Low-income countries hurt by natural disasters, HIV, wars, or civic strife are integrating mental health services into their general health care. They are even including proven forms of psychotherapy as part of the treatment provided in primary care settings, including in communities with very low resources (Patel et al., 2013; Eaton et al., 2012).
While The Affordable Health Act in the United States stands to increase the number of people who will receive mental health services in general health care and requires that mental health be on a par with medical care, psychotherapy may not be part of the services patients receive because of its diminishing role in the United States.
The increased use of psychotherapy in low-income countries has been based on evidence for its effectiveness for depression, the most prevalent of the mental conditions and one that produces great emotional and economic burden. A review of clinical trials of psychotherapy in countries with profound humanitarian crises found that psychotherapy worked! It produced better outcomes than usual care or in those on a waiting list -- often used as control groups in public health studies (Tol et al., 2011).
Psychotherapy in high-income countries has also recently received attention in Nature (2013) where a report on 198 clinical trials, which included over 15,000 adults with depression, showed robust effects for several common forms of psychotherapy (Barth et al., 2013).
A glimpse of what is occurring in poorer countries.
A private foundation funded two clinical studies of psychotherapy for the treatment of depression in Uganda. Psychotherapy reduced depression and its beneficial effects were sustained (Bolton et al., 2003). A clinical trial is now underway in Goa, India, to treat depression in primary care using brief psychotherapy (Patel et al., 2010; Miller, 2012). The Canadian government recently gave a $1 million grant to train health workers in psychotherapy in Ethiopia (Ravitz, personal communications, 2012) (https://www.mshfoundation.ca/page.aspx?pid=1822).
Health workers in primary care in Haiti are being trained to deliver brief psychotherapy in areas hit by the earthquake (Verdeli, personal communications, 2013). Physicians and other health and mental health professionals are being trained in psychotherapy in Brazil and in Congo for women and children who have been sexually abused (Mello, personal communications, 2012).
Supported by The World Health Organization (WHO), mental health professionals in Jordan are being trained in evidence based psychotherapy to provide services in primary care (Verdeli, personal communications, 2013). A clinical trial of psychotherapy by community health workers for depressed pregnant mothers was carried out in rural Pakistan and showed a reduction in mother's symptoms at six months, improvement that was sustained at one year (Rahman et al., 2008). A study of psychotherapy for patients with repeated primary care consultations for medically unexplained symptoms in general medical clinics in Sri Lanka was found to be effective in reducing symptoms of distress and number of visits (Sumathipala et al., 2000). These are all remarkable findings.
A glimpse at the U.S.
In contrast, in the United States a survey of outpatient psychotherapy trends revealed a decline between 1998 and 2007 in the annual percent of persons receiving outpatient psychotherapy either alone (25 percent decline) or with medication (17 percent decline) for depression, and a concurrent decline in the average number of therapy visits per patient (9.7 to 7.9). There was also a 35 percent decrease in total annual psychotherapy expenditures at the national level. During the same period, the use of psychotropic medication alone increased by over 23 percent (Olfson and Marcus, 2010).
Training in evidence-based (proven) psychotherapy in accredited graduate programs in the U.S. for psychiatrists, psychologists, and social workers, the main mental health providers of psychotherapy, also finds large gaps (Weissman et al., 2006). A survey of training programs in the U.S., answered by the training directors themselves, showed that only 28 percent of psychiatry residency training programs offer teaching and clinical supervision (this combination being the gold standard for training) in an evidence-based psychotherapy
Why?
Why is what is endorsed as a treatment for depression in some low income countries decreasing in use, training and reimbursement in the U.S.?
For one thing, psychotherapy in the popular press often shares the stigma of mental illness. It is perceived as undefined, interminable, unproven, and an indulgence for the "worried well" who can afford it. This is wrong. In fact, modern psychotherapies are well defined and described in manuals for training; many are time limited in duration. They are called evidence-based because they have been subjected to clinical trials with designs comparable to what is used to test if medications work.
The Nature article noted identified seven psychotherapies that meet evidence-based standards. These were interpersonal psychotherapy (IPT), cognitive behavioral therapy (CBT), behavioral activation (ACT), problem solving therapy (PST), psychodynamic therapy (DYN), social skills training (SST), and supportive counseling (SUP). All seven were found to be better than waiting list control conditions. CBT, IPT and PST had the most robust findings in the greatest number of clinical trials. It is important to note that all of the available clinical and research reports from low income countries have used evidence based psychotherapies -- usually CBT or IPT, and in a few cases these are combined with PST.
New studies, using positron emission tomography (PET), show the effect of CBT was not just "in your head" but also in your brain, or as Nobel prize winner Eric Kandel (2013) stated, "psychotherapy ... produced lasting detectable changes in our brain" (McGrath et al., 2013).
Health workers, including community health workers, nurses, social workers, possibly even primary care doctors in the U.S. -- as in poor countries -- need to learn to do time-limited, evidence-based psychotherapy as part of their education. Currently, with few exceptions, they learn these treatments in a limited manner on the job, at a workshop, or when a new program is trying them out. With the exception of CBT, they are not part of the required curriculum in psychiatry, psychology or social work, the major providers of psychotherapy.
As health care finances change in the years ahead there needs to be reimbursement to allow for evidenced-based psychotherapy. These are proven treatments that warrant coverage no different from medications or surgery. Depression is a highly common condition that impairs functioning. When present with other illnesses, like diabetes, heart disease and asthma, depression impairs recovery from a person's primary medical illness; that causes morbidity and mortality, and costs more money. We can't afford to not detect and provide effective treatment for this condition.
An effective treatment for mild to moderate depression is one of the evidence-based psychotherapies described here, with or without medication. It belongs as a standard treatment in primary care for the sake of patients, families, and to reduce the unnecessary costs associated with ignoring it. If low income countries are starting to do this why can't we?
References:
Barth J, Munder T, Gerger H, Nüesch E, Trelle S, et al. (2013) Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454
Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P, Speelman L, Ndogoni L, Weissman M. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003 Jun 18;289(23):3117-24.
Eaton J, McCay L, Semrau M, Chatterjee S, Baringana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and middle-income countries. The Lancet. 2011;378(9802):1592-1603.
Kandel E. (2013, September 8). The new science of mind. The New York Times, pp.12.
McGrath CL, Kelley ME, Holtzheimer III PE, Dunlop BW, Craighead WE, Franco AR, Craddock C, Mayberg HS. Toward a neuroimaging treatment selection biomarker for major depressive disorder. JAMA Psychiatry, 2013;70(8):821-829. Doi:10.1001/jamapyschiatry.2013.143
Nature. Psychotherapy helps depression. 49, 385 (July 25, 2013). Doi:1038/499383e
Olfson M, Marcus SC. National trends in outpatient psychotherapy. Am J Psychiatry. 2010 Dec;167(12):1456-63. Epub 2010 Aug 4.
Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, et al. (2013) Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms. PLoS Med 10(5): e1001448. doi:10.1371/journal.pmed.1001448
Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, De Sila MJ, Bhat B, Araya R, Simon G, Verdeli H, Kirkwood BR. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 2010 Dec 18;376(9785):2086-95. Epub 2010 Dec 13.
Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behavior therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008 Sep 13;372(9642):902-9.
Sumathipala A, Hewege S, Hanwella R, Mann AH. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Psychol Med. 2000 Jul;30(4):747-57. Therapy deficit. Nature, 2012 Sept 27;489(7417):473-4.
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