‘Friendship Bench’: A Blueprint for Tackling Developing World’s Mental Health Crisis

Grand Challenges Canada, Toronto

In Zimbabwe, Friendship Bench therapy reduces prevalence of depression to less than 14 percent, compared to 50 percent in control group; First at-scale model of community mental health care in Africa has diagnosed and treated over 27,500 people for common mental health disorders

FBToronto / Harare — Their offices are simple wooden seats, called Friendship Benches, located in the grounds of health clinics around Harare and other major cities in Zimbabwe.

The practitioners are lay health workers known as community “Grandmothers,” trained to listen to and support patients living with anxiety, depression and other common mental disorders.

But the impact, measured in a ground-breaking study, shows that this innovative approach holds the potential to significantly improve the lives of millions of people with moderate and severe mental health problems in countries where access to treatment is limited or nonexistent.

Six months after undergoing six weekly “problem solving therapy” sessions on the Friendship Benches, participants showed significant differences in severity of depression, anxiety, and suicidal thoughts based on locally-validated questionnaires: the Shona Symptom Questionnaire (SSQ), the Patient Health Questionnaire (PHQ) and the Generalised Anxiety Disorder scale (GAD).

Funded by the Government of Canada through Grand Challenges Canada, the randomised controlled trial was conducted by the University of Zimbabwe, the London School of Hygiene & Tropical Medicine and King’s College London.

The study is published Dec. 27 in JAMA, the world’s most widely-circulated medical journal.

Striking results

* 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.

* 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.

* 50 percent of patients who received standard care still had symptoms of depression compared to 14 percent who received Friendship Bench (based on PHQ).

* 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),

* 12 percent of patients who received standard care still had suicidal thoughts compared to 2 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. 86 percent of the study’s participants were women, over 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 (population 15 million) has only 10 psychiatrists and 15 clinical psychologists.

“Common mental disorders impose a huge burden on all countries of sub-Saharan Africa,” says Dr. 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 CDN $1 million in funding from Grand Challenges Canada earlier this year, the Friendship Bench has since been scaled to 72 clinics in the cities of Harare, Gweru and Chitungwiza (total population 1.8 million). Through collaborating 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.

To date, over 27,500 people have accessed treatment.

“In developing countries, nearly 90 percent of people with mental disorders are unable to access any treatment,” says 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,” says 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 centres of the eastern highlands on the border with Mozambique.

“The Friendship Bench team, working with the Zimbabwe Ministry of Health, has been able to substantially scale up services for some of the most deprived people in the community,” says Dr. Shekhar Saxena, Director of Mental Health and Substance Abuse at the World Health Organization.

“By supporting the uptake of mental health innovations like the Friendship Bench, Canada is helping to turn the tide in the global mental health challenge.”

The study 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: 573

* Participants were all at least 18 years old (median age 33)
* All had been assessed at 9 or higher on a 14-level “Shona Symptoms Questionnaire” (SSQ-14), an indigenous measure of common mental disorders in Zimbabwe’s Shona language (http://bit.ly/2h2SQch). 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 3 months post-partum, 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 counselling, 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,” (median age 53) 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 6-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.

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Grand Challenges Canada is dedicated to supporting Bold Ideas with Big Impact in global health. We are funded by the Government of Canada and we support innovators in low- and middle-income countries and Canada. The bold ideas we support integrate science and technology, social and business innovation – we call this Integrated Innovation. Grand Challenges Canada focuses on innovator-defined challenges through its Stars in Global Health program and on targeted challenges in its Saving Lives at Birth, Saving Brains and Global Mental Health programs. Grand Challenges Canada works closely with Canada’s International Development Research Centre (IDRC), the Canadian Institutes of Health Research (CIHR) and Global Affairs Canada to catalyze scale, sustainability and impact. We have a determined focus on results, and on saving and improving lives.

Example coverage
Voice of America (Television), USA, Zimbabwe’s ‘Friendship Bench’ a Possible Model for Mental Health Treatment, click here (distributed to affiliate stations in 75 countries,  eg. PTV, Philippines, click here).  VOA Online, Zimbabwe Tackles Mental Health With ‘Friendship Benches’, click here

National Public Radio, USA, The Friendship Bench Can Help Chase The Blues Away, click here

SciDev, UK, Bench talk boosts mental health in Zimbabwe, click hereFrench: Des méthodes innovantes pour stimuler la santé mentale au Zimbabwe, click here

Press Trust of India, ‘Friendship Bench’ may help fight mental illness, click here

BBC World Service English to Africa, Focus on Africa, starts at the 15:30 mark, click here

BBC Swahili, UK, Gumzo la benchi, tiba ya magonjwa ya kiakili, click here

Newser, USA via Fox News, ‘Friendship Bench’ chats ease symptoms of depression, says study, click here

Medical Daily, USA, Are ‘Friendship Benches’ The Cure For Depression, Anxiety In Poor Countries?, click here

IndoAsian News Service, India, Community-based Therapy May Alleviate Depression, Anxiety: Study, click here

Newser, USA, 5 most incredible discoveries of the week, click here

Upworthy, USA, This country has only 10 psychiatrists. That’s where ‘professional grandmothers’ come in, click here

Agencia EFE, Spain Charlas Semanales Con Abuelas Reducen Dramaticamente Enfermedades Mentales (Weekly talks with grandmothers dramatically reduce mental illness), via Yahoo News, USA, click here

South Africa Broadcasting Corp.

Ontario Farmer, Canada helps Zimbabwe with bench strength

Forskning, Norway, Mindre depresjon med bestemor på en benk, click here

Psychology Today, USA, What if You’re Depressed or Anxious and Can’t Find Help? Friendship Benches offer a new tool in the fight against depression and anxiety, click here

FJ China (+ several other news sites), China, 这群大妈每天找人闲聊,却做着救人的大事被称为“黄金夫人, click here

Good News Network, USA, ‘Friendship Benches’ Alleviate Mental Illness Symptoms For Thousands, click here

Health Canal, USA, Friendship Bench therapy reduces anxiety and depression in Zimbabwe, click here

Psych Central, USA, Friendship Bench Therapy Proves Effective in Treating Mental Illness, click here

MedIndia, India, Friendship benches help reduce mental illness in developing countries, click here

MedScape, USA, Novel Strategy May Boost Access to Mental Health Care, click here

Quo, Spain, En este puedes confiar: nace el banco de la amistad (Psychology — In this you can trust: the Friendship Bench is born; It is a resource that has proven extremely useful for treating depression), click here

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News release in full, click here

Coverage summary, click here