Several days ago, I delivered a lecture on the use of interpersonal psychotherapy in primary care for women with depression. This lecture took place in Dushanbe, Tajikistan, and was delivered to a large group of leading mental health and health professionals, none of whom had ever learned about or practiced psychotherapy before.
I have been working in Tajikistan since 2005, and for the past several years have been leading the Fogarty UIC Global Mental Health and Migration Research and Training Program. Our aim is to address the impact of migration on mental health and health by building the capacity of individual researchers and institutions in Tajikistan, as well as Kosovo, to address these needs. This work is funded by the National Institute of Health’s Fogarty International Center and the National Institute of Mental Health.
We supported Dr. Gulya Pirova of the Tajik State Medical University to conduct a study which showed that a quarter of women in primary care have moderate to severe depression, many of whom have migrant husbands and have suffered physical and verbal abuse. Presently, for the vast majority of these women, their condition is not acknowledged, diagnosed, nor treated. Imagine what it is like to suffer on your own.
Psychiatrists in Tajikistan predominantly treat the severely mentally ill in psychiatric institutions, not common mental disorders like depression, anxiety, and post-traumatic stress disorder which are often seen in primary care, but not regarded as mental illness in Tajikistan. Now Dr. Pirova is working with several other local professionals, and researchers from the University of Illinois at Chicago, to develop and implement mental health services for women in primary care.
We are developing a model of ‘stepped care’ which uses nurses, and peers who have previously received mental health treatment, as the service providers, given that psychiatrists are in shorty supply in Tajikistan. One of the key components of the stepped care model is interpersonal psychotherapy (IPT), originally developed by Klerman & Weissman in the 1970s.
A large number of prior randomized controlled trials of IPT have found it to be an efficacious treatment of depression. Landmark studies, including the National Institute of Mental Health Treatment of Depression Collaborative Research Program, found that IPT was statistically comparable to imipramine on several outcomes and superior to a placebo control for more severely depressed patients. In other trials, IPT was efficacious in treating depression in medically ill patients, peripartum women, depressed adolescents, and geriatric depressed patients.
Especially important for Tajikistan is that IPT has also been found to be effective in low and middle income countries, for example in treating PTSD among Sudanese refugees in Egypt, and in treating depression among men and women in rural Uganda.
IPT is based on the premise that depression or other common mental disorders can be associated with interpersonal problems. It aims to improve interpersonal functioning and enhance communication in relationships. This of course means that we need to adapt IPT to fit with the interpersonal and sociocultural contexts in Tajikistan.
Accordingly, we held some focus groups with depressed women, peers, and providers to learn of their experiences and perspectives on our approach. They thought it was important to tell the women that they have depression, and that depression was a health problem, and to emphasize that it is common, treatable, and nothing to be ashamed of. “People die from stupidity, not disease," they all agreed.
The women encouraged us to build into the therapy these common life problems for Tajik women: young women in forced marriages, women being beaten by husbands or mother-in-laws, wives abandoned by their migrant husbands, and women whose husband had taken a new wife. We could help women by re-framing their situations as addressable health problems driven by adverse life situations.
At times when hearing these difficult stories, I sometimes wondered if IPT would work at all in Tajikistan, where women do not have as much agency or power as women in Western countries. How could teaching women how to make changes in their relationships possibly work? Even while acknowledging such challenges, all of the women we spoke with strongly endorsed the use of IPT and our overall plan. “First, she must change her behavior, and then if necessary, she can change her husband,” they said. They really liked IPT because it could give women support, education, skills, and hope.
At the end of my lecture, encouraged by their enthusiastic reception, I said. “Thursday April 27th, 2017. Let’s mark this as the date when psychotherapy in Tajikistan began. You were there! Now I ask you to take the ideas I have shared and use them help woman in Tajikistan. Don’t let them suffer alone!”
Bolton, P., Bass, J., Neugebauer, R., Verdeli, H., Clougherty, K. F., Wickramaratne, P., ... & Weissman, M. (2003). Group interpersonal psychotherapy for depression in rural Uganda: A randomized controlled trial. JAMA, 289(23), 3117-3124.
Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., ... & Fiester, S. J. (1989). National Institute of Mental Health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry, 46(11), 971-982.
Meffert, S. M., Abdo, A. O., Alla, O. A. A., Elmakki, Y. O. M., Omer, A. A., Yousif, S., ... & Marmar, C. R. (2014). A pilot randomized controlled trial of interpersonal psychotherapy for Sudanese refugees in Cairo, Egypt. Psychological Trauma: Theory, Research, Practice, and Policy, 6(3), 240-249.
Mufson, L., Weissman, M. M., Moreau, D., & Garfinkel, R. (1999). Efficacy of interpersonal psychotherapy for depressed adolescents. Archives of General Psychiatry, 56(6), 573-579.
O'hara, M. W., Stuart, S., Gorman, L. L., & Wenzel, A. (2000). Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry, 57(11), 1039-1045.
Reynolds III, C. F., Frank, E., Perel, J. M., Imber, S. D., Cornes, C., Miller, M. D., ... & Pollock, B. G. (1999). Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years. JAMA, 281(1), 39-45.
Weine, S.M.(2007). The Collapse of Psychiatry in Tajikistan. Psychiatric Times, Vol. 24 No. 13. Retrieved from: http://www.psychiatrictimes.com/articles/collapse-psychiatry-tajikistan
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York, NY: Basic Books.