The Friendship Benches, located on the grounds of health clinics around Harare and other major cities in Zimbabwe, are staffed by lay health workers known as community “Grandmothers,” trained to listen to and support patients living with anxiety, depression, and other common mental disorders.
The new study shows that this innovative approach holds the potential to significantly improve the lives of millions of people with mental health problems in countries where access to treatment is limited or nonexistent.
Funded by the Government of Canada through Grand Challenges Canada, the randomized controlled trial was conducted by the University of Zimbabwe, the London School of Hygiene & Tropical Medicine, and King’s College London.
Researchers discovered that six months after undergoing six weekly “problem solving therapy” sessions on the Friendship Benches, participants showed significant differences in the severity of depression, anxiety, and suicidal thoughts based on questionnaires for depression and anxiety, including the Shona Symptom Questionnaire (SSQ), the Patient Health Questionnaire (PHQ), and the Generalized Anxiety Disorder scale (GAD).
Patients with depression or anxiety who received problem-solving therapy through the Friendship Bench were more than three times less likely to have symptoms of depression after six months, compared to patients who received standard care, according to the study’s findings.
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 study found that 50 percent of patients who received standard care still had symptoms of depression compared to 14 percent who received Friendship Bench (based on PHQ).
According to researchers, 48 percent of patients who received standard care still had symptoms of anxiety compared to 12 percent who received Friendship Bench (based on the GAD), and 12 percent of patients who received standard care still had suicidal thoughts compared to two percent who received Friendship Bench (based on SSQ).
The Friendship Bench intervention was also shown to be well suited to improve health outcomes among highly vulnerable individuals, according to researchers. For example, 86 percent of the study’s participants were women, more than 40 percent were HIV positive, and 70 percent had experienced domestic violence or physical illness.
Lead author of the study, Dr. Dixon Chibanda, a consultant psychiatrist in Harare, co-founded the Friendship Bench network in response to the appalling shortage of evidence-based treatment for people with mental disorders in Zimbabwe, a problem common throughout Africa.
While about 25 percent of the country’s primary care patients suffer from depression, anxiety, and other common mental disorders, Zimbabwe — which has a population of 15 million — has only 10 psychiatrists and 15 clinical psychologists.
“Common mental disorders impose a huge burden on all countries of sub-Saharan Africa,” said Chibanda. “Developed over 20 years of community research, the Friendship Bench empowers people to achieve a greater sense of coping and control over their lives by teaching them a structured way to identify problems and find workable solutions.”
With one million dollars in funding from Grand Challenges Canada earlier this year, the Friendship Bench has since been expanded to 72 clinics in the cities of Harare, Gweru, and Chitungwiza.
Through a collaboration with a Médecins Sans Frontières psychiatric program in Zimbabwe, the Friendship Bench is working to create the largest comprehensive mental health program in sub-Saharan Africa, according to its founders.
To date, more than 27,500 people have accessed treatment.
“In developing countries, nearly 90 percent of people with mental disorders are unable to access any treatment,” said Dr. Peter A. Singer, Chief Executive Officer of Grand Challenges Canada. “We need innovations like the Friendship Bench to flip the gap and go from 10 percent of people receiving treatment to 90 percent of people receiving treatment.”
“In many parts of Africa, if you are poor and mentally ill, your chances of getting adequate treatment are close to zero,” added Dr. Karlee Silver, Vice President Programs at Grand Challenges Canada. “In Zimbabwe, that’s changing thanks to the Friendship Bench, the first project with the potential to make mental health care accessible to an entire African nation.”
In 2017, the team will focus on expanding the model to reach other vulnerable populations, including youth and refugees. In partnership with the Swedish NGO SolidarMed, the team intends to expand implementation of this model in Masvingo province and subsequently in the refugee centers of the eastern highlands on the border with Mozambique.
The study, published in JAMA, was conducted from September 2014 to June 2015, and involved:
- Identifying participants at 24 primary care clinics in Harare, divided into an intervention group (287 participants) and a control group (286). Total participants was 573.
- Participants were all at least 18 years old, with a median age of 33.
- All had been assessed at nine or higher on a 14-level “Shona Symptoms Questionnaire” (SSQ-14), an indigenous measure of common mental disorders in Zimbabwe’s Shona language. Changes in depression were measured using the PHQ-9 scale.
- Excluded were patients with suicidal intent (those who were clinically depressed with suicidal thoughts and a plan for suicide), end-stage AIDS, were currently in psychiatric care, were pregnant or up to three months postpartum, presented with current psychosis, intoxication, and/or dementia (such patients were referred to a higher level clinic in Harare).
- The control group received standard care (nurse assessment, brief support counseling, medication, referral to see a clinical psychologist and/or a psychiatrist, and Fluoxetine if warranted), plus education on common mental disorders.
- Intervention group participants met on a wooden bench on the grounds of municipal clinics with trained, supervised lay health workers, popularly known as “grandmothers,” who provided problem solving therapy with three components — “opening up the mind, uplifting the individual, and further strengthening.”
- The 45-minute sessions took place weekly for six weeks, with an optional six-session group support program available.
- The “grandmothers” used mobile phones and tablets to link to specialist support. They also used a cloud-based platform that integrated the Friendship Bench project’s training, screening, patient referral, and follow-up components.
- After three individual sessions, participants were invited to join a peer-led group called Circle Kubatana Tose, or “holding hands together,” which provided support from men and women who had benefitted from the Friendship Bench earlier. At these weekly meetings, people shared personal experiences while crocheting purses made from recycled plastic materials, the latter being an income-generating skill for participants.
Source: Grand Challenges Canada
Photo: Assessed after six months, the prevalence of depression was less than 10 percent among roughly 250 Friendship Bench participants versus roughly one-third in a control group of similar size. Credit: Dixon Chibanda.