Group Therapy for Depression in Uganda Part 1 of 2

The blog Rolling back depression in Uganda presented some of the work of Doctor Etheldreda Nakimuli-Mpungu, Senior Lecturer and Psychiatric Epidemiologist, Makerere University. In the video Doctor Nakimuli described her work with people with depression and also infected or not infected with HIV/AIDS. This blog will introduce the work of Doctor Nakimuli and present the first part of the results of the qualitative study that was the basis of the video. 

The work of Doctor Nakimuli is important for persons with disabilities (PWDs) for several reasons. In the blog Prejudice and Depression it was seen that facing prejudice is a significant factor for developing depression. Add to this the findings of the blog Mental Health: Depression in Uganda which noted that approximately 1 in 5 Ugandans have major depressive disorder (MDD). Additionally PWDs score significantly less on all socioeconomic risk factors for MDD. It follows therefore that MDD or depression is a significant problem for PWDs. 

There are 2 further reasons the work of Doctor Nakimuli is important for PWDs. Firstly people with HIV/AIDS have a significant disability according to the social model of disability (See Albinism in Uganda). The social model of disability describes disability in terms of barriers. For people with HIV/AIDS the disabling barriers are attitudes like stigma and prejudice as well as physical barriers like no ramps or no sign language interpreter. Secondly, PWDs are thought to have a higher incidence of HIV/AIDS than other populations because of a high reported incidence of sexually transmitted diseases (see HIV/AIDS and Disability in Uganda). 

Group therapy is an important development that offers hope to all people with depression. Doctor Nakimuli's work primarily focuses on HIV/AIDS infected people because those with depression have less compliance taking their medications and as a consequence are at greater risks from the complications of HIV/AIDS. 

Dr. Nakimuli teaching Gulu health workers about emotional self-care

The article Treating depression in remote communities provides an overview of how people with HIV/AIDS and depression are given group therapeutic counselling. The article opens:

Can HIV health workers in rural Uganda be trained to treat the mental health of their patients as well as the physical?
The project: Finding effective treatment for depression in rural northern Uganda is anything but easy.
But health workers do visit isolated communities to care for people who live with HIV. So Etheldreda is training those health workers to recognise and respond to depression too – by delivering group psychotherapy.
The process: By working within existing health systems, Etheldreda is bringing depression therapies to areas that would otherwise have been unreachable.
She trains health workers to identify the symptoms of depression and to run group psychotherapy sessions. That training is continually refined, to ensure treatment is as effective as possible.
The potential: As Uganda continues to rebuild following years of conflict, this project is helping people who live with depression to access treatment that otherwise wouldn’t have been available.
But its potential impact goes far further. Accessing effective mental health treatment is a huge problem in many isolated places – and what Etheldreda learns through this project can lay the foundations for similarly innovative outreach work elsewhere.

Doctor Nakimuli has published a qualitative study of her group therapy work the following is taken from that 2014 paper Developing a culturally sensitive group support intervention for depression among HIV infected and non-infected Ugandan adults: A qualitative study. The paper opens setting the scene for the work:

