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

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Where There is No Where There is No Psychologist: Psychologist: Community-level Treatment Community-level Treatment of Depression using of Depression using Interpersonal Group Interpersonal Group Therapy Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT LMFT Director of Health Programs, Food for Director of Health Programs, Food for the Hungry the Hungry Presentation for CCIH Conference, Presentation for CCIH Conference, June 2006 June 2006

Transcript of Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group...

Page 1: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Where There is No Where There is No Psychologist:Psychologist:

Community-level Community-level Treatment of Depression Treatment of Depression

using Interpersonal Group using Interpersonal Group TherapyTherapy

Tom Davis, MPH & Gracia Blees, MEd, LPC, Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFTLMFT

Director of Health Programs, Food for the Director of Health Programs, Food for the HungryHungry

Presentation for CCIH Conference, Presentation for CCIH Conference, June 2006June 2006

Page 2: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Depression in Developing Depression in Developing Countries: Countries:

Your ExperiencesYour ExperiencesTake five minutes to talk with Take five minutes to talk with your neighbor using the following your neighbor using the following questions: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?

Page 3: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Some Causes of Some Causes of DepressionDepression

Chronic illness (and the prolonged pain that Chronic illness (and the prolonged pain that often accompanies it)often accompanies it)

Loss of a friend or relativeLoss of a friend or relative Disappointment and relationship problems at Disappointment and relationship problems at

home, work, or school home, work, or school Alcohol or drug abuse Alcohol or drug abuse Spousal abuseSpousal abuse Chronic stress Chronic stress Childhood events like abuse or neglect Childhood events like abuse or neglect Social isolation (common in the elderly) Social isolation (common in the elderly) Nutritional deficiencies (e.g., folate, B12) Nutritional deficiencies (e.g., folate, B12)

How often do you see these precursors in How often do you see these precursors in developing countries??developing countries??

Page 4: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Leading Burden of Disease Leading Burden of Disease (Worldwide)(Worldwide)

1990 20201990 2020

1. Lower resp. infections1. Lower resp. infections

2. Diarrheal diseases2. Diarrheal diseases

3. Perinatal conditions3. Perinatal conditions

4. 4. Unipolar major Unipolar major depressiondepression

5. Ischemic heart disease5. Ischemic heart disease

6. Cerebrovascular disease6. Cerebrovascular disease

7. TB7. TB

8. Measles8. Measles

9. Road traffic accidents9. Road traffic accidents

10. Congenital abnormalities10. Congenital abnormalities

1. Ischemic heart disease1. Ischemic heart disease

2. 2. Unipolar major Unipolar major depressiondepression

3. Road traffic accidents3. Road traffic accidents

4. Cerebrovascular disease4. Cerebrovascular disease

5. COPD5. COPD

6. Lower resp infections6. Lower resp infections

7. TB7. TB

8. War injuries8. War injuries

9. Diarrheal diseases9. Diarrheal diseases

10. HIV10. HIV

#4 in terms of leading causes of disability-adjusted life years (DALYs)

Page 5: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Depression is now Depression is now the #1 the #1

global cause of global cause of disabilitydisability•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]

Page 6: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Prevalence in primary health care settings by city

Current depression

(%)

All mental disorders (according to CIDIa) %

Santiago, Chile 29.5 52.5

Manchester, UK 16.9 24.8

Rio de Janeiro, Brazil

15.8 35.5

Paris, France 13.7 26.3

Ankara, Turkey 11.6 16.4

Mainz, Germany 11.2 23.6

Bangalore, India 9.1 22.4

Athens, Greece 6.4 19.2

Seattle, USA 6.3 11.9

Ibadan, Nigeria 4.2 9.5

Nagasaki, Japan 2.6 9.4

Depression throughout the Depression throughout the world…world…

Page 7: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Depression and Abuse in Depression and Abuse in Mozambique and KenyaMozambique and Kenya

37% of all Mozambican mothers 37% of all Mozambican mothers (Sofala province) felt depressed on (Sofala province) felt depressed on half or more days of the week. half or more days of the week.

42% of the Kenyan women interviewed 42% of the Kenyan women interviewed (Marsabit area) were depressed on (Marsabit area) were depressed on half of the days of the week or more.half of the days of the week or more.

96% of Kenyan women interviewed 96% of Kenyan women interviewed said that it was okay for a man to hit a said that it was okay for a man to hit a woman.woman.

