Hostname: page-component-69cd664f8f-vwfj8 Total loading time: 0 Render date: 2025-03-12T09:58:21.479Z Has data issue: false hasContentIssue false
  • English
  • Français

Psychological treatments delivered by community health workers in low-resource government health systems: effectiveness of group interpersonal psychotherapy for caregivers of children affected by nodding syndrome in Uganda

Published online by Cambridge University Press:  15 February 2018

Byamah B. Mutamba ,
Jeremy C. Kane ,
Joop T. V. M. de Jong ,
James Okello ,
Seggane Musisi  and
Brandon A. Kohrt
Byamah B. Mutamba*
Affiliation:
Butabika National Mental Hospital, Kampala, Uganda Amsterdam Institute of Social Science Research, Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands
Jeremy C. Kane
Affiliation:
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Joop T. V. M. de Jong
Affiliation:
Amsterdam Institute of Social Science Research, Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands
James Okello
Affiliation:
Department of Mental Health, Gulu University, Gulu, Uganda
Seggane Musisi
Affiliation:
Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
Brandon A. Kohrt
Affiliation:
Department of Psychiatry, George Washington University, Washington, DC, USA
*
Author for correspondence: Byamah B. Mutamba, E-mail: [email protected], [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Despite increasing evidence for the benefits of psychological treatments (PTs) in low- and middle-income countries, few national health systems have adopted PTs as standard care. We aimed to evaluate the effectiveness of a group interpersonal psychotherapy (IPT-G) intervention, when delivered by lay community health workers (LCHWs) in a low-resource government health system in Uganda. The intended outcome was reduction of depression among caregivers of children with nodding syndrome, a neuropsychiatric condition with high morbidity, mortality and social stigma.

Methods

A non-randomized trial design was used. Caregivers in six villages (n = 69) received treatment as usual (TAU), according to government guidelines. Caregivers in seven villages (n = 73) received TAU as well as 12 sessions of IPT-G delivered by LCHWs. Primary outcomes were caregiver and child depression assessed at 1 and 6 months post-intervention.

Results

Caregivers who received IPT-G had a significantly greater reduction in the risk of depression from baseline to 1 month [risk ratio (RR) 0.25, 95% confidence interval (CI) 0.10–0.62] and 6 months (RR 0.33, 95% CI 0.11–0.95) post-intervention compared with caregivers who received TAU. Children of caregivers who received IPT-G had significantly greater reduction in depression scores than children of TAU caregivers at 1 month (Cohen's d = 0.57, p = 0.01) and 6 months (Cohen's d = 0.54, p = 0.03). Significant effects were also observed for psychological distress, stigma and social support among caregivers.

Conclusion

IPT-G delivered within a low-resource health system is an effective PT for common mental health problems in caregivers of children with a severe neuropsychiatric condition and has psychological benefits for the children as well. This supports national health policy initiatives to integrate PTs into primary health care services in Uganda.

