JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you've joined us today. In this episode, Spencer speaks with Sean Mayberry about depression intervention in Africa, group oriented treatment, and scaling and measuring impact.

SPENCER: Sean, welcome.

SEAN: Thank you so much, Spencer.

SPENCER: Today we're going to talk about one of the greatest causes of suffering, which is depression. Do you want to start talking about why is depression such a big problem in the world?

SEAN: Yeah. Depression is a huge problem in the world, Spencer. It's the number one mental illness globally. Everywhere you go, there's at least about, right now, 350 million people on the planet who suffer from depression. And it's the leading cause of disability; depression disables more people on this planet than anything else.

SPENCER: Why do you think that so many people suffer from depression?

SEAN: That's a great question. And yeah, I can give you my experience and my hypothesis. When you think about the symptoms, there's nine standard symptoms for depression, some of which include fatigue, inability to focus or concentrate, which is what I think a lot of people think about when they think about depression. We are seeing the rates of depression increase. There is no one answer as to what that is, given our nine years of work in Africa, treating coming up on 200,000 patients. We have some ideas in terms of what is driving that increase for sure.

SPENCER: So you actually do see it increasing? You think there's more depression now than there was like five years ago, or 10 years ago?

SEAN: It seems that way. Now you have to isolate for the pandemic. Certainly, we saw an increase in depression from the pandemic, which I think is understandable. I think the World Health Organization, everyone, saw an increase in depression worldwide. But when I think back to when we started treating depressed patients in Uganda in 2014 to today, we feel that the demand is much higher. There's a number of reasons. I think outside of the pandemic, what's really driving depression is just an increased sense of loneliness on the planet. There's a lot less social connectivity. People are spending a lot more time alone. And as we all know, we're a really social species. And there are some experts out there who have actually posited the same approach that it's really loneliness that is increasing almost hand in hand with depression.

SPENCER: So in the US, people often talk about loneliness as being related to things like social media, like instead of hanging out with their friends, people are tweeting at each other, and this is sort of isolating people. I'm wondering, in the countries that you work, do you think a similar thing is happening? Or do you think loneliness is driven by totally different forces? Or what would you point to

SEAN: Loneliness is increasing in our countries, which are more on the developing side. Social media has a factor there; it's not as pervasive there as in the West. When you think of just smartphone ownership, for example, which is quite small. So social media, I think, is restricted. But you still see loneliness increasing from other factors: the growing increase of rural to urban migration; people leave their homes, their families, their communities, in small rural settings, moved to the big city, live in slums, and their connections with people are much more difficult. And I think that contributes certainly to the increase in loneliness. So I think loneliness is increasing across the planet, when you look at the data, and it depends where you are as to what are the reasons that it's increasing.

SPENCER: It's interesting to me that you point to loneliness with regards to depression. I absolutely believe that that can be a big cause of depression. But I think that there are other causes as well. So I'm kind of curious to see whether we agree on this, whether we disagree, but I guess I think of the core of depression as a belief that you can't produce value. And it could be value through human relationships, like having people that love you and that you love. It could be value through your work, like you don't think there's work that's meaningful for you to do. It could be other forms of value, or even self value, like I think I'm a valuable person or I think I'm a worthwhile person. And to me, depression tends to stem, maybe not in every case, but tends to stem from the sense that the things that are valuable can't be done or can't be created. I'm just curious about your reaction to that.

SEAN: That's really interesting. I've never heard it put that way. I don't immediately disagree. I'd have to think a little bit more. Our modality for treating depression at StrongMinds is called group interpersonal psychotherapy. So that's really the basis where I come from in terms of what is causing depression. So for our type of therapy, it really comes down to having common triggers. If you kind of keep asking "why are you depressed? Why do you feel this way?" — the seven ways of getting to a problem by asking why seven times — those common triggers include disagreements, life change, social isolation. So for me, depression comes from one of those triggers. Our most common triggers in Uganda, Kenya, Zambia where we work are really social disagreements. It's about, "I'm disagreeing with my spouse or my neighbor. And those disagreements caused me a lot of angst that will increase my depressive symptoms and give me depression." If you try to connect that to your thinking about not creating value, I'm sure you could make that kind of catwalk, if you will, between disagreements or social isolation are triggers to what you're saying your triggers are in your thinking. So I think they're probably pretty similar.

