Group Therapy for Depression in Uganda Part 2 of 2

Group Therapy for Depression in Uganda Part 1 of 2 introduced the work of Doctor Etheldreda Nakimuli-Mpungu and described its importance for persons with disabilities (PWDs) and the people of Uganda. This blog will describe Doctor Nakimuli's work in more detail. Firrst it will continue describing the results of the qualitative study Developing a culturally sensitive group support intervention for depression among HIV infected and non-infected Ugandan adults: A qualitative study which has already considered Community perceptions of depression and mental health problems, Community strategies used to combat depression in the acholi community and Community perceptions of counseling. It next discusses the appropriateness of group therapy:

Structure and content of the group support intervention

When asked what would be the culturally appropriate structure of a group support intervention in terms of content, group size, composition, frequency and duration of sessions, attributes of group leaders and meeting venues, participants emphasized the need for a community based group intervention that not only focused on treatment of their depression symptoms but also provided them with skills to improve their livelihoods.

“In my experience, I have interacted with many people with depression. Medication alone cannot help. Counseling to heal the stress is the most important. We realized that people who have access to socio-economic support, counseling and medication have faster recovery”. (Mental health workers, Gulu District)

Participants believed that group members should be of the same gender and age-group who share a similar disease condition.

“People have different problems and it would be better if the people who have gone through the same problem should be involved since they know the problem better. People below 18 years should not be mixed with adults because they will not be free to share their problems and they can be scared by problems of their elders. Men and women should not be mixed because women fear to talk their minds when men are there and they feel that its men who are great thinkers with wise decisions.”(Male participants Namukora, Kitgum district) 

Most participants considered a group size of 10–15 people, a group session lasting 2–3 h, and quiet, isolated meeting venues either in the village or village health center to be appropriate...

"Group meetings can take place in an isolated place under a tree or a quiet place in a home in the village selected by group members.” (Female participants, Mucwini, Kitgum district) 

Simple cognitive behavioral techniques such as assigning homework activities, sharing one's personal feelings with others, helping people to identify unhelpful ways of thinking and teaching them helpful ways of thinking, were deemed acceptable and culturally appropriate.

“It's possible to share personal feelings with others. It is happening in all the parishes in Mucwini where HIV/AIDS people are sharing their problems in groups and are playing drama together. Here, women also have credit loan society; sometimes they meet their friends and share personal problems”. (Caregivers, Namukora, Kitgum district) 

“Even at clan level, clan leaders talk to clan members who are going against the community and change their behavior. (Male participant, Namukora Kitgum district)“It is possible to assign some activities to do at home. You can assign a group member to join recreational activities like dancing at home, or with a community group. A group member can be encouraged to work in the fields and not spend all his time crying.”(Female participants, Mucwini Kitgum district) 

Many participants desired that the facilitators of the groups to be respectable members of their community who could understand what the group participants have been through and to be able to empathize with them. Participants emphasized that group facilitators do not always have to be health professionals but individuals with some knowledge of the problem at hand and with good community standing such as community elders, spiritual leaders, teachers, clan leaders and policemen. They also thought that those who have experienced depression and have recovered could be trained to deliver the intervention. Group facilitators should not only build and earn the trust of group members but also ensure that confidentiality of sessions is preserved. Table 3 provides a summary of the key themes and their underlying descriptive codes.

Conclusions are summarized from the abstract:

Results: Our study revealed community misperceptions about etiology, presentation and treatment of depression. Regardless of HIV status, most FGD participants who were not health workers linked depression symptoms to HIV infection. Although there were concerns about confidentiality of issues disclosed, many FGD participants were supportive of a group support intervention, tailored to their gender and age, that would not only focus on treating depression but also provided them with skills to improve their livelihoods. Simple CBT techniques were deemed culturally appropriate and acceptable.
Limitation: Generalizability of study findings may be limited given that the sample was primarily of Luo ethnicity yet there are different ethnic populations in the region.
Conclusion: Local communities can directly inform intervention content. The participants' preferences confirmed the need for a gender-specific intervention for depression that extends beyond medications and empowers them emotionally, socially and economically

The winners of the 2016 Elsevier Foundation Award for Women in Science in the Developing World, Second from the left Etheldreda Nakimuli‐Mpungu, PhD (Uganda)

Finally, if you are having trouble getting to grips with all the qalitative evidence, this 2016 article describes the work of Doctor Nakimuli very clearly. (The article is reproduced in its entirity at the request of the publisher):

Depression and HIV: the search for solutions in sub-Saharan Africa

Etheldreda Nakimuli-Mpungu, Makerere University

Many people with HIV worldwide suffer from some form of mental health problem. Although antiretroviral therapy has drastically reduced HIV-related death and disability, reports of the psychiatric repercussions of HIV are on the increase.

In high-income countries, HIV-related depression – the most common mental health problem in HIV-positive people – was recognised early in the AIDS epidemic as a factor that affects treatment outcomes. Yet it is only recently that the issue has drawn attention in sub-Saharan Africa, where research has found that one in three people living with HIV suffers from depression.