(No relationship between material (No relationship between material depression and child’s malnutrition depression and child’s malnutrition found [but small sample])found [but small sample])

Page 8: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Group Interpersonal Group Interpersonal Psychotherapy for Depression in Psychotherapy for Depression in Rural Uganda: A Randomized Rural Uganda: A Randomized

Control TrialControl Trial Paul Bolton, MBBSPaul Bolton, MBBS Judith Bass, MPHJudith Bass, MPH Richard Neugebauer, PhD, MPHRichard Neugebauer, PhD, MPH Helen Verdeli, PhDHelen Verdeli, PhD Kathleen F. Clougherty, MSWKathleen F. Clougherty, MSW Priya Wickramaratne, PhDPriya Wickramaratne, PhD Liesbeth Speelman, MALiesbeth Speelman, MA Lincoln Ndogoni, MALincoln Ndogoni, MA Myrna Weissman, PhD Myrna Weissman, PhD

JAMA, June 18, 2003 – Vol 289, No. 23, 3117-3124JAMA, June 18, 2003 – Vol 289, No. 23, 3117-3124

Page 9: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Adapting group interpersonal Adapting group interpersonal therapy for a developing country: therapy for a developing country:

experience in rural Ugandaexperience in rural Uganda

Verdeli et al.Verdeli et al. World Psychiatry, 2:2, June 2003, World Psychiatry, 2:2, June 2003,

114-123114-123

Page 10: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Context of the Rural Uganda Context of the Rural Uganda Study on Study on

IPT-G for Treatment of IPT-G for Treatment of DepressionDepression

1.1. World Vision project areas (Uganda) World Vision project areas (Uganda)

2.2. February – June 2002February – June 2002

3.3. 30 villages in Masaka and Rakai 30 villages in Masaka and Rakai districts of Uganda (of 154 villages in districts of Uganda (of 154 villages in all of Rakai province and contiguous all of Rakai province and contiguous half of Masaka province in SW half of Masaka province in SW Uganda).Uganda).

4.4. Three-stage screening process done by Three-stage screening process done by WV staff (explained later…)WV staff (explained later…)

Page 11: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Context of the Rural Uganda Context of the Rural Uganda Study on Study on

IPT-G for Treatment of IPT-G for Treatment of DepressionDepression

5.5. Studied men in 15 communities and Studied men in 15 communities and women in 15 communities (randomly women in 15 communities (randomly assigned)assigned)

6.6. Interviewed adult men or women who Interviewed adult men or women who they or other villagers believed to they or other villagers believed to have depression-like symptoms.have depression-like symptoms.

7.7. (Feasibility and efficacy psychotherapy (Feasibility and efficacy psychotherapy for depression never tested previously for depression never tested previously in Uganda.)in Uganda.)

Page 12: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Context of the Rural Uganda Context of the Rural Uganda Program to Treat DepressionProgram to Treat Depression

8.8. Interviewed using (1) a locally-Interviewed using (1) a locally-adapted Hopkins Symptom adapted Hopkins Symptom Checklist and (2) an instrument Checklist and (2) an instrument assessing function.assessing function.

9.9. Created lists for each village: 341 Created lists for each village: 341 men/women who met DSM-IV men/women who met DSM-IV criteria for major depression or criteria for major depression or subsyndromal depression.subsyndromal depression.

Page 13: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Context of the Rural Uganda Context of the Rural Uganda Program to Treat DepressionProgram to Treat Depression

10.10. Revisited in order of decreasing Revisited in order of decreasing symptoms until they had 8-12 persons symptoms until they had 8-12 persons per village (working with the most per village (working with the most depressed individuals).depressed individuals).

11.11. 248 (75%) agreed to be in trial; 9 248 (75%) agreed to be in trial; 9 refused; remainder died/relocated.refused; remainder died/relocated.

12.12. 108 men and 116 women completed 108 men and 116 women completed the study (90%).the study (90%).

Page 14: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

The Intervention:The Intervention:Interpersonal Group TherapyInterpersonal Group Therapy 8/15 male villages and 7/15 female villages 8/15 male villages and 7/15 female villages

randomly assigned to the intervention randomly assigned to the intervention arm. Remainder to control arm.arm. Remainder to control arm.

Intervention Group

• Group Interpersonal Therapy for Group Interpersonal Therapy for depression as weekly 90-minute depression as weekly 90-minute sessions for 16 weeks. sessions for 16 weeks.

