We were surprised to learn that mental health problems are more common than cancer and heart disease combined. In fact, the World Health Organization predicts that by 2030 more people will be affected by depression than any other health problem.
Mental disorders are truly universal and are found in all regions, all countries and all societies, among rich and poor, in both urban and rural areas. The overall prevalence is the same among men and women. The prevalence of the severe mental disorders schizophrenia and bipolar disorder is also the same. But depression is more common among women, and substance abuse disorders are more common among men.
In many communities, mental illness is still not considered a real medical condition and is stigmatized or viewed as a weakness of character. In the past, many with mental illness were warehoused into large mental institutions where they were often abused.
Poorer countries have more depression than richer countries and even poor people in rich countries have a higher incidence of depression compared with richer people in the same countries.
In poorer countries, attention to mental health is minimal. Treating depression in countries where there are many other problems is often considered a luxury. Depression is especially prevalent were people have experienced war and major deprivations like serious illness, death or seeing your children go hungry. Besides, how could treatment be done? Drugs are expensive and most poor countries have few psychiatrists or psychologists outside private clinics.
How do you close treatment gaps where there are hardly any professionals? Let’s listen to Vikram Patel, professor and psychiatrist at the London School of Hygiene,who also works in Goa, India.
He maintains that some problems arise from the remoteness of psychiatry and its allied professions in the communities they serve. Interventions are heavily medicalized, do not engage sufficiently with personnel and community resources, are delivered in highly specialized, expensive setting and use language and concepts that alienate ordinary people.
The way language is used is important. For example, in Lesotho, there is no equivalent for the English term “counseling” in the local language. In a study in Uganda, it was realized that the term “depression” was not culturally appropriate. Equivalent phrases are used, like “hating oneself” or “pitying oneself.”
The strategy that has been used for preventing and curing disease all over the world where health care professionals are few is task-sharing. That means training and supporting people with lower levels of education to do the work of doctors and nurses. It is much better if the people are local. Similarly, training local lay people to provide psychological interventions has had impressive results. Field studies have shown that effective therapy for depression can be delivered in the poorest setting by lay people. Some examples:
- In a story in a Uganda study described by Helena Verdeli, an assistant professor and director of the Global Mental Health lab at Columbia University’s Teachers College in New York: Amadi was inside her hut, sitting in the semidarkness, when a local woman named Christina came to her door to invite her to do something that would have been unheard of in her Ugandan village before: join a therapy group for depression. She was 59 and had lost five of her nine children, three of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden, or do her mat-weaving. She resisted, saying it won’t bring her children back.After some urging, she agreed. The group consisted of eight women facilitated by Christina. They met weekly, first spending their time describing their problems and comforting each other. Together they visited the graves of their loved ones and held a formal mourning service. All the women, including Amadi, gradually got better. The women all became active in the community.
- Another successful study included nearly 3000 people with symptoms of depression or anxiety in Goa, India: Post-conflict Sierra Leone established child-soldier rehabilitation projects, which provide counseling and support for children traumatized by war. For the gender-based violence in Congo,there were established Listening Houses, where women can talk through their experiences in a safe environment.
- Mentally ill persons need humane treatment and their dignity respected: A remarkable example of such humane treatment goes back over 700 years in Geel, Belgium. During the Middle Ages the church was the primary source for those with various forms of what today we would call mental illness. Many sought treatment by making their way to Geel for intervention through the church of St. Dymphna, the patron saint of the mentally ill. As those seeking help filled the church and the city, the city developed a lack of housing. So the church elders instructed townspeople to offer their homes to the pilgrims. What followed was a tradition of foster family care for the mentally ill, which endures until today. There are still several hundred in residence today, sharing their lives with their host families for years. About half of them have jobs in sheltered workshops. In 1861, a hospital appeared in town, but it was simply a place where boarders came to be assessed before taking up their lodgings in town. This combination of medical supervision and family care has been copied in dozens of towns in Belgium, France and Germany in their own version of the “geel system.”