Great questions! I should probably do a bit more reading on both topics before making a definitive statement, but just like the emphasis on well-being from Happier Lives Institute, I think considering the suffering risk of populations is a high moral priority. Mental health is an investment in the betterment of all areas of life. We see it can increase productivity, the number of meals a family eats, and the amount of school children attend. It impacts all areas of life and health, and similarly, restoring mental health creates thriving communities and stronger economies. From the longtermism philosophy, I think there is much to consider outside of simply eliminating existential threats and improving humanity. The results of climate change are already devastatingly impacting some of the communities we work in, which has serious implications for mental health and overall well-being. If we genuinely wish to eliminate suffering, we must address the crises and unrest at the root of the depression triggers.
Sean Mayberry
Hi John! I have not forgotten this question. I aim to have an answer for you by the end of the week. I wanted to wait until our CFO had the opportunity to review to ensure we have the most recent figures for you. I’ll be back in touch on this very soon. Thanks for your interest!
Thank you! I appreciate your curiosity, and I’m not put off by the questions or anything; it’s just many of them are not in my area of expertise, and this happens to be a pretty busy time of year at StrongMinds. It may take some time to fully gather what you’re asking for. We aren’t a large research institute by any means, so our clinical team is relatively small. Additionally, some of the work you are referencing is nearly a decade old, so we have shifted some of the ways we operate to be more effective or better based on our learnings. That said, I will dig back in when I can to help answer your additional questions via email or direct message.
To answer the remaining four from your original note to close the loop:
5) Since HLI generated the $170 figure, they have the best information on that particular breakdown, but I am collecting the most recent info on our CPP for another question, and I will share that with you later this week when I have the updated numbers.
6) As mentioned above, we are currently in the process of assessing the right questions and framework for an RCT looking at the results and impact of our therapy model. We are hoping to be able to launch the RCT late in 2023.
7) We switched our model to teletherapy to continue to treat clients during the pandemic lockdowns. It was not ideal, but we wanted to continue reaching as many women as possible despite the challenges. Though it proved tricky in some cases to reach our target demographic, we did find that some women preferred the flexibility teletherapy offered them. For the most part, we have switched back to our original model, but we still see some groups via teletherapy in Uganda. All research shared publicly from our initial year using teletherapy can be found here.
8) We track individuals that attend most of their therapy sessions, as we saw that the effects of therapy were still statistically significant and that attending additional sessions did not produce incremental impact. Due to the individual roles and responsibilities of the women that attend, it’s sometimes challenging for them to make it to all 12 sessions.
Thanks again for the questions!
I agree that based on all of the barriers and life challenges that it seems like it would be harder to treat depression in Kampala. As mentioned in some of the other answers, I think the model itself, being culturally appropriate and community-centered, as well as the interpersonal bonds, play a significant role in the program’s success. Also, the fact that we work where the women are, in refugee camps, slums, or schools, to deliver our services.
Thanks for these questions! I appreciate the time you took to really look at our data, and I think some of the questions will help us ponder what we need to be looking at next within StrongMinds. Please note, as the Founder, I’m not a researcher or clinician by trade, so my answers may not be as granular as you would hope, but I’ll do my best to respond. I’m going to tackle the first four tonight.
a. The NNTs could be different due to a variety of theoretical factors. NNTs are really only as good and accurate as the data provided. We are planning an RCT for 2023, so hopefully, we will have more to consider and dig into once those numbers are available. b/c. Yes, the numbers are surprising. As I’ve mentioned in some of the other responses, I largely think the success has to do with the interpersonal nature of IPT and how it works within the community-centered culture of Uganda and Zambia.
I believe the 10% figure is part of the HLI analysis, and I am not an expert on that, so I’ll let their team speak to that or let the numbers speak for themselves.
An RCT certainly could have been done as a pilot, but they are pretty costly to complete, and at the time, StrongMinds was just finding its footing and searching for funders. I was working as a volunteer at StrongMinds for the first 18 months of operation.