• IPT-G carried out by WV staff IPT-G carried out by WV staff members who received a two-week members who received a two-week training in IPT-G by authors of studytraining in IPT-G by authors of study

Page 15: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

The Intervention:The Intervention:Interpersonal Group TherapyInterpersonal Group Therapy

IPT-G process:IPT-G process:Facilitator reviews each person’s depressive Facilitator reviews each person’s depressive

symptomssymptomsAsks person to describe past week’s events and Asks person to describe past week’s events and

to link events to his/her moodto link events to his/her moodFacilitates support and suggestions for change Facilitates support and suggestions for change

from other group membersfrom other group members

Attendance was moderate: 54% attended Attendance was moderate: 54% attended 14+ sessions. 14+ sessions.

Dropout rate was 7.8%Dropout rate was 7.8%

(More later…)(More later…)

Page 16: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

The Intervention:The Intervention:Interpersonal Group TherapyInterpersonal Group Therapy

Control Group

Control Group: No IPT-G. (free to seek Control Group: No IPT-G. (free to seek other interventions.)other interventions.)

Told all that if the intervention worked, Told all that if the intervention worked, it would be made available to controls it would be made available to controls eventually. (WV is doing this eventually. (WV is doing this presently.)presently.)

Page 17: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Measurement of Program Measurement of Program ResultsResults

Examined depression and Examined depression and dysfunction scores dysfunction scores

Scales adapted and validated for Scales adapted and validated for local use. local use.

Measured proportion of persons Measured proportion of persons meeting DSM-IV major depression meeting DSM-IV major depression diagnostic criteria.diagnostic criteria.

Page 18: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Measurement of Program Measurement of Program Results:Results:

Dysfunction ScaleDysfunction ScaleDysfunction 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 difficulty2 = a moderate amount more difficulty3 = a lot more difficulty4 = 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)

Page 19: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Measurement of Program Measurement of Program Results:Results:

Dysfunction & Depression ScaleDysfunction & 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

Page 20: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

How persistent is this?

Page 21: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

16% decrease

16% decrease

74% decrease

Page 22: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.
Page 23: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

How much did function How much did function vary?vary?

At baseline, both groups had an average of At baseline, both groups had an average of about 1.4 for each task ( = A little / moderate about 1.4 for each task ( = A little / moderate amount more difficult in completing the task amount more difficult in completing the task than other people … but it’s an average).than other people … but it’s an average).

At follow-up, the intervention group had an At follow-up, the intervention group had an average of 0.47 (no more difficulty) and the average of 0.47 (no more difficulty) and the control group had an average of 0.96 (a little control group had an average of 0.96 (a little more difficulty than most people).more difficulty than most people).

BUT, some differences were greater than BUT, some differences were greater than others …others …

Page 24: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

0.77

0.16

Page 25: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.
Page 26: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

… … So what effect does So what effect does Depression have on Food Depression have on Food

Security?Security? Largely unexamined question… BUT, we Largely unexamined question… BUT, we

know that anemia affects productivity. For know that anemia affects productivity. For example…example…

Hookworm infection in adults is Hookworm infection in adults is associated with a diminished capacity to associated with a diminished capacity to carry out physical workcarry out physical work11

PProductivity of Kenyan workers with roductivity of Kenyan workers with moderate anemia was 24% below non-moderate anemia was 24% below non-anemic workers (34% less for severely anemic workers (34% less for severely

anemic workers)anemic workers)22 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.

Page 27: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Review of ResultsReview of Results Average (mean) reduction in depression Average (mean) reduction in depression

severity was 17.47 points for the severity was 17.47 points for the intervention groupintervention group

3.55 point reduction for controls.3.55 point reduction for controls.

Mean reduction in dysfunction was 8.08 Mean reduction in dysfunction was 8.08 points for the intervention group points for the intervention group

3.76 point reduction for controls.3.76 point reduction for controls.

Page 28: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Review of ResultsReview of Results

Following the intervention, depression Following the intervention, depression dropped from 86% to 6.5% (-92%) in the dropped from 86% to 6.5% (-92%) in the intervention groupintervention group

Depression dropped 94% to 54.7% in Depression dropped 94% to 54.7% in the control group (42%)the control group (42%)

Six month follow-up: Groups still Six month follow-up: Groups still meeting (?)meeting (?)

Page 29: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Review of ResultsReview of Results Odds of post-intervention Odds of post-intervention

depression among controls depression among controls was 17.31 compared to the was 17.31 compared to the odds of depression in the odds of depression in the intervention group (CI: 7.63-intervention group (CI: 7.63-39.27) … that is, 39.27) … that is, controls controls were 17.3 times more were 17.3 times more likely to be depressed at likely to be depressed at follow-up (four months follow-up (four months later) than those who later) than those who received IPT-Greceived IPT-G..