Keywords

Caregiversdepressiongovernment health systemgroup interpersonal psychotherapylow- and middle-income countrynodding syndromeUgandaID ISRCTN11382067
Type
Original Articles
Information
Psychological Medicine , Volume 48 , Issue 15 , November 2018 , pp. 2573 - 2583
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Abbo, C, Ekblad, S, Waako, P, Okello, E and Musisi, S (2009) The prevalence and severity of mental illnesses handled by traditional healers in two districts in Uganda. African Health Sciences 9(Suppl 1), S16–S22.Google Scholar
Aganyira, R (2013) Stigma and Associated Factors in Caregivers of Patients Diagnosed with Schizophrenia Attending Butabika National Referral Mental Hospital in Nakawa Division, Kampala District. Kampala, Uganda: Diploma in Clinical Psychiatry, Butabika School of Psychiatric Clinical Officers.Google Scholar
Ayikoru, T (2015) Perceived Stigma and Associated Factors in Caregivers of Patients Diagnosed with Epilepsy Attending the out-Patients Mental Health Clinic at Entebbe District Hospital in Uganda. Butabika, Kampala, Uganda: Diploma in Clinical Psychiatry, School of Psychiatric Clinical Officers.Google Scholar
Azur, MJ, Stuart, EA, Frangakis, C and Leaf, PJ (2011) Multiple imputation by chained equations: what is it and how does it work? International Journal of Methods in Psychiatric Research 20, 40–49.Google Scholar
Bazos, DA, Lafave, LRA, Suresh, G, Shannon, KC, Nuwaha, F and Splaine, ME (2015) The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda. Implementation Science 10, 1.Google Scholar
Beardselee, WR, Versage, EM and Giadstone, TR (1998) Children of affectively ill parents: a review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry 37, 1134–1141.Google Scholar
Betancourt, TS (2011) Attending to the mental health of war-affected children: the need for longitudinal and developmental research perspectives. Journal of the American Academy of Child & Adolescent Psychiatry 50, 323–325.Google Scholar
Betancourt, TS, Yudron, M, Wheaton, W and Smith-Fawzi, MC (2012) Caregiver and adolescent mental health in Ethiopian Kunama refugees participating in an emergency education program. Journal of Adolescent Health 51, 357–365.Google Scholar
Birleson, P (1981) The validity of depressive disorder in childhood and the development of a self-rating scale: a research report. Journal of Child Psychology and Psychiatry 22, 73–88.Google Scholar
Bolton, P, Bass, J, Betancourt, T, Speelman, L, Onyango, G, Clougherty, KF et al. (2007) Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. Journal of the American Medical Association 298, 519–527.Google Scholar
Bolton, P, Bass, J, Neugebauer, R, Verdeli, H, Clougherty, KF, Wickramaratne, P et al. (2003) Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. Journal of the American Medical Association 289, 3117–3124.Google Scholar
Bruffaerts, R, Demyttenaere, K, Borges, G, Haro, JM, Chiu, WT, Hwang, I et al. (2010) Childhood adversities as risk factors for onset and persistence of suicidal behaviour. British Journal of Psychiatry 197, 20–27.Google Scholar
Buchmann, K (2014) ‘You sit in fear’: understanding perceptions of nodding syndrome in post-conflict northern Uganda. Global Health Action 7, 25069.Google Scholar
Campanini, RF, Schoedl, AF, Pupo, MC, Costa, ACH, Krupnick, JL and Mello, MF (2010) Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial. Depression and Anxiety 27, 72–77.Google Scholar
Cuijpers, P, Donker, T, Weissman, MM, Ravitz, P and Cristea, IA (2016) Interpersonal psychotherapy for mental health problems: a comprehensive meta-analysis. American Journal of Psychiatry 173, 680–687.Google Scholar
Elbedour, S, Ten Bensel, R and Bastien, DT (1993) Ecological integrated model of children of war: individual and social psychology. Child Abuse & Neglect 17, 805–819.Google Scholar
Ford, T (2003) Introduction to epidemiological study designs. In Martin Prince, RS, Ford, T and Hotopf, M (eds.) Practical Psychiatric Epidemiology. Great Britain: Oxford University Press, pp. 85–96.Google Scholar
