (to respect other family members). 18Behaviors in homes have improved. 16
We get counseling and advice concerning our problems from our fellow members. 16
We behave in a way that society expects us. (aka, people behave well). 14There is peace in families. 13We still lack some support (financial). 13
We give each other advice about animal and crop husbandry and how to overcome problems. 13There is unity (and cooperation). 12We dig/cultivate crops together. 11We consider working very important because it is the means through which we get some money. 10There is no more depression. 10We now get some happiness (we have pleasant times). 10Children now get involved in working. 9They save some money in their groups. 9
Collective Resilience
Michael Ungar, Co-Director of the Resilience Research Center in Halifax, has suggested that resilience is better understood as follows:
"In the context of exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being, and their capacity individually and collectively to negotiate for these resources to be provided in culturally meaningful ways."
No health without mental health. No development either.
Depression is a condition of hopelessness and helplessness
By assisting depressed community members to break the social isolation, generate options, identify advocates when powerless, and have more hope, we can help communities find greater access to resources available
We now have feasible, inexpensive, culturally acceptable, and highly effective tools to treat depression
Lets do it.
Learned Helplessness
Worldview / Mindset: Pessimistic attributional style & other
fatalistic beliefs
Depression / Despair
Difficult roleFulfillment (as
parent, as farmer)
Gender-based
Violence
Maternal Distress:Depression /
Anxiety
Negative attitudes(e.g., about child)
More stunting & Underweight / Less
programimpact
Lowered responseto new opportunities /
behavior change
Some connections …
My hope is that mental health interventions will increasingly be included in food security programs. But first we need to make the case that they could be effective and that it's something that implementers could do with the proper training.” Tom Davis
This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Food for the Hungry and do not necessarily reflect the views of USAID or the United States Government.