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Talking to a trained community health worker once a week, on a simple wooden seat in a health clinic, can make a difference to the lives of people affected by mental disorders such as anxiety or depression, according to a clinical trial in Harare, Zimbabwe.

The study, published in the journal JAMA this week (December 27), found that patients who used the ‘friendship benches’ for support were less likely to have symptoms than patients who received standard treatment.

Peter Singer, CEO of Grand Challenges Canada which funds the programme through support from the government of Canada, told SciDev.Net the study proves that it’s possible to plug the mental health treatment gap. “It shows a simple innovation can work and can be integrated into the healthcare system.”

The study adds to "mounting evidence" that community health workers working in routine care facilities can effectively deliver the psychological therapies sorely missing in many resource-poor countries, according to Vikram Patel, psychiatrist and professor at the London School of Hygiene and Tropical Medicine in the U.K. 

A clinical trial by Patel and colleagues, also published in the Lancet this month, showed that brief treatment by lay counsellors for severe depression in Goa, India, was beneficial and cost-effective.

"[These treatments] are terrific value for money," Patel told SciDev.Net. "This is not even a research question worth exploring any more: the real question is how to take this innovation to scale." 

Staff shortages are a major obstacle to mental healthcare in many developing countries, where the majority patients cannot access treatment. In Zimbabwe, just 10 psychiatrists are on hand to care for about four million people who suffer from mental disorders, according to the authors.

“This is not even a research question worth exploring any more: the real question is how to take this innovation to scale.”

Vikram Patel, London School of Hygiene and Tropical Medicine

The Friendship Bench approach empowers patients to gain coping strategies and better control of their lives, according to lead author Dixon Chibanda. But it took a year-long formative research to adapt it so trainers could use idioms of distress understood in the local culture.

“We came up with a few concepts, like kuvhura pfungwa (which translates to “opening up the mind”) – it became a critical component, and the community could identify that term,” Chibanda said in an interview with SciDev.Net. "Other terms included kusimudzira, which means “to uplift”, and kusimbisa, which means “to strengthen”.

That early research also prompted a renaming from ‘mental health bench’ to ‘friendship bench’, removing the stigma that kept people away.

The programme has since been implemented in 72 clinics in Harare as well as Gweru and Chitungwiza. Singer and Chibanda believe that cultural adaptation was key to scaling up because both the community and the healthcare system are then more likely to accept it.

The team first tested the approach in Harare by randomly recruiting 573 adults who sought care for unrelated complaints in 24 clinics across the city. Those who scored high on a mental health screening test were invited to participate.

About half the participants met with health workers on the bench. The other half received standard care and education, including referral to a psychiatrist and medication.
Prior to the programme, the health workers had no specialised mental care training. All were women, and their average age was 53. This reflects a perception by the city health department that older women are more acceptable figures for conversation about mental health issues, Chibanda explained. 
They offered weekly 45-minute sessions of ‘problem solving therapy’, followed by optional group sessions, and used mobile phones and tablets to link to specialist support. After the six-month period all participants were assessed for symptoms and psychological health using locally validated questionnaires. Patients who used the bench were more than three times less likely to have symptoms of major depression after six months (13.7 per cent and 49.9 per cent prevalence of symptoms respectively). They were also four times less likely to have anxiety symptoms (12.2 per cent vs 48 per cent) and five times less likely to have suicidal thoughts than the control group (12.7 per cent vs 64 per cent).

How long the positive effect lasts after the programme ends is a question the study has yet to answer. Chibanda tells SciDev.Net anecdotal evidence one year on suggests lasting improvements. 

Over a third of those recruited had experienced domestic violence or physical illness (70 per cent) and many were HIV positive (40 per cent). Most participants were women (86 per cent), reflecting the gender balance of people using health services, according to Chibanda. The low percentage of men enrolled is a limitation which the authors plan to address.