Depression is ranked first among neuropsychiatric diseases that contribute to the burden of disease in low- and middle-income countries (LMIC) (Mathers and Loncar, 2006). War-related violence, chronic diseases such as HIV/AIDS and socio-economic disadvantage including poverty and low education have been found to be major risk factors for depression in these countries (Patel and Thornicroft, 2009). Indeed, high prevalence rates of depression symptoms have been reported in the northern region of Uganda which suffered two decades of brutal civil wars, with estimates ranging from 45% to 70% (Roberts et al., 2008; Vinck et al., 2007).
Depression is associated with low energy level and feelings of inefficacy which results in an inability to care for self, and adhere to medical, behavioral or economic interventions. Indeed, several studies have reported that depression affects an individual's work productivity and subsequently the economic productivity of an entire nation (Wedegaertner et al., 2013). For these reasons, there is urgent need of culturally appropriate interventions for depression especially in low resource settings.
The World Health Organization (World Health Organization, 2010) recommends treating depression with basic psychosocial support combined with antidepressant medication or psychotherapy, such as cognitive behavior therapy (CBT). However, these treatments are limited in low resource settings like northern Uganda (Patel et al., 2007). Further, recent studies (Fournier et al., 2010; Kirsch et al., 2008; Khan et al., 2002) have found that antidepressants are superior to placebo only in cases of moderatesevere depression and may present no advantage over placebo in treatment of mild or sub-threshold depression which is more common in low resource settings like northern Uganda (NakimuliMpungu et al., 2013a, 2013b; Roberts et al., 2008). Psychotherapeutic intervention may provide safer alternatives to medications in such cases. There is substantial evidence to support the use of CBT in the treatment of depression (Cuijpers et al., 2013), and psychological therapies are recommended by WHO as first line treatments for cases of mild or sub-threshold depression (WHO, 2010).
Although most research on development of psychotherapeutic interventions for depression has been concentrated in developed countries (Huntley et al., 2012), studies in Indonesia (Bass et al., 2012), Uganda (Bolton et al., 2007) Congo (Bass et al., 2013), and South Africa and Tanzania (Kaaya et al., 2013) indicate that both adapted western psychotherapeutic interventions and locally developed psychotherapeutic interventions can be efficacious in alleviating symptoms of depression. Provision of these therapies in group format can help to maximize the use of scare resources and thus improve access to the therapy for those who need it and decrease costs associated with providing psychological therapies.
In northern Uganda, there is urgent need to develop culturally sensitive interventions for depression. The development of culturally appropriate psychotherapeutic interventions for depression requires an understanding of the target population perceptions of the etiology, presentation and community care pathways. By integrating population-specific beliefs about depression with the CBT, it is possible to develop a theoretically grounded intervention that is tailored to the needs of this population (Jemmott, 2012). Moreover, because mental health problems and help-seeking behavior are found to be interlinked with gender roles, it is important to take gender into consideration when developing intervention models (Danielsson et al., 2011; Wiklund et al., 2010). Studies indicate that stressors such as sexual or domestic violence are closely linked to women's experiences of distress and impaired mental health (Devries et al., 2013).
This paper reports the results of a qualitative study in which we aimed to obtain information on the cultural understanding of depression symptoms, complications and treatment methods used in post-conflict communities in northern Uganda in order to inform the development of an indigenous group support intervention to treat depression. The paper also describes the features of the developed group support intervention.

Who took part in this qualitative study? (Where n=the number of people in each group).

A total of 110 men and women participated in the focus group discussions. Two gender specific focus groups of HIV positive individuals (n=20), two gender specific focus groups of HIV negative individuals (n=20), two gender specific focus groups of caregivers of individuals with current or past depression (n=20), two focus groups of mental health workers (n=25) and two focus groups of non-governmental organization (NGO) and general health workers (n=25) were convened on separate dates during the study period. The average age of study participants was 42 years (range: 19–68), 52% were males, 70% were married, 76% had primary level education, 90% were peasant farmers, 48% were HIV positive and 66% reported having had current or past depression. All participants reported experiencing war-related traumatic events. The mean number of trauma events was 7 (range: 5–16 events). Other socio-demographic and clinical characteristics of study participants are summarized in Table 1.

Community perceptions of depression and mental health problems

Although some participants were able to identify environmental stressors including war traumatic experiences, excess alcohol consumption and sudden loss of a loved one as precipitants of mental health problems, many still attributed mental health problems such as depression to ancestral spirits and witchcraft. The following excerpts from focus group discussions (FGDs) highlight some of these views:

“Mental illness comes as a result of evil spirits of those who died a long time ago. They can get on somebody and result in mental illness.” (FGD participant, Kitgum district) “You can develop mental illness by being bewitched by someone, for example a co-wife can bewitch you and you develop mental illness.” (FGD participant, Kitgum district) “I know that mental illness is the sickness of the mind. But, in our culture people say that it is caused by witchcraft or failing to do some rituals. For example, when you kill someone as it happened to those who were abducted during the war, there are some rituals which have to be performed otherwise you get mental illness.” (Mental health worker, Gulu district) 

Many participants were aware of complications of depression such as suicide but there was limited knowledge regarding the fact that depression could result in increased incidence of sexual risk behavior which could lead to acquisition of HIV/AIDS. FGD participants were not aware that infectious diseases such as HIV/ AIDS could also precipitate mental health problems. Interestingly, when presented with a case vignette describing a person with symptoms of depression and asked to identify the disease condition that the person has, most patients and their caregivers participants regardless of HIV status said that the person was suffering from HIV/AIDS.

“Ms. AB is having HIV but she is not aware. There is need for her to get counseling. I went through the same problems and I was helped by counseling.” (Male participants, Namukora, Kitgum district)

Many of the HIV positive participants shared personal experiences of rejection by family, friends, and significant others.

“HIV/AIDS causes depression due to stigma. Other people if you are struggling for something with them they ask you, when will you die? How I wisyou die sooner.”(Male participant, Namukora, Kitgum district)

Community strategies used to combat depression in the acholi community

Depression may be handled differently depending on the individual's social network or religious beliefs. Some participants said that depressed persons are usually taken to community elders, close relatives or church leaders for counseling.

