Addressing a silent disparity – for the price of two cups of coffee
by Atif Rahman, University of Liverpool, UK
Many parts of the globe have made significant strides in recognising and celebrating the immense contributions of women to every sphere of life, from running households to running countries. But much more needs to be done, especially in poorer countries. Female gender disadvantage continues to affect parity in the most basic of human rights – the right to good mental health. Today, the first ever World Maternal Mental Health Day is highlighting this human right.
Depression is twice as common in women compared to men
While the physical health of women has been emphasized in international policy guidelines such as the sustainable development goals, the mental dimensions of their health remain ignored. For example, depression is a debilitating disorder, with symptoms such as depressed mood, tiredness, insomnia, lack of energy, low self-esteem, and a lack of interest in one’s environment. It is the fourth leading cause of disease burden and the largest cause of non-fatal burden of disease, accounting for almost 12% of all total years lived with disability worldwide. Depression is twice as common in women compared to men, a reflection of the poor social status and stress women face in their everyday lives. One in five woman of childbearing age suffers from the condition.
Lack of mental health professionals to deliver treatment
Until relatively recently, the treatment of depression through counseling and psychotherapy was considered an expensive luxury that could only be afforded by the well-off in rich countries. The lack of mental health professionals represented the greatest barrier to millions of women receiving a basic human right – access to treatment that could reduce their suffering and in many cases save lives. Over the last decade, researchers have worked to simplify sophisticated psychotherapies such as cognitive-behaviour and interpersonal therapies so that these can be delivered by non-specialist health workers. These community health workers form the back-bone of health services in most poor countries and are known well to the community they serve.
The Thinking Healthy Programme: treating perinatal depression for US$10 per woman per year
One such programme is the Thinking Healthy Programme, developed after years of research with depressed women in rural areas where access to treatment was non-existent. The Thinking Healthy Programme (THP) aims to reduce perinatal depression in low socioeconomic settings and to improve health outcomes in their children through the adaptation and integration of Cognitive Behaviour Therapy (CBT) into the routine work of community health workers. Starting from pregnancy until one year after birth, participants receive 16 sessions of the evidence based “talking therapy”.
The approach in the THP includes specific cognitive behavioral therapy (CBT) strategies, in order to achieve 3 main goals:
- To identify and modify maladaptive thinking styles – in particular those leading to poor self-esteem, inability to care for their infants, and disengagement from social networks – and to substitute these with more adaptive ways of thinking
- Behavioral activation to rehearse these strategies between sessions
- Problem-solving to overcome barriers to practicing such strategies. THP also aims to improve women’s social support and status using the family’s shared commitment to the baby’s wellbeing as an entry point.
Funded by the Wellcome Trust, UK, the intervention has been evaluated in one of the largest randomized trial for psychological interventions to be conducted in the developing world, providing rigorous evidence on how well it worked.
In a rural Pakistani population of 1.2 million, about 4000 pregnant women were screened to identify 903 with perinatal depression. In partnership with the Primary Health Care Services, 42 Community Health Workers were trained to deliver THP. The intervention costs less than USD $10 per woman per year – less than the price of two cups of coffee in an up-scale coffee shop – and led to recovery in 3 out of every 4 woman treated.
The results of this research show that common mental disorders can be treated effectively and relatively cheaply by non-specialists. Despite the evidence from these, and many other studies done all over the world, we allow millions of women to suffer in silence.
What needs to be done to address women’s mental health disparity
The global community can take a number of actions to ensure that there is parity when it comes to the mental health of women in low-income settings:
- There needs to be recognition at the highest levels that mental health of women is a public health priority. Women’s mental health and well-being is a generic component of maternal and child health programmes that does not compete with other health priorities such as physical and reproductive health but complements them. Today’s World Maternal Mental Health Day marks a good start.
- Programmes such as Thinking Healthy should be integrated into the routine training and supervision of community and lay-health workers so they can manage women’s depression in the community. This will enable them to be more effective health-care workers, as well as integrating mental health into general community care.
- Investments for deployment of community workers, their training, supervision, monitoring and evaluation need to be made to allow governmental and non-governmental organizations to integrate such interventions into existing programmes focused on MCH, gender empowerment and poverty reduction.
At the same time, research also shows that the origins of such high rates of depression in women can be traced to the social circumstances of their lives.
As Desjarlais and colleagues pointed out some years ago:
“Hopelessness, exhaustion, anger and fear grow out of hunger, overwork, violence, and economic dependence. Understanding the sources of ill health for women means understanding how cultural and economic forces interact to undermine their social status. If the goal of improving women’s well-being from childhood through old age is to be achieved, healthy policies aimed at improving the social status of women are needed along with health policies targeting the entire spectrum of women’s health needs.”
Despite progress to overcome this huge disparity, much more needs to be done.
Find out more
Thinking Healthy: A manual for psychological management of perinatal depression on the World Health Organization website