Our facilitators are all lay community members. In Uganda, 100% of our facilitators are Ugandan. In Zambia, they are all Zambian. They don’t need to have a college degree in Psychology; in fact, they don’t even need to have a high school degree. The most critical factor when we are interviewing potential facilitators is their empathy level. We have found that the higher their empathy level, the better they are as facilitators.
Hi, harriet! Thanks for the questions! Yes, there are advantages and disadvantages to both individual and group therapy, and as you mentioned, cost certainly favors the group model. We can offer a woman an entire course of treatment for $105. In terms of patient outcomes, StrongMinds doesn’t utilize individual therapy, but some studies have shown that effectiveness overall is pretty similar, and it really comes down to individual (and sometimes cultural) preferences to determine what type of therapy is best. I hope that helps!
In terms of SSRIs, yes, they can certainly be effective. In some cases where we think the client is a risk to themselves or others during therapy pre-screening, we refer them to where they have access to other methods, including SSRIs or other prescription options. That said, there are some significant challenges with the availability of SSRIs, given the treatment gap and the fact that everyone may not have the access needed to get to a trained psychiatrist/psychologist or nurse to prescribe them. This is one of the reasons the WHO recently cited and recommended community-based models and methods using lay community workers rather than trained mental health professionals as a key way to meet the growing need for services.
In terms of cost-effectiveness, prescribed medication is reasonably affordable, but the cost can add up over a lifetime of use. For $105 USD on our end (and entirely free for the women we treat), we can provide long-term depression-free rates. Our results show that for every woman who restores her mental health, four additional members of her family feel the benefits. The HLI cost analysis looks at the benefits for the whole family as well as some of the long-term impacts as well, which is what makes our model so cost-effective.
Currently, StrongMinds is actively looking to hire for a few positions listed here. We are growing and are always looking for smart, ambitious, and creative people to join our team. We encourage everyone to follow us on LinkedIn for our most up-to-date job openings. At this time, we currently do not use volunteers.
StrongMinds seeks to treat 300,000 women and adolescents between 2022 through 2024. To do that, we need to raise $30M U.S. dollars. To date, we’ve raised about $13M, which leaves us at a shortfall of $17M. So there is lots of room for more funding!
In 2022 we expect the cost to treat one patient will be $105 USD. By the end of 2024, we anticipate the cost per patient will have decreased to just $85. We will continue to reduce the cost of treating one woman even while our numbers increase. This is through effective scaling and continuing to evaluate where we can gain more cost savings. A donation to StrongMinds will be used as effectively and efficiently as possible. And when you think about what it costs for therapy in the United States, to spend just $105 and treat a woman for depression is a pretty incredible feat.
Thanks so much for your kind words and for following our work! I appreciate your comment about the incredible impact mental health can have. We’ve certainly seen it change women’s lives far beyond what we could have predicted, such as helping a woman’s children eat more meals a day or even helping individuals with HIV adhere to their antiretroviral treatments more regularly.
We completely switched to a teletherapy model during the COVID-19 lockdowns in Uganda and Zambia, which required a lot of creative thinking on a short timeline. This made it somewhat tricky to reach our target demographic since many women share a phone with their family or neighbors (and some don’t own a phone at all.) Fortunately, the depression-free rates were comparable to in-person group therapy, and some ultimately preferred the flexibility it offered. We usually work in communities, offering therapy directly where the women live to make access easy (our motto was often to diagnose on a doorstep, treat under a tree.) We had to reach new clients using things like radio ads, social media, and a mental health WhatsApp-based chatbot to help ensure resources were available as often as needed. You can read more about our key learnings from the COVID-19 pandemic here.
