Breaking Through Depression

What is the best way to reach people suffering from depression in resource-poor settings?

Depression can ruin the lives of individuals and families, but it also stands in the way of economic development in some of the world’s poorest countries. How can we effectively tackle this widespread illness, limiting its impact not only on individuals and families but on communities and nations as well?

Depression is the leading cause of disability worldwide, with more than 350 million people suffering globally. Seventy-five percent of sufferers are likely to be living in resource poor areas, and 85 percent of these people are unlikely to be receiving any treatment. Arguably, those living with depression in developing countries suffer disproportionally, their depression contributing to and compounded by a lack of understanding and treatment, inadequate food, clothing, and shelter, and a complete denial of opportunities for change.

Despite the obvious size of the problem, to my surprise I have found that tackling depression is sometimes portrayed as a luxury in both richer and poorer nations, something to aspire to when basic standards of living, and basic levels of physical health, are met. The reality, however, is that without good mental health, all other areas of life unravel. Depression prevents people from studying or working and impairs their relationships with others. It can also damage physical health, as an individual’s ability to look after themselves is reduced. In resource-poor settings, sufferers find their social standing is decimated as they become unable to contribute economically to their family, and their unusual behaviour makes them feared and rejected by their community.

Depression disproportionally affects young people, so its untreated presence can stunt a county’s economic growth. A report by the World Economic Forum and the Harvard School of Public Health estimates that the macro-economic effect of non-communicable diseases (such as cardiovascular disease, chronic respiratory disease, cancer, diabetes, and mental health) represent “a cumulative loss of $47 trillion over the next two decades.” The Mental Health component of this group alone costs $16.1 trillion.

At BasicNeeds, the organization that I founded in 2000, we find that diagnosing depression can be complicated. There are culturally specific elements, which vary from country to country, to how depression is understood and experienced. For example, in parts of Africa, a belief that mental illness is somehow related to sin or spiritual problems is not uncommon, causing families and communities to, at best, attempt ineffective treatments with local healers. At worst, those suffering from depression are locked up or ostracised.

This strong cultural component of depression is only heightened by its lack of visible or easily describable symptoms, which regularly accompany physical disease. However, the ubiquity of depression’s symptoms — sadness, loss of interest in life, low self-worth, and lethargy—and the global similarity of effective treatments means that a universal framework to improve the quality of life for those with depression can be very successful, even when allowing for cultural variation. For example, if a woman is not thriving due to post-partum depression, she may be less able to bond with her child; this common condition may be expressed in a culturally specific way and still have a recognisable common context. Treatment for it works across countries.

When I started BasicNeeds some 14 years ago, I devised a simple model combining medical, social, and economic features that I felt would be of particular value to people with mental health problemmes in low-resource settings. Since then, through the organisation’s programs in 12 different countries, I have learned how people with depression can best be reached:

  • Providing evidence-based treatment and support to individuals. Medication and psychological support can help people in a range of cultures. Recently, we were able to demonstrate that “talking therapies” can be delivered well in this manner to people suffering from general anxiety disorder and depression in our Vietnamese programme.
  • Strengthening existing health and care systems rather than creating new channels, specifically for delivering mental health care. Where there are few mental health professionals, BasicNeeds uses a “task shifting” approach that aims to provide everyone working in health care with basic mental health skills (e.g. GPs, nurses, and others in primary health care clinics, community health workers, community volunteers). BasicNeeds also works with other organisations in partnership and offers a social franchise of the BasicNeeds model. This flexible approach ensures that diagnosis, treatment, and support can reach a greater number of people.
  • Engaging families and communities. This ensures that they understand that depression is a treatable disease. It also helps them recognise symptoms and seek appropriate help and support, rather than ostracise sufferers.
  • Empowering the individual through self-help groups. This gives individuals control over their lives, a key component of the recovery process. Channelling support via groups means that individuals benefit from collective support, reducing the risk of them feeling overwhelmed by new responsibilities at a time when they may be at risk of a relapse, while at the same time responding to their pressing financial and material needs. The self-help groups are also a safe platform for people to share their problems, identify solutions, and advocate for their needs. The value of this approach has been clearly demonstrated.
  • Empowering the individual through productive work. Helping people to earn an income or find productive work can be one of the most powerful ways to combat depression. For example, within the self-help groups described above, participants learn skills like farming, horticulture, and animal husbandry, which are crucial to sustaining their recovery and reducing household poverty. A return to productive work also alleviates pressure on caregivers, the majority of whom are women. When people can feed and clothe themselves and contribute to their families, they feel accepted and valued in society.

One of our many success stories is 41-year-old Akela (not her real name), from the Khamkeut district in Lao PDR. Akela, who is married with five children and now engaged in farming, says, “I used to work as a nurse at the clinic of a military camp and had to resign in the year 2008 due to my illness. I felt so disappointed being unemployed and considered as a useless person by my family and my neighbours. After having treatment since December 2010 with the BasicNeeds programme, I got better and my confidence has returned. I am able to help my family to earn a living. I can now work growing mushrooms and selling them at the market. I earn about 600,000 LAK (or £50) per week from selling mushrooms! My family’s financial situation is improved and I feel so proud of myself being again an asset to my family.” The economic importance of BasicNeeds model is a very important contribution to survival and to self worth.

Akela’s story of successful recovery is echoed throughout our programmes. To date we have reached 624,926 people with mental illness and epilepsy, their caregivers, and family members across 12 African and Asian countries. We have improved access to treatment for 86 percent of people with mental illness in our program areas, improved symptom reduction for 73 percent, and helped 80 percent find productive work.

The failure to tackle depression in resource-poor settings is a particular travesty, because effective and low cost approaches for treatment are available. It means millions suffer needlessly, both from depression and poor economic progress — a double blow, to their personal development and that of their country.

Chris Underhill is a global expert in the delivery of health and rehabilitation systems to very poor people. A serial social entrepreneur his latest organisation, BasicNeeds, concerns the delivery of a holistic model to mentally ill people and people with epilepsy in the poorest communities of the world. The BasicNeeds Model is a significant innovation in community mental health care delivery combining medical, social, economic and personal aspects into one successful programme. By September 2014 a cumulative total of 624,926 beneficiaries (participant, carer, family) had been served in the global BasicNeeds programme. Chris is a Senior Fellow of the Ashoka Fellowship, a recipient of the Skoll Award for Social Entrepreneurship and a Schwab Foundation Social Entrepreneur. In 2000 Chris was made an MBE by the Queen for his services to disability and development.

The World Economic Forum’s Annual Meeting 2015 will take place from 21–24 January in Davos-Klosters, Switzerland, under the theme “The New Global Context.” You can find out more about the meeting here.