Fulton, BD, Scheffler, RM, Sparkes, SP, Auh, EY, Vujicic, M and Soucat, A (2011) Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Human Resources for Health 9, 1.Google Scholar
Goodman, R, Ford, T, Simmons, H, Gatward, R and Meltzer, H (2000) Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. The British Journal of Psychiatry 177, 534–539.Google Scholar
Gullone, E and Robinson, K (2005) The inventory of parent and peer attachment – revised (IPPA-R) for children: a psychometric investigation. Clinical Psychology & Psychotherapy 12, 67–79.Google Scholar
Hogan, BE, Linden, W and Najarian, B (2002) Social support interventions: do they work? Clinical Psychology Review 22, 381–440.Google Scholar
Idro, R, Musubire, KA, Byamah, MB, Namusoke, H, Muron, J, Abbo, C et al. (2013) Proposed guidelines for the management of nodding syndrome. African Health Sciences 13, 219–225.Google Scholar
Idro, R, Opar, B, Wamala, J, Abbo, C, Onzivua, S, Mwaka, DA et al. (2016) Is nodding syndrome an Onchocerca volvulus-induced neuroinflammatory disorder? Uganda's story of research in understanding the disease. International Journal of Infectious Diseases 45, 112–117.Google Scholar
Johnson, TP, Tyagi, R, Lee, PR, Lee, M-H, Johnson, KR, Kowalak, J et al. (2017) Nodding syndrome may be an autoimmune reaction to the parasitic worm Onchocerca volvulus. Science Translational Medicine 9, eaaf6953.Google Scholar
Kigozi, F, Ssebunnya, J, Kizza, D, Cooper, S and Ndyanabangi, S (2010) An overview of Uganda's mental health care system: results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS). International Journal of Mental Health Systems 4, 1.Google Scholar
Kilbourne, AM, Neumann, MS, Pincus, HA, Bauer, MS and Stall, R (2007) Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implementation Science 2, 1.Google Scholar
Kinyanda, E, Hoskins, S, Nakku, J, Nawaz, S and Patel, V (2011) Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda. BMC Psychiatry 11, 1.Google Scholar
Kinyanda, E, Kizza, R, Abbo, C, Ndyanabangi, S and Levin, J (2013) Prevalence and risk factors of depression in childhood and adolescence as seen in 4 districts of north-eastern Uganda. BMC International Health and Human Rights 13, 1.Google Scholar
Klerman, G, Weissman, M, Rounsaville, B and Chevron, E (1984) Interpersonal Psychotherapy of Depression. SC: BasicBooks.Google Scholar
Kohrt, BA, Jordans, MJ, Tol, WA, Luitel, NP, Maharjan, SM and Upadhaya, N (2011) Validation of cross-cultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal. BMC Psychiatry 11, 1.Google Scholar
Lewandowski, R, Bolton, P, Feighery, A, Bass, J, Hamba, C, Haroz, E et al. (2016) Local perceptions of the impact of group interpersonal psychotherapy in rural Uganda. Global Mental Health 3, e23. doi: 10.1017/gmh.2016.15.Google Scholar
Morris, J, Belfer, M, Daniels, A, Flisher, A, Villé, L, Lora, A et al. (2011) Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries. Journal of Child Psychology and Psychiatry 52, 1239–1246.Google Scholar
Mugisha, J, Muyinda, H, Malamba, S and Kinyanda, E (2015 a) Major depressive disorder seven years after the conflict in northern Uganda: burden, risk factors and impact on outcomes (The Wayo-Nero Study). BMC Psychiatry 15, 48.Google Scholar
Mugisha, J, Muyinda, H, Malamba, S and Kinyanda, E (2015 b) Major depressive disorder seven years after the conflict in northern Uganda: burden, risk factors and impact on outcomes (The Wayo-Nero Study). BMC Psychiatry 15, 1.Google Scholar
Mugisha, J, Muyinda, H, Wandiembe, P and Kinyanda, E (2015 c) Prevalence and factors associated with posttraumatic stress disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study). BMC Psychiatry 15, 1.Google Scholar
Mugisha, J, Muyinda, H, Wandiembe, P and Kinyanda, E (2015 d) Prevalence and factors associated with posttraumatic stress disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study). BMC Psychiatry 15, 170.Google Scholar
Mutamba, B, Abbo, C, Muron, J, Idro, R and Mwaka, A (2014) Stereotypes on nodding syndrome: responses of health workers in the affected region of northern Uganda. African Health Sciences 13, 986–991.Google Scholar