SPENCER: The way I think about it is that what is valuable is different for different people. So, for a very social person, having an active social life might be the source of value. Or, for a very family oriented person, having strong family ties might be a source of value. And so, depending on what the person values, if they feel like they can no longer create it, then I think that tends to lead to depression. And then there's also a kind of self version of that. If you think yourself are not valuable, I think that tends to lead to depression. So yeah, I don't know, it doesn't contradict what you're saying, I just have a different frame on it.

SEAN: Yeah, I think it works. I think they're very complementary and work hand in hand. It could be, you might be on to an entirely new modality of treating depression with different triggers, but yet the same.

SPENCER: Another thing that comes up here is the link between anxiety and depression. And this is something we've actually done a bunch of research on. I was really shocked in one study we ran, where we asked people a standard depression questionnaire, the PHQ-9 and a standard anxiety questionnaire, the GAD-7, along with a hundred plus other questions. And we just, for fun, looked at every correlation between pairs of questions just to see how they're all correlated. And what really surprised me is the single most correlated pair was the depression measure and the anxiety measure had a correlation of more than 0.7 and might've even been as high as 0.8. And that was just kind of mind blowing, how related they were. And so I'm wondering, do you think about treating anxiety as well? Or do you think of that as sort of different?

SEAN: No, we really view them almost very, very much the same. And I think that correlation that you saw, we're seeing this more just in general kind of mental health guidance, that anxiety and depression are working more hand in hand. It's very hard or almost not necessary to separate out the two in terms of treating just anxiety or depression, that if you have depression, many times, you're going to have anxiety. So we view anxiety as something else that we're treating, and it works quite well in terms of treating it with the modality of group interpersonal psychotherapy. So when we see when we've reduced depression, we are also reducing anxiety. So in that sense, we're quite fortunate that it doesn't take any completely new intervention to battle the increase in anxiety as well.

SPENCER: Well, anxiety and depression are so highly linked, and the treatment for one is often similar to the treatment for the other. I do think they have some substantive differences. We've investigated this, and I just want to mention to the listener, I don't want people to be confused and think they're the same thing. So we did this interesting study, we collected hundreds of variables related to anxiety and depression. And then for each of them, we tried to predict it using someone's anxiety and using their depression, and then using the two together to see whether it was really driven more by anxiety, more depression, or by both. And so I just want to point out a couple things that sort of were in one camp and not the other. So, agreeing to statements like, "I tend to worry about things" or "My worries overwhelm me," or "I frequently think about what I would do in hypothetical 'what if' scenarios," were really driven by the anxiety piece. Whereas, things driven by the depression piece we're, "Taking all things together, I'm not happy," "I have a low opinion of myself," "I feel that I didn't deserve to be treated with respect by others," "I don't believe there's a reason or purpose behind the things that happen in life." And then we've had a whole bunch of things that were connected to both anxiety and depression, which is partly why I think they're so correlated. So for example, "My thoughts prevented me from focusing on other things," "I lacked confidence in my ability to accomplish what I set out to do," "I often tell myself that I look stupid or ugly." These were all things that both anxious and depressed people had in common. So anyway, I just want to flag that.

SEAN: No, it's very interesting.

SPENCER: So what is the structure of the program? Is there a certain material that's covered always in session one, other material covering session two, or is it more freeform?