Addressing co-occuring mental health problems is a necessary step in controlling the HIV epidemic. But mental health care is not yet part of the HIV care package in the region.

There are efforts to change this. Our research shows how group psychotherapy interventions that give HIV-positive people emotional and social support, as well as positive coping and income-generating skills, can make a difference.

The link between mental health and HIV

There are biological, psychological and social factors that can cause mental health problems in HIV-positive people.

Depression is the natural grief response to being diagnosed with a terminal illness and to the chronic disability that may arise from it. It can also be linked to the stigma and discrimination associated with the illness. And new psychiatric symptoms and syndromes may occur as the virus affects the brain, or because of opportunistic diseases or treatment side-effects.

Mental health issues can, in turn, influence treatment outcomes. Co-morbid depression may affect motivation to seek HIV treatment or adhere to antiretroviral therapy.

It is also linked to behaviour that may facilitate HIV transmission. People commonly internalise negative stereotypes, expecting discrimination and devaluing themselves. This can interfere with their ability to choose sexual partners and negotiate safer sexual behaviour.

Depression is also associated with reduced coping capacity, poor HIV-related disease prognosis, diminished quality of life, greater social burden, increased health-care costs and higher mortality.

Our research focused on rural primary care settings in Uganda where we developed a group support psychotherapy model to treat depression. Group support psychotherapy treats depression by providing emotional and social support, and teaching positive coping and income-generating skills.

HIV-positive people suffering from depression met in eight weekly, gender-specific sessions. They were provided with information about depression and HIV. They were guided to share personal problems and taught problem-solving and coping skills. These included how to deal with anxiety and unhelpful ways of thinking, and basic livelihood skills.

High level of engagement

Unlike previous studies of group psychotherapy for depression in sub-Saharan Africa, the participants in our group support psychotherapy sessions were eager to engage in the process. More than 80% attended six or more sessions. Given the stigma attached to HIV and mental illness, this was surprising.

There are three possible explanations for the programme’s success.

First, the target community was involved in developing the model. Group support psychotherapy had also been piloted prior to the study and word had spread in the community about its benefits.

Second, trained mental health workers created a safe environment in which the participants could experience the therapeutic processes of group therapy. For example, facilitators reported that all participants had powerful cathartic experiences. Such catharsis has been shown to result in immediate and long-lasting change.

As sessions progressed, group members also began to provide feedback and support each other, during therapy and later, in their livelihood groups. The opportunity to help others, or altruism, has been shown to restore a sense of significance and increase self esteem.

Third, unlike other psychotherapeutic interventions, facilitators taught income-generating skills to mitigate poverty, which has been shown to be a potent risk factor for depression.

Addressing depression in resource-poor settings

Our study provides the first evidence of the success of this kind of group intervention in breaking the negative cycle of poverty and poor mental health in a resource-poor setting.

Six months after the programme ended, 80% of participants said the intervention had reduced their depression and motivated them to make positive changes in their lives.

Our findings also suggest that it is possible to roll out this kind of treatment in poorly resourced rural areas. Non-mental health professionals can be trained to deliver psychotherapeutic interventions in places where it is not possible to employ sufficient numbers of mental health providers.

The shifting of mental health-related tasks from health professionals to para-professionals or non-health professionals has been well-documented in non-HIV populations.

But less is known about the effectiveness of such a shift in HIV-positive populations. We now have evidence that specialists at tertiary institutions can train mid-level mental health workers to effectively deliver group support psychotherapy.

Looking ahead

We plan to expand capacity at primary health-care centres in three districts in northern Uganda. This will allow for depression diagnosis and treatment for those receiving HIV services at these centres.

Strategies include developing tailored training curricula to teach non-specialised health workers to recognise depression and employ group support psychotherapy in its treatment.

They will also be trained to teach lay health workers to deliver group support psychotherapy to HIV-positive people. This will make first-line treatments more widely accessible and sustainable.



Etheldreda Nakimuli-Mpungu, Senior Lecturer and Psychiatric Epidemiologist, Makerere University

This article was originally published on The Conversation. Read the original article.

In summary, the work of Doctor Nakimuli is a very important homegrown, home developed, culturally appropriate treatment for people with HIV/AIDS and depression. This treatment has implications for PWDs who are vulnerable to depression in 4 ways:

1. As already noted, 1 in 5 Ugandans have a MDD (see Mental Health: Depression in Uganda).
2. PWDs are victims of prejudice which is known to cause depression (see Prejudice and Depression).
3. PWDs score significantly less on all socioeconomic indicators means they are susceptible to MDD (see Mental Health: Depression in Uganda).
4. The probable high incidence of HIV/AIDS amongst PWDs (see HIV/AIDS and Disability in Uganda) is a further risk factor for developing depression

Above all in a country with few mental health professionals this work is of major importance to all Ugandans. The significance and impact of this work should not be underestimated.