Mwaka, AD, Okello, ES, Abbo, C, Odwong, FO, Olango, W, Etolu, JW et al. (2015) Is the glass half full or half empty? A qualitative exploration on treatment practices and perceived barriers to biomedical care for patients with nodding syndrome in post-conflict northern Uganda. BMC Research Notes 8, 386.Google Scholar
Nakigudde, J, Musisi, S, Ehnvall, A, Airaksinen, E and Agren, H (2009) Adaptation of the multidimensional scale of perceived social support in a Ugandan setting. African Health Sciences 9(Suppl 1), S35–S41.Google Scholar
Nakigudde, J, Mutamba, BB, Bazeyo, W, Musisi, S and James, O (2016) An exploration of caregiver burden for children with nodding syndrome (lucluc) in northern Uganda. BMC Psychiatry 16, 255.Google Scholar
Nakigudde, J, Tugumisirize, J and Musisi, S (2005) Validation of the SRQ-20 in primary care in Uganda. In Proceedings of the First Annual Makerere University Faculty of Medicine Scientific Conference.Google Scholar
Nakimuli-Mpungu, E (2012) Development of a local function assessment tool: a field-based example from the Peter C Alderman Foundation Psycho-Trauma Clinics in northern Uganda. In Proceedings from the 5th PCAF Pan African Psycho trauma Conference, pp. 16–20.Google Scholar
Nakimuli-Mpungu, E, Okello, J, Kinyanda, E, Alderman, S, Nakku, J, Alderman, JS et al. (2013) The impact of group counseling on depression, post-traumatic stress and function outcomes: a prospective comparison study in the Peter C. Alderman trauma clinics in northern Uganda. Journal of Affective Disorders 151, 78–84.Google Scholar
Nakimuli-Mpungu, E, Wamala, K, Okello, J, Alderman, S, Odokonyero, R, Mojtabai, R et al. (2015) Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-centre randomised controlled trial. The Lancet HIV 2, e190–e199.Google Scholar
Okello, J, Nakimuli-Mpungu, E, Musisi, S, Broekaert, E and Derluyn, I (2013) War-related trauma exposure and multiple risk behaviors among school-going adolescents in northern Uganda: the mediating role of depression symptoms. Journal of Affective Disorders 151, 715–721.Google Scholar
Okello, J, Nakimuli-Mpungu, E, Musisi, S, Broekaert, E and Derluyn, I (2014) The association between attachment and mental health symptoms among school-going adolescents in northern Uganda: the moderating role of war-related trauma. PLoS ONE 9, e88494.Google Scholar
Okello, J, Onen, T and Misisi, S (2007) Psychiatric disorders among war-abducted and non-abducted adolescents in Gulu district, Uganda: a comparative study. African Journal of Psychiatry 10, 225–231.Google Scholar
Okewole, A, Dada, M, Ogun, O, Bello-Mojeed, M and Usoh, T (2011) Prevalence and correlates of psychiatric morbidity among caregivers of children and adolescents with neuropsychiatric disorders in Nigeria. African Journal of Psychiatry 14, 306–309.Google Scholar
Ovuga, E, Boardman, J and Wasserman, D (2005) The prevalence of depression in two districts of Uganda. Social Psychiatry and Psychiatric Epidemiology 40, 439–445.Google Scholar
Patel, V, Chisholm, D, Parikh, R, Charlson, FJ, Degenhardt, L, Dua, T et al. (2016) Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities. The Lancet 387, 1672–1685.Google Scholar
Perlick, DA, Miklowitz, DJ, Link, BG, Struening, E, Kaczynski, R, Gonzalez, J et al. (2007) Perceived stigma and depression among caregivers of patients with bipolar disorder. The British Journal of Psychiatry 190, 535–536.Google Scholar
Perrin, S, Meiser-Stedman, R and Smith, P (2005) The Children's Revised Impact of Event Scale (CRIES): validity as a screening instrument for PTSD. Behavioural and Cognitive Psychotherapy 33, 487.Google Scholar
Petersen, I, Bhana, A, Baillie, K and Consortium, MRP (2012) The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. Community Mental Health Journal 48, 336–341.Google Scholar
Petersen, I, Hancock, JH, Bhana, A and Govender, K (2014) A group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: a randomized controlled pilot study. Journal of Affective Disorders 158, 78–84.Google Scholar
