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News Briefs: Building the Infrastructure of Hope

Building the Infrastructure of Hope

In the wake of a disaster in the developing world—like war, epidemic or a natural calamity—the global community often responds to the immediate crisis at hand with food, medication and material supplies.

But scarcity of provisions may only be one part of what goes wrong in a large-scale crisis.

"If a mother is depressed," says Judith Bass, PhD '04, assistant professor of Mental Health, "she may not access the resources set up to help her children. Without hope, all the resources set out in front of her are useless."

Her colleague Paul Bolton, research associate at the School's Center for Refugee and Disaster Response, couldn't agree more. Originally trained as a physician, Bolton has worked with various nongovernmental organizations (NGOs) in war and disaster settings since 1988. "A severely dysfunctional individual is a big problem for the community and can be far worse than one who just dies," he says. "A dysfunctional person ends up using up the community's resources without being able to contribute anything back."

The World Health Organization ranked depression as the fourth leading contributor to the global burden of disease in 2000, and projects that by the year 2020, depression will reach second place in the ranking. Yet, WHO reports, nearly half (48 percent) of the countries in the world have no mental health policy, and 38 percent do not provide treatment for severe mental disorders at the primary care level.

While depression in the United States is effectively treated through long-term medication and counseling, such options are usually not viable in poorer countries.

"Although we need to deal with the root causes of the mental health problems resulting from wars and disasters, it is important to embark on a program that deals with the prevention of these mental health problems using the available community resources," says Haroutune Armenian, MD, DrPH, a Bloomberg School professor of Epidemiology, who is noted for his studies on the effects of civil war at the population level during the 1980s in Lebanon and the long-term effects of the 1988 earthquake disaster in Armenia.

One such program that has proven successful, say Bass and Bolton, is group therapy led by an NGO-trained community member. The two researchers are founders (with Laura Murray of Boston University) of the Applied Mental Health Research (AMHR) Group, which provides technical assistance to NGOs and other mental health care providers for populations in low- and middle-income countries.

The AMHR recently published findings from a 2005 mental health survey of Ugandan teens in displaced persons camps, in which they evaluated relatively low-cost NGO interventions used to treat depression in the adolescents. Many of the 314 teens (ages 14 to 17) in the randomized, controlled trial had survived horrifying events—rape, torture, abduction—that are the result of 20 years of conflict between the government of Uganda and the Lord's Resistance Army.

The study participants were divided among three groups: One group received "interpersonal psychotherapy intervention," psychotherapy sessions involving single sex groups of six to eight teens that were facilitated by a counselor of the same sex; the second took part in creative play, age-appropriate activities such as art, music, and games; and the third "wait-control group" received no treatment until the end of the 16-week study.

The AMHR's findings: Group interpersonal psychotherapy sessions were more effective in reducing depressive symptoms among girls than boys, while the creative play group showed no improvement for either girls or boys as compared with the control group. The study results appeared in the August 1, 2007, issue of JAMA.

Bass and Bolton suggest that the girls' measured improvement may be tied to their willingness to talk about emotional problems; and the boys had more substance abuse and post-trauma symptoms. The ineffectiveness of the creative play, the researchers say, may be attributed to the Acholi teens' grim upbringing; they are more like adults than children.

The study's implementers, World Vision Uganda and War Child Holland, agreed to use the findings to improve the creative play interventions with more culturally appropriate adaptations, and to continue providing the more effective group therapy, led by an NGO-trained community member.

"Health care is more than purely things that save lives," concludes Bolton. "Improving mental health in developing countries will actually help them develop, not just by saving lives but by enabling them to function."

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