IPT-G was found to be highly IPT-G was found to be highly efficacious in reducing efficacious in reducing depression and dysfunction.depression and dysfunction.

Page 30: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Background on Interpersonal Background on Interpersonal Group Therapy (IPT-G)Group Therapy (IPT-G)

Brief, time-limited psychotherapy Brief, time-limited psychotherapy developed for treatment of non-bipolar, developed for treatment of non-bipolar, nonpsychotic depressed patients. nonpsychotic depressed patients.

IPT based on work of Adolf Myer: IPT based on work of Adolf Myer: Psychological problems are a result of Psychological problems are a result of maladaptive adjustment to one’s social maladaptive adjustment to one’s social environmentenvironment

Adapted for use with groups by Denise Adapted for use with groups by Denise Wilfley and others in 1989.Wilfley and others in 1989.

Page 31: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Background on Interpersonal Background on Interpersonal Group Therapy (IPT-G)Group Therapy (IPT-G)

Assumes the development of Assumes the development of depression occurs in a social and depression occurs in a social and interpersonal context and that interpersonal context and that onset, response to tx, and onset, response to tx, and outcomes are influenced by outcomes are influenced by interpersonal relationsinterpersonal relations

Bolton et al felt it was more similar Bolton et al felt it was more similar to problem-solving approach used to problem-solving approach used in SSA cultures (part of in SSA cultures (part of family/community).family/community).

Page 32: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

IPT-G’s SuccessesIPT-G’s Successes

IPT-G has demonstrated success:IPT-G has demonstrated success: Major depression (including treatment-resistant Major depression (including treatment-resistant

depression)depression) Recurrent depressionRecurrent depression Bipolar mood disordersBipolar mood disorders BulimiaBulimia Binge eatingBinge eating Abused women with acute PTSDAbused women with acute PTSD

Used with:Used with: AdolescentsAdolescents CouplesCouples Patients with co-morbid medical conditions (e.g., Patients with co-morbid medical conditions (e.g.,

HIV+, recent cancer diagnosis)HIV+, recent cancer diagnosis) OthersOthers

Page 33: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Differences between IPT-G Differences between IPT-G and other Therapiesand other Therapies

IPT-G isIPT-G is Time limited, not long termTime limited, not long term Focused, not open-endedFocused, not open-ended Addresses current relationships, not past onesAddresses current relationships, not past ones Interpersonal rather than intrapsychic or Interpersonal rather than intrapsychic or

taking a CBT approachtaking a CBT approach Semi-structured (strategies, but no established Semi-structured (strategies, but no established

agenda for meetings or thematic discussions)agenda for meetings or thematic discussions) Very action-oriented – person is expected to Very action-oriented – person is expected to

put what they learn in the group into practice put what they learn in the group into practice outside the group.outside the group.

Page 34: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Principles of Interpersonal Principles of Interpersonal Group TherapyGroup Therapy

Most groups have Most groups have 12-24, 90-minute weekly 12-24, 90-minute weekly sessionssessions. (In Uganda, used 16 weekly . (In Uganda, used 16 weekly sessions.)sessions.)

Aimed at resolving problems (depression Aimed at resolving problems (depression triggers) in four areastriggers) in four areas::1.1. Book: Book: GriefGrief Uganda: Uganda: Death of a loved oneDeath of a loved one

2.2. Interpersonal role disputesInterpersonal role disputes ( (DisputesDisputes). Work: ). Work: Communicating directly/effectively find solutions Communicating directly/effectively find solutions to conflict.to conflict.

3.3. Role transitionsRole transitions ( (life changes life changes [e.g., [e.g., loss of job, loss of job, becoming HIV+) Usual work: Identify +/- becoming HIV+) Usual work: Identify +/- aspects of the old and new role. Uganda: aspects of the old and new role. Uganda: Identify areas you can control, skills-building, and Identify areas you can control, skills-building, and identification of options. Goal: identification of options. Goal: powerlessness powerlessness

4.4. Interpersonal deficits Interpersonal deficits lead to problems in lead to problems in initiating or maintaining health relationships. initiating or maintaining health relationships. ((Loneliness/shyness) Loneliness/shyness) Can include binge eating, Can include binge eating, promiscuity, excessive anger, excessive passivity, promiscuity, excessive anger, excessive passivity, other social skills deficits).other social skills deficits).

Page 35: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Groups should be homogenous (e.g., having Groups should be homogenous (e.g., having the same target problem, like grief).the same target problem, like grief).