Rahman, A, Malik, A, Sikander, S, Roberts, C and Creed, F (2008) Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet 372, 902–909.Google Scholar
Roberts, B, Ocaka, KF, Browne, J, Oyok, T and Sondorp, E (2008) Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry 8, 38.Google Scholar
Roberts, B, Ocaka, KF, Browne, J, Oyok, T and Sondorp, E (2011) Alcohol disorder amongst forcibly displaced persons in northern Uganda. Addictive Behaviors 36, 870–873.Google Scholar
Shaw, DS, Connell, A, Dishion, TJ, Wilson, MN and Gardner, F (2009) Improvements in maternal depression as a mediator of intervention effects on early childhood problem behavior. Development and Psychopathology 21, 417–439.Google Scholar
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E et al. (1998) The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59(Suppl 20), 22–33.Google Scholar
Sheehan, DV, Sheehan, KH, Shytle, RD, Janavs, J, Bannon, Y, Rogers, JE et al. (2010) Reliability and validity of the mini international neuropsychiatric interview for children and adolescents (MINI-KID). The Journal of Clinical Psychiatry 71, 313–326.Google Scholar
Singla, DR, Kohrt, BA, Murray, LK, Anand, A, Chorpita, BF and Patel, V (2017) Psychological treatments for the world: lessons from low- and middle-income countries. Annual Review of Clinical Psychology 13(April), 5.1–5.33.Google Scholar
Stadnick, NA, Stahmer, A and Brookman-Frazee, L (2015) Preliminary effectiveness of Project ImPACT: a parent-mediated intervention for children with autism spectrum disorder delivered in a community program. Journal of Autism and Developmental Disorders 45, 2092–2104.Google Scholar
Struening, EL, Perlick, DA, Link, BG, Hellman, F, Herman, D and Sirey, JA (2001) Stigma as a barrier to recovery: the extent to which caregivers believe most people devalue consumers and their families. Psychiatric Services 52(12), 1633–1638.Google Scholar
Thornicroft, G, Alem, A, Santos, RA, Barley, E, Drake, RE, Gregorio, G et al. (2010) WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry 9, 67–77.Google Scholar
Thornicroft, G, Chatterji, S, Evans-Lacko, S, Gruber, M, Sampson, N, Aguilar-Gaxiola, S et al. (2017) Undertreatment of people with major depressive disorder in 21 countries. The British Journal of Psychiatry 210(2), 119–124.Google Scholar
Thornicroft, G, Deb, T and Henderson, C (2016) Community mental health care worldwide: current status and further developments. World Psychiatry 15, 276–286.Google Scholar
Tracy, EM and Whittaker, JK (1987) The evidence base for social support interventions in child and family practice: emerging issues for research and practice. Children and Youth Services Review 9, 249–270.Google Scholar
Verdeli, H, Clougherty, K, Bolton, P, Speelman, L, Lincoln, N, Bass, J et al. (2003) Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda. World Psychiatry 2(2), 114–120.Google Scholar
Verdeli, H, Clougherty, K, Onyango, G, Lewandowski, E, Speelman, L, Betancourt, TS et al. (2008) Group Interpersonal Psychotherapy for depressed youth in IDP camps in Northern Uganda: adaptation and training. Child and Adolescent Psychiatric Clinics of North America 17(3), 605–624.Google Scholar
Wainberg, ML, Scorza, P, Shultz, JM, Helpman, L, Mootz, JJ, Johnson, KA et al. (2017) Challenges and opportunities in Global Mental Health: a research-to-practice perspective. Current Psychiatry Reports 19, 28.Google Scholar
Weissman, MM, Markowitz, JC and Klerman, GL (2000) Comprehensive Guide to Interpersonal Psychotherapy. New York: Basic Books.Google Scholar
Whiteford, HA, Degenhardt, L, Rehm, J, Baxter, AJ, Ferrari, AJ, Erskine, HE et al. (2013) Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet 382, 1575–1586.Google Scholar
World Health Organization (2016) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings – Version 2.0. Geneva: World Health Organization.Google Scholar
Zimet, GD, Dahlem, NW, Zimet, SG and Farley, GK (1988) The multidimensional scale of perceived social support. Journal of Personality Assessment 52, 30–41.Google Scholar
Zou, G (2004) A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology 159, 702–706.Google Scholar