Lay health workers dramatically improve anxiety and depression in Zimbabwe

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Brief psychological treatment delivered by Zimbabwean lay health workers dramatically improved the symptoms of patients with mental health problems, according to research by the University of Zimbabwe, the London School of Hygiene & Tropical Medicine and King’s College London.

It found patients with depression or anxiety symptoms who received problem-solving therapy through the Friendship Bench Programme were more than three times less likely to have symptoms of depression after six months, compared to patients who received standard care (14% of patients in Friendship Bench group compared to 50% patients in control group). They were also four times less likely to have anxiety symptoms and five times less likely to have suicidal thoughts than the control group after follow-up.

The randomised controlled trial was conducted by the University of Zimbabwe, the London School of Hygiene & Tropical Medicine and King’s College London, and supported by the government of Canada through Grand Challenges Canada.

Low-income countries face a particularly heavy burden of mental illness for a variety of reasons, including poverty and inadequate access to healthcare. Crucially, many countries have a chronic lack of professional support to help those with problems. Zimbabwe is particularly affected – over one in four adults attending primary healthcare facilities are believed to have depression or anxiety.

The Friendship Bench consists of six structured 45-minute one-to-one counselling sessions delivered on a wooden bench in a discreet area within the grounds of a clinic. They are given by supervised lay health workers, known as ‘grandmother health providers’, who have received training in problem solving therapy – a type of cognitive-behavioural therapy (CBT) geared to improve an individual’s ability to cope with stressful life experiences.

This study involved more than 550 patients with anxiety or depression, all aged 18 or over, at 24 randomised primary care clinics in Harare. Patients at 12 control group clinics were given standard care while those in the treatment group at 12 other clinics received Friendship Bench. After six months, all participants were then re-assessed using locally validated questionnaires for depression and anxiety; the Shona Symptom Questionnaire (SSQ), the Patient Health Questionnaire (PHQ) and the Generalised Anxiety Disorder scale (GAD).

The results were striking. 50% of patients who received standard care still had symptoms of depression compared to 14% who received Friendship Bench (based on PHQ). 48% of patients who received standard care still had symptoms of anxiety compared to 12% who received Friendship Bench (based on the GAD), and 12% of patients who received standard care still had suicidal thoughts compared to 2% who received Friendship Bench (based on SSQ).

Dr Dixon Chibanda, from the University of Zimbabwe who co-founded the Friendship Bench Programme, said: “Zimbabwe has a large treatment gap for mental, neurological and substance use disorders, with only 10 psychiatrists serving a population of 15m. The Friendship Bench offers an opportunity to fill this void and make a real difference to the lives of those with mental health problems.”

Ricardo Araya, co-author and professor of global mental health at the London School of Hygiene & Tropical Medicine, said: “Countries with substantial resources and modern healthcare facilities are struggling to cope with the global mental health crisis, so it’s no surprise that nations such as Zimbabwe aren’t able to provide adequate support. The Friendship Bench Programme is low-cost and, as this study showed, highly effective.

Training lay health workers to deliver brief psychological treatment could be a blueprint for tackling poor mental health in Africa. “Developed countries can also learn from this model by increasing mental health services in primary care using less well trained health workers – not only because it’s cheaper than referring to a psychiatrist, but also because it’s more effective. This is already happening in the UK and we should monitor its effectiveness as well as quality and safety.”

With CDN $1m in funding from Grand Challenges Canada earlier this year, the Friendship Bench Programme has since been scaled-up to 72 clinics in the cities of Harare, Gweru and Chitungwiza (total population 1.8m). To date, over 27,500 people have accessed treatment.

Dr Melanie Abas, co-author and associate professor in global mental health from King’s College London, said: “King’s College London is privileged to have been connected with research on depression in Zimbabwe for over twenty years. One of the most exciting aspects of the Friendship Bench is that it has emerged through empowering local health workers to use their own natural skills, bolstered by training in evidence-based problem-solving therapy.

“These ‘grandmother’ health workers find it rewarding to learn new techniques to improve mental health in their own communities. The Friendship Bench is set to become the largest mental health programme for depression in any low-income African country, being feasible to scale-up, low cost and culturally acceptable.”

Dr Peter A Singer, CEO of Grand Challenges Canada, said: “In developing countries, nearly 90% of people with mental disorders are unable to access any treatment. We need innovations like the Friendship Bench to flip the gap and go from 10% of people receiving treatment, to 90% of people receiving treatment.”

The authors acknowledge limitations of the study including that participants were only followed up after six months, so the long-term effects of the Friendship Bench Programme are unknown. There were also few men in the study as they are less likely to attend primary care clinics.

Importance: Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap.
Objective: To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care.
Design, Setting, and Participants: Cluster randomized clinical trial with 6 months’ follow-up conducted from September 1, 2014, to May 25, 2015, in Harare, Zimbabwe. Twenty-four clinics were randomized 1:1 to the intervention or enhanced usual care (control). Participants were clinic attenders 18 years or older who screened positive for common mental disorders on the locally validated Shona Symptom Questionnaire (SSQ-14).
Interventions: The Friendship Bench intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders.
Main Outcomes and Measures: Primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cutpoint of 9. The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire, with a range of 0 (best) to 27 and a cutpoint of 11. Outcomes were analyzed by modified intention-to-treat.
Results: Among 573 randomized patients (286 in the intervention group and 287 in the control group), 495 (86.4%) were women, median age was 33 years (interquartile range, 27-41 years), 238 (41.7%) were human immunodeficiency virus positive, and 521 (90.9%) completed follow-up at 6 months. Intervention group participants had fewer symptoms than control group participants on the SSQ-14 (3.81; 95% CI, 3.28 to 4.34 vs 8.90; 95% CI, 8.33 to 9.47; adjusted mean difference, −4.86; 95% CI, −5.63 to −4.10; P < .001; adjusted risk ratio [ARR], 0.21; 95% CI, 0.15 to 0.29; P < .001). Intervention group participants also had lower risk of symptoms of depression (13.7% vs 49.9%; ARR, 0.28; 95% CI, 0.22 to 0.34; P < .001).
Conclusions and Relevance: Among individuals screening positive for common mental disorders in Zimbabwe, LHW-administered, primary care–based problem-solving therapy with education and support compared with standard care plus education and support resulted in improved symptoms at 6 months. Scaled-up primary care integration of this intervention should be evaluated.

Dixon Chibanda; Helen A Weiss; Ruth Verhey; Victoria Simms; Ronald Munjoma; Simbarashe Rusakaniko; Alfred Chingono; Epiphania Munetsi; Tarisai Bere; Ethel Manda; Melanie Abas; Ricardo Araya

London School of Hygiene and Tropical Medicine material
JAMA abstract

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