Global Mental Health

Question 1

List the evidence-based psychological therapies

Answer 1

There are many evidence-based psychological therapies. The common ones used are:
• Cognitive Behavioural Therapy (CBT) - good evidence base for depression
• Cognitive Analytical Therapy (CAT)
• Interpersonal Therapy (IPT) - good evidence base for depression
• Brief solution focused therapy
• Psychodynamic psychotherapy
• Eye movement desensitization and reprocessing(EMDR) - good evidence base for PTSD
• Family therapy
• Dialectical Behavioural Therapy (DBT)
• Motivational Interviewing

All these therapies where developed in High Income Countries. Would these therapies still be applicable to low-income countries.

Question 2

Explain the rationale for CBT

Answer 2

CBT centres on three pillars:

• Emotions
• Thoughts
• Behaviours

The rationale of CBT is that: the way we think affects how we feel and the way we feel affects how we behave and how we behave affects how we feel.

The more we can change one of these, the more we can change the others, in a domino effect. How can we change negative thoughts? By changing the way we think (cognitive) and by changing our behaviours. CBT is more like a combination of two treatments - cognitive therapy and behavioural therapy.

Question 3

What evidence supports that CBT is applicable across cultures?

Answer 3

Pakistan
Rahman et al (2008) delivered CBTs by local health workers (not experts from London). He found that pregnant woman who had CBT had lower rates of depression at 6 months, then again at 12 months.

Chile
Araya et al (2003) delivered CBT in Santiago. Half of patients received CBT + Usual care, and other half only CBT.

Nigeria
Dr Ani and his group delivered short sessions of CBT to school children and found that 6 and 16 weeks later, the group of children who received CBT had lower levels of depression. There is a significant level of stigma attached to attending psychological clinics in Nigeria, so CBT was delivered at the school.

The summary is that CBT does work in low-income countries, provided there are adaptations for that particular country.

Question 4

Why are adaptions necessary to translate psychological therapies to other countries?

Answer 4

Adaptations are required because of:
• Relatively lower resources available in LMICs (Lower-Middle Income Countries). You cannot run the same service in London than in Ghana because of the lack of man-power and expertise.

• Language - CBT and associated lexicon where developed in High-Income English-Speaking countries. Which can be (sometimes very) different to other languages.
• Culture - there are huge differences in culture, which affect the social side of the biospsychosocial model.
○ The patient-therapist relationship is often hierarchical. Patients see the therapist as an expert, and expect him/her to act that way by showing authority and being directive.
§ A therapist attempting to be collaborative in such context may unwittingly convey the impression of lack of expertise to the patient.
○ Low income countries rely heavily on religion as a coping mechanism.
• Distance/logistics - the patient may live in a remote area that is hard to reach. So it is not uncommon that you may not see them again.
• Service organisation - Referral pathways for CBT may not exist. If it does exist, it may not be accessible for the clinician or patient. So the clinician seeing the patient on that occasion may be the only person who could offer the patient some CBT techniques.

Question 5

What adaptations can be made to translate psychological therapies to other countries?

Answer 5

• Group intervention - most cost effective. It also fits the collectivist culture of the LMICs. Meta-analyses of group CBT has shown that they are as effective as individual CBT.
• Delivery by lay people/non-specialist workers. The principles of CBT are relatively easy to convey, and CBT lends itself to manualisation. Several RCTs of CBTs in LMICs have shown good outcomes with treatments delivered by non-specialists.
• Change the content to focus more on behaviour and less on cognitive. Behavioural techniques are easier to explain, quicker to understand. Behavioural therapy is as effective as CBT or cognitive therapy.
• More directive approach - more in line with hierarchical relationship
• Language - adapt, translate, into local language, idioms and metaphors.
• Incorporate more helpful cultural/religious coping strategies. You can encourage helpful religious coping mechanisms.
• Involving families is consistent with the collectivist culture. The family can remind the patient of CBT methods.