“It's difficult to handle, but a depressed person can be counseled by an elder in the community or a close friend to find out the problem. She can also share her problem with her neighbor.”(Female participant, Mucwini, Kitgum district)“You can approach such a person and encourage her/him daily. Can be taken to the church for spiritual healing. The priest reads a verse in the Bible that can encourage her/him. He or she can also be taken to the traditional healer who sometimes gives local herbs.”(Caregivers, Mucwini, Kitgum district) 

If the depression is severe, then they may be referred to hospital for medication and further counseling. Others reported concurrent use of witch doctors, faith healers and hospital care.

“In Acholi, elders always stay close to a person with depression, sharing, and encouraging the person; for example if you lost your loved one. If they fail, they go to traditional healers to find the cause because they believe such a problem could be due to spiritual ancestors who died longtime ago.” (Caregivers, Kitgum district)“Sometimes they are taken to traditional healers prior to being taken to the hospitals. If the traditional healer fails to control their symptoms then they are brought to hospital. Others go to church to seek spiritual healing where they are prayed for.” (Mental health workers, Kitgum district) 

Many participants acknowledged that some depressed individuals, especially men, are reluctant to seek any form of treatment. They may drink excessively or using illicit drugs.

“In our community some individuals don't know that they have depression. When they explain their problems to you, you find that they have symptoms of depression. Many of them end up drinking alcohol every evening to calm their minds”.(Mental health worker, Gulu district) “There is a saying in Acholi culture that you should be a man, so others especially men try to show that they are strong by suppressing the problem.” (Mental health worker, Kitgum district)

Most FGD participants reported that women may try to cope in a positive way.

“Some people go to play netball or football. Some go for cultural entertainment like dancing. It is common with women in our area that they sing a lot when they are depressed and they make up their own songs as they do other family activities.” (Mental health worker, Gulu district)

While the community is responsive to those with depressed feelings, it does not tolerate those who attempt or commit suicide.

“Elders do the counseling in the community (dig into the cause and generate solutions). They also have different ways of handling the problem. In the case that someone attempts suicide; the elders have their ways of punishing the person. In complete suicide the dead body is beaten before laying the body to rest.” (Male participant Namukora, Kitgum district

Community perceptions of counseling

Most participants conceptualized counseling as sharing ideas with one who has a problem with the goal of solving that person's problem:

“It can be unity among 2 people who are having problem. It can heal people just like medicine if they are helped properly by the counselor.” (Female participant, Mucwini Kitgum district) 

"In Acholi, counseling is asking your friend what their problem is and helping them to overcome it. It's a way of reducing pain by sharing problems. Sharing ideas with one who has a problem and comforting him or her. Slowly talking to someone so that they can open up to you.” (Male participant, Namukora, Kitgum district)

 Group counseling was perceived as a better form of counseling than individual counseling.

“You are encouraged and comforted from your distress by group members. You learn new coping skills and you will not be lonely. Group members can mobilize themselves to support a member who is having more problems, like digging for someone who is too depressed, taking them to the hospital.” (Caregivers,Gulu district)

“I feel it is so helpful and it fights discrimination since you will see one another as one. There is unity; you look at yourselves as brothers and sisters. It promotes openness among group members. They get to know one another with the same problem. The group members can brainstorm and start an income generating activity.” (Male participant, Namukora, Kitgum district)

Although many felt that confidentiality would be more assured during individual than group counseling, participants in group therapy were perceived to have a greater opportunity for expanding their social networks and learning coping skills than those participating in individual therapy.

“Counseling in group can encourage group members and reduce death due to suicide. It can also help by sensitizing community about healthy matters. You get encouraged by strength and courage you see from those who join the group and you develop resilience against stigma. It promotes healthy habit like going to hospital to seek health; even going to church.”(Male participants, Namukora Kitgum district)

Through discussions, group members could learn from each other and realize that they were not alone. Further, more people who need counseling would be reached through group counseling than individual counseling.

“It helps to reduce poverty through other group activities. You learn new skills in handling different situations.”(Male participants, Namukora Kitgum district)“You can engage in income generating activities. You get encouraged by strength and courage you see from those who join the group and you develop resilience against stigma. In group you can also engage in other activities like farming. It promotes healthy habit like going to hospital to seek health; even going to church.”(Male participants, Namukora Kitgum district)

The rest of this study will be described in the next blog post with an article about Doctor Nakimuli's work. It is clear that this work is of great importance to all Ugandans and particularly PWDs.