Book says: Do not include people with suicidal Book says: Do not include people with suicidal ideation, antisocial, psychopathic, highly ideation, antisocial, psychopathic, highly defensive, or have extremely low or no defensive, or have extremely low or no motivation to change.motivation to change.

If gender is an issue: Consider one male + one If gender is an issue: Consider one male + one female facilitatorfemale facilitator

Principles of Interpersonal Principles of Interpersonal Group TherapyGroup Therapy

Page 36: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Modifications to Approach in Modifications to Approach in UgandaUganda

Changed names of four problem areasChanged names of four problem areas

Created detailed scripts in simple language for use in Created detailed scripts in simple language for use in trainingstrainings

Modifications based on trainee group members ideas: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 Debated povertypoverty as a trigger for depression: as a trigger for depression: Decided it was a “risk factor,” but not a trigger.Decided it was a “risk factor,” but not a trigger.

Page 37: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Training of FacilitatorsTraining of Facilitators

Facilitators were WV non-clinical, college-Facilitators were WV non-clinical, college-level educated employees (not psychologists, level educated employees (not psychologists, and not CHWs)and not CHWs)

Emphasize – no handouts. Emphasize – no handouts.

Group is for mutual support to find out Group is for mutual support to find out which situations contribute to their which situations contribute to their depression and what to do to feel better. depression and what to do to feel better.

Discuss confidentiality. Discuss confidentiality.

Explore triggers for depression.Explore triggers for depression.

Dydactic + experiential group process: Role Dydactic + experiential group process: Role plays and practice on each stage of plays and practice on each stage of treatment. Used trainees as a group to talk treatment. Used trainees as a group to talk about loss, disputes, etc.about loss, disputes, etc.

Page 38: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Initial Phase (Sessions #1 -5):Initial Phase (Sessions #1 -5): Create cohesive group atmosphere and positive group Create cohesive group atmosphere and positive group

normsnorms Promote active member-to-member interactions. Promote active member-to-member interactions. Understand each members focal issues. Understand each members focal issues. Most learning is between group members. Most learning is between group members.

Intermediate Phase (Sessions #6-13):Intermediate Phase (Sessions #6-13): Group members provide support and challenges to other Group members provide support and challenges to other

group membersgroup members Apply group learning to current life situation. Apply group learning to current life situation. Facilitator encourages/models enthusiasm for each Facilitator encourages/models enthusiasm for each

member’s work and curiosity regarding how they are member’s work and curiosity regarding how they are applying what they have learned. applying what they have learned.

Focus on current rather than past events.Focus on current rather than past events.

Termination Phase (Sessions #14-16):Termination Phase (Sessions #14-16): Confine new issues. Confine new issues. Explore feelings about the group ending. Explore feelings about the group ending. Make plans to maintain gains.Make plans to maintain gains.

What happens in group: Phases What happens in group: Phases of IPT-Gof IPT-G

Page 39: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Last thoughts…. Last thoughts…. Depression also affects Depression also affects treatment compliance…treatment compliance…

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

Adherence Adherence measuremeasure

PTSDPTSD DepressionDepression

Uncovered Uncovered minutesminutes

.21 (p<.01).21 (p<.01) .20 (p<.02).20 (p<.02)

Correct daysCorrect days -.22 (p<.01)-.22 (p<.01) -.24 (p<.01)-.24 (p<.01)Correct dosesCorrect doses -.23 (p<.01)-.23 (p<.01) -.25 (p<.01)-.25 (p<.01)

Correlations of PTSD and Depression with Adherence1

1. http://www.fenwayhealth.org/site/DocServer/safren_to_signs_dot_com_sbm_map_ptsd_poster.ppt?docID=263#256,1,Slide 1

Page 40: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Why else is this important?Why else is this important?

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

Page 41: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

““Taken together, these findings Taken together, these findings show a protective effect [on show a protective effect [on depression] of depression] of intrinsic religiosityintrinsic religiosity of roughly the same magnitude as of roughly the same magnitude as that of selected serotonin reuptake that of selected serotonin reuptake inhibitors." inhibitors."

Religiosity as a Protective Factor in Religiosity as a Protective Factor in Depressive DisordersDepressive Disorders (Miller et al., Am J (Miller et al., Am J Psychiatry, 1999)Psychiatry, 1999)

What can the Church add?

Page 42: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

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.

Page 43: Where There is No Psychologist: Community-level Treatment of Depression using Interpersonal Group Therapy Tom Davis, MPH & Gracia Blees, MEd, LPC, LMFT.

Questions and (Possibly!) Questions and (Possibly!) AnswersAnswers