SEAN: It's actually very structured. When you look at the current eight weeks, a group leader going and be a StrongMinds employee or volunteer knows exactly what he or she needs to accomplish in that week. If it's week three, their curriculum, what they need to be doing is different from week two or week four. So it's not freeform at all, which I think is one of the contributing factors on why it's so successful; it's the standardization we have in that model. So when you think about it across eight weeks, in the first couple of weeks, we are really getting the group to kind of form together, to become comfortable with each other, to be able to share their difficult aspects of their lives. And then in the middle weeks, which we call 'the working phase', it's really going through the group and helping individuals to understand the triggers they are suffering, making suggestions to one another, assigning homework, having you come back a week later. For example, the earlier case we were using about being a depressed mom in Uganda, struggling with disagreements with a spouse, so other group members will make suggestions, "Try this, talk to him differently, or try to negotiate this. You go home, you try that out." You come back next week, and they are like, "How did it work? Did the homework work? Are you getting along better?" Maybe you did, maybe you didn't. And if not, then what's plan B? What are we going to do differently? So, it's a lot of iterative process. It's a lot of group members helping each other, it's not the group leader standing up at a lecture and saying, "You will be doing this, and you will be doing that." It's people helping people. And then tracking that, typically over time. Again, if I'm that Ugandan mother, I will be coming back in weeks five, six, or seven and saying that, "Typically, I'm being successful with my homework, I'm being successful dealing with my challenge with my disagreement aspect (with my trigger), and my trigger is reducing, and I'm feeling better because as I dialed down my trigger, my overall depression reduces." And then the last couple of weeks is really about helping people to make sure that they're comfortable leaving the group when the group terminates or ends, and that they understand that they have the right skill set now, to be able to deal with depression, that they're not depressed today, most likely, at least 80% of them aren't. And that in the future, what they can do, if they feel episodes coming back, how they can rely on their own skills, or rely on the social bonds of the group that they have.

SPENCER: So the homework, it sounds like it's taking ideas that they learned during the group sessions and trying to put them into practice in their life, and then kind of reporting back on how that went. Is that correct?

SEAN: Yeah, it's a very simple approach. I think another point there is, it's helping just to show and give the individuals just control over their lives. And if you do this differently, you can reduce depression. It's also showing them that depression is not coming from inside of yourself. It's coming, in this case, through your interpersonal communications and in their interactions with others. So if you do this differently with your husband, it most likely will reduce your triggers, so that you have the power to understand what's happening, and you have the power to influence it. And I think an important thing to understand is during these groups, we're very quantitatively focused. So we're taking the PHQ-9 at beginning, middle and end. But the PHQ nine is a lengthy tool, particularly when many of our patients are illiterate, it can't be self administered. So what we'll do in other weeks, like weeks two, three, and fours, we have a shorter tool that can help people understand how they are feeling today very quickly. And we do that weekly for everyone, and it helps to understand whether they are feeling better or not, and giving some kind of quantitative focus there. And if you're feeling better, one of the questions from the group leader is, "Why, what happened in your life this week?" If you're not feeling better, or even feeling worse than last week, it's "Why, what happened this week, to maybe connect that?" And it's helping depression sufferers to connect the dots, to show them that what happens in your life impacts you — good and bad — and that depression isn't a curse or something that you can't understand. And so over time, we're peeling back the layers of the onion for people to understand that depression is understandable, and that you can manage it and influence it based on the experience that you have over these eight weeks.

SPENCER: When I think about the treatment modality of interpersonal therapy, some of the pieces that I'm aware of that come into play are: 1) supportive listening, so I imagine that that's achieved through kind of the group listening to that person; and then 2) you've got role playing. So I'm wondering, is role playing an aspect of this?

SEAN: Yeah, we do lots of roleplay. Again, going to our example for this depressed African mom who's suffering disagreements with a spouse, we could very easily — and I've seen it done many, many thousands of times to other people in the group — you get up in roleplay, one person would roleplay me, as the wife, and one person would roleplay the spouse and walk through a conversation of how to deal with this. A lot of times there's a lot of humor there. Someone may be kind of exaggerating the personality of the spouse, taking it out on men, for example. But a lot of roleplay we have are just posters and pictures, that kind of picture being worth a thousand words. So the groups are fairly lively, interactive, a lot going on. It's a great group. If you ever have the chance to see them, Spencer, or the listeners, you walk up to a group, there's 10 or 12 Ugandans, typically women, lots of kids, they're bringing all their kids there, the kids are crawling all over each other. It's also like a nursery going on. For the groups that I'm in, I tend to try to be sitting quietly in a corner hiding, although sometimes that's hard. The kids are crawling over me, they're quite lively, a lot going on. It feels very African. Towards the end, as people are leading and getting better, in week seven and eight, there's a lot of big smiles going on.

SPENCER: It sounds really interesting. And then a third piece I think about with interpersonal therapy is communication analysis. How does that play a role here? Is that something that the facilitator is going to do, or is just sort of everyone involved in that?

