Sekesai Hwiza, an 82-year-old Zimbabwean grandmother, spends most mornings sitting on a park bench talking to people who are emotionally broken by the stresses of life. She has met with more than 2,000 people in her community over the last three years, most of them young people who are depressed and suicidal. Each person who joins Hwiza on the bench finds a patient listener who gives nonjudgmental advice based on the best practices of psychology.
But not everyone has access to grandmothers like Hwiza.
One evening last August in Harare, a 26-year-old woman named Tanaka fed her two young children cups of cornmeal porridge laced with poison. She then read them a bedtime story before drinking a cup of the concoction herself. Hours later, her husband and neighbors rushed Tanaka, unconscious, to the emergency room. Five days later, she was dead. Neither of her children survived.
The young mother had been suffering from untreated depression for more than three months. Her family had noticed her illness, but there was no one in their community who could treat it. In fact, there are only 10 psychiatrists in Zimbabwe — a country in dire need of trained mental health workers.
Across the developing world, we are failing to address a silent crisis in global health.
Tanaka’s story is not unique. Globally, suicide is the leading cause of death among people ages 15 to 29. More than 1 million people kill themselves each year, with most of these deaths occurring in low- and middle-income countries. These deaths are often triggered by negative life events, such as experiencing conflict, disaster, violence, abuse or loss and isolation. The World Health Organization estimates that one person commits suicide somewhere in the world every 40 seconds.
Despite these figures, funding for global mental health has remained consistently poor over the last 20 years, with most low- and middle-income countries allocating less than 1% of their healthcare budgets to mental health.
The single most common cause of suicide is depression, which is also the leading disability globally. We know that treating depression can avert suicide, but global resources to treat the illness are limited, particularly in poorer countries where there is often only one psychiatrist for populations of over a million (Zimbabwe has more than 15 million people). Most people who need mental healthcare simply don’t have access to it.
Over the last decade, growing evidence from several countries, including Zimbabwe, shows that there is an alternative approach to bridging the treatment gap for depression. The solution emphasizes the use of community health workers and volunteers.
And that is where grandmothers like Hwiza can help. In Zimbabwe, we developed a talk therapy program that is carried out on park benches by trained elderly community health workers. We call them “grandmother health providers.” While all are not actual grandmothers, they are all elderly women who are culturally referred to as grandmothers.
The program, known as the Friendship Bench, was developed under my charge as the only psychiatrist in the country working in a public health facility. This approach — engaging in individual problem-solving therapy by trained lay health workers — is backed up by research proving its effectiveness in reducing depression, anxiety and thoughts of suicide. The findings were recently published in the Journal of the American Medical Assn.
Already deeply respected in their communities for their wisdom, the grandmothers undertake a monthlong training program in the use of basic principles of cognitive behavior therapy, with emphasis on problem solving, and are given access to psychiatrists and psychologists who support them via mobile phone platforms such as Skype and WhatsApp. They are then set up with a park bench in their communities and begin seeing patients referred by local clinics and other sources.
Using three locally developed techniques — kuvhura pfungwa (opening the mind), kusimudzira (uplifiting) and kusimbisa (strengthening) — the grandmothers have successfully treated depression and anxiety and reduced suicidal thoughts. For instance, only 2% of those who initially reported having suicidal thoughts were still thinking about taking their own lives six months after receiving therapy from a grandmother.
While talk therapy sessions delivered by nonprofessionals can reach more people and are cost effective, concern has been raised by professionals in the field about the ability of nonprofessionals to address complex mental health issues. These are genuine concerns. But the growing body of evidence shows the success of such approaches, even for relatively difficult cases, has grown exponentially in recent years. Cases that the grandmothers are unable to manage are referred to professionals.
The grandmothers working in Zimbabwe can address complex emotional and behavioral challenges faced by HIV patients, who are dealing with mental health problems stemming both from the emotional burden of receiving their diagnosis and from the physical effects of the disease.
While this example from Zimbabwe focuses on elderly women, similar findings have been reported from India, Pakistan, South Africa and Tanzania, where a diverse age range of health workers is deployed. The evidence is strong enough for a global call to action to scale up treatments delivered by community mental health workers.
Care for depression in most low- and middle-income countries could be made more widely accessible through the existing strategies of the World Health Organization. These include training programs for nonprofessionals that are freely available and help to guide and assess the qualities required to do this work.
Developed nations could also benefit from this simple approach, offering initial care to those affected by depression or experiencing suicidal thoughts before the more serious cases are referred to the next level.
In the United Kingdom, thousands of people attempt suicide while waiting, sometimes for months, on the National Health Service list to see a psychologist. Similarly, long waiting lists have been reported in the United States. Rolling out programs involving grandmothers could help speed treatment for those who need it most.
Sadly, young mother Tanaka did not have access to a grandmother sitting on a park bench. If grandmother Hwiza could sit on benches in all local communities, it could be the first step toward providing treatment for depression globally and reducing the number of lives lost to suicide.