Like most in the mental health field, we saw a sharp increase in the need for services, particularly during the lockdowns. Unfortunately, since then, we have seen other climate-related humanitarian crises causing things like flooding and drought, undoubtedly worsening mental health conditions. Additionally, Uganda currently has some Ebola lockdowns in place, stressing already thinned health resources. StrongMinds has made ourselves available to support in these cases. We know mental health care is critical during high-stress times, and rates are only projected to increase in the coming decades. The good news, though, is, as you’ve eloquently stated, the interpersonal nature of group talk therapy enhances outcomes. We’ve seen that 72% of former clients we spoke to in Uganda were still in touch with their group mates. This extends years later in many cases.
Absolutely! I’ve often said that the hardest part of our job is finding depressed individuals and getting them into a group. Depression can make simply getting out of bed a challenge, so this can be tricky. The group model works well to help with this scenario, though, because group members can hold each other accountable and check in on each other. Uganda and Zambia still have many stigmas associated with mental health, so advocacy and psychoeducation are critical to our work in-country. You can read more about the complete therapy assessment process and how we work to educate about mental health here in this Psychology Today article by our talented Uganda Country Director/Clinician, Tina Ntulo.
Similarly, a small door-to-door study led by StrongMinds in Mukono District, Uganda, estimated that the prevalence of moderate to severe depression in adult women was about 20%. We also have about 85% of individuals with no access to other forms of treatment. IPT works particularly well in these settings and is currently a WHO-recommended first-line treatment for depression in low-resource settings. Other forms of community-based models using a rights-based approach are a great way to empower individuals to seek recovery and focus on the value of human rights within the mental health space.
Thanks for the question! We decided to start the StrongMinds programming in Uganda because the initial RCT had such positive results there. We wanted to see if we could replicate those findings and reach even more women. I also had some experience there in my prior work as a diplomat and through my work with other NGOs. My family and I lived just across the border in the Democratic Republic of Congo for over four years, so I have many friends and connections in sub-Saharan Africa and have seen the dire need for treatment options and the consequences of untreated depression there firsthand.
I suggest doing your research (the information we received from the researchers who conducted the initial John Hopkins/Columbia University RCT was instrumental to our success.) Also, know your audience. We try to consider each woman in our therapy program’s perspective. How did she hear about us? How is she accessing information about the program? The more demographic information you have about your audience, the better you can target your outreach/messaging and achieve results. Other considerations are what staffing is needed to make the product or tech run? And what frameworks need to be in place? We had to do a lot of this evaluation ourselves when switching our model to teletherapy during the pandemic. The model, resources, and modes of communication available will all have a huge impact on the specific strategy.
Both are true! Numerous studies have shown that when you help an African Mom, the downstream effects are significantly more substantial. Globally, women have a depression rate of 1.5 times higher than that of men. An African woman with depression, compared with her healthy peers, suffers greatly: she is less productive, has a lower income, and has poorer physical health. If she is a Mother, the negative impact extends to her entire family. Research shows that children of depressed Mothers are more likely to have poor health, struggle in or miss school, and suffer from depression themselves.
Furthermore, because depression impairs the ability to focus and concentrate, depression sufferers do not respond to health initiatives or livelihood trainings, rendering these programs less effective.
This impaired ability to function in day-to-day life creates profound hardship in Uganda and Zambia, where life is community-centered and reliant on each person fulfilling her role and where depression carries a great stigma. When a woman cannot perform her social responsibilities, she can become a target of criticism and social exclusion. Women in these communities also often have far less access to resources.
Thanks for your kind words and for the great questions!
The relationship between poverty and mental health disorders, including depression, is complex. Poverty exacerbates depression, and depression, alongside other mental health disorders, can drive people further into poverty through reduced productivity, decreased income, and isolation. (Lund et al. 2011) But it is incorrect to conclude that poverty on its own causes depression. If it did, we would see rates of depression at 100% rather than 25% in the slums of Kampala. Our model looks at four distinct triggers for depression: grief, life changes, loneliness/isolation, and conflict. Interestingly, we see from our well-being indicators that many times, restoring a woman’s mental health can increase her productivity and livelihood; for instance, 16% of our former clients reported increases in work attendance after the conclusion of therapy.
Yes, in self-reported data, we have to be very careful to ensure we measure correctly and there aren’t existing biases or misrepresentations. We work directly with an external firm to help with this. They conduct our endline evaluations. As mentioned above, we also look at well-being indicators to help demonstrate our impact, such as a 13% increase in family food security, a 30% increase in school attendance, and a 28% increase in women feeling socially connected.
Thank you! We try to be open to challenging questions at StrongMinds. It’s part of our culture, and we think asking tough questions can lead to better results.
Sam Glover- We looked at this with a control study and found that a statistically significant number of women were depression-free after completing StrongMinds therapy versus those that received no treatment. Additionally, using the PHQ-9 (an international standardized tool to assess depression), we saw an average difference of 12 pts after the conclusion of therapy. To contextualize that, in western countries, a change of 4 pts is considered significant in terms of depression recovery.
Greg S- I wish we had 400B at our fingertips because I can only imagine what impact we could have. In all honesty, our model is very low-tech. There are no apps or fancy gadgets. We also don’t use prescription medicine (which may be why a pharma company has yet to snap us up!) Finally, the women we treat mostly live on less than $2 a day, so they aren’t in an income bracket that many investors might want as consumers. While apps, tech, and pharmaceutical partnerships receive considerable funds, mental health in low and middle-income countries trying to help with poverty reduction is not heavily funded. Yearly global costs from mental, neurological, and substance use disorders are estimated at between $2.5 and $8.5 trillion dollars a year. That figure is projected to nearly double by 2030. Mental health is still frequently overlooked in health budgets. Most African governments devote less than 1% of their budgets to mental health services.
You raise a good point, though, to which we have given a little thought. Is there space to look at our model and make it self-sustainable and profitable? We would never consider this with our current clients, but is there room to have a for-profit arm that funds the non-profit, or should we consider a franchise model? We constantly push ourselves beyond what is comfortable, and we’ve had some early discussions. While I have no answers, I wanted to flag that we had considered new and different ways to fund our work.
Hi Yonatan. Thanks for the questions. I wouldn’t quite say we solved it, but we have found a solution that has had tremendous results in Uganda and Zambia. There are probably a few reasons for this. Most of the communities we work in are very close-knit and interpersonal, so the group talk therapy model of IPT-G works well. Additionally, around 85% of women in sub-Saharan Africa don’t have access to quality mental health care. There is a huge treatment gap, for instance, Uganda has approximately 30 trained psychiatrists serving a population of 45M, so we are also filling a dire need by providing these free services using lay community health workers. The symptoms of depression are still not commonly known in Uganda and Zambia, and many people think they are just fatigued, sick, or just unmotivated/lazy, so discovering that there is a way to treat their symptoms and that there are other people experiencing this too is life-changing. Many women in therapy groups form a bond and continue to meet long after therapy ends. They now have a new support system and are no longer isolated. All of these factors play a role in our success.
The program model can be replicated in other geographical locations, and IPT has been shown to work well cross-culturally. We are currently exploring an American pilot where the need is also extreme in underserved BIPOC communities. Our pilot is happening in the Newark, NJ area just outside of NYC. That said, we have to do quite a bit of work to determine how western preferences fit into this, and we are collecting data from some initial groups now.
StrongMinds therapy model is based on an RCT from 2002 in Uganda. It has shown to be a highly effective way to reach women in underserved and remote areas that would otherwise not have access to mental health treatment options.
Thanks so much to everyone that took the time to ask me questions and participate in this AMA. It was really refreshing to speak to so many people that are curious about our work. Many of the questions got me thinking about how we work and the ways we can do a better job moving into 2023. I appreciate all of your thoughts, ideas, and support!