SEAN: We're not doing a lot of formal communication analysis. When group members are making suggestions to others on how to negotiate or talk to somebody, I think it's like a de facto approach of communication analysis, but it is helping people to just understand what they are going to say to their husband, because in that case it was a disagreement. Or in a life change, "What would you say differently?" and things like that. So I think it's not formal communication analysis, it's more just like a pragmatic, communicative approach or something like that.

SPENCER: And the fourth and final piece I think about with interpersonal therapy is encouraging people to kind of experience their emotions or 'the encouragement of affect' ss sometimes called, which sometimes people don't let themselves feel what they're feeling or don't let themselves think about or talk about it. I'm wondering, is that a formal part of the program or does it just come about naturally?

SEAN: I think it more comes about naturally. They understand over time that they're in a safe space, having sat through many hundreds of groups. Those first few weeks (weeks one, two, and three) are very intense. They're very emotional. People are coming together, who've been suffering depression for weeks, months, maybe years. They've, in many times, been somewhat socially kind of isolated, pushed out of their communities. And then they're sitting down with a group of people just like them and being encouraged to open up and talk about their stories. So, there's a lot of, I think, just pent up emotion that has been gathering over weeks and months and years that just starts to come out. And it really bonds the group. I don't know how many groups I've sat in, with and without translation, just weeping along with women. You just feel in the air just from human empathy, you know when someone is suffering, and you don't know why because you don't understand what they're saying, but you're crying along with them because you could see their pain, you can feel it. So it's not a formal aspect. But definitely there's a lot of emotion flowing through these groups. I think the fascinating part is when I was painting the picture for weeks one, two, and three, the last couple of weeks (week seven and eight, always week eight) these groups, if I parachuted you in Spencer and said, "Here you are." You wouldn't want to believe that it's a depression group. By week eight, people are quite happy, joyous, the smiles are ear to ear. It's just a huge testament to the power of the therapy that we're using and the power of the group as well. It's really transformative.

SPENCER: So I'm wondering, why do you frame what you're doing in terms of treating depression, rather than treating depression and anxiety?

SEAN: That's a good question. We've been in existence for nine years, we could certainly say that we treat depression and anxiety, we just haven't chosen to kind of change that approach. But our staff is fully trained in that. We use the same diagnostic tool as you did on anxiety. So it could just be coming down to just how do we openly communicate that we do address anxiety as well.

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SPENCER: Tell us more about this treatment modality, the group interpersonal psychotherapy.

SEAN: Yeah, it's fascinating. It originated in the 1970s, actually out of New York City, and I stumbled across in 2013. I found an old randomized control trial from 2002, so more than 10 years old. It was run by Johns Hopkins University and Columbia University. It was the first time any form of modality had been used successfully to treat depression in Africa; in this case, in Uganda. It showed a major impact in terms of reducing the symptoms of depression in 2002. I found it 11 years later in 2013, and it had been sitting on a shelf the entire time. So for us, we saw a great opportunity to use that modality, the RCT findings, in terms of scaling up an intervention to treat depression in Africa and to really make a difference. And now, nearly more than nine years later, by the end of this year, we will have treated over 200,000 depression sufferers. So it's been a great journey.

SPENCER: That's fantastic. Could you walk us through how the modality works? I know it's a group treatment, so it's a bunch of people brought together. But could you just step by step give us the process?

SEAN: Yeah, definitely. I'll give you the overview. Feel free to ask questions. It could take many hours to explain it. But at the higher level, we'll have a group of depression sufferers that come together. Group size can be anywhere from 10, 12 up to 18 people. A group of 10 to 12 people will have one leader. For the group 18, we'd have two leaders because of the size. Today, we meet once a week for between 60 and 90 minutes, for eight weeks. We believe by the end of this year, we will be able to reduce that duration down to six weeks.

SPENCER: Just to clarify the leader is someone who's trained or somebody's gone through the program before? Who is the leader?

SEAN: No, great question. There's different kinds of leaders. So we have StrongMinds staff. These are full time employees trained in Group Interpersonal Psychotherapy, our approach. So they're salaried employees running groups. We also have a growing cadre of volunteer leaders. Some cases, these are women who have graduated from StrongMinds depression groups, but that's not a requirement. In many cases, volunteers are people who have never suffered depression themselves. They've all been trained by StrongMinds to run groups. And that is really how we are seeing greater impact, and more people reach through volunteers just because in Uganda today, we have over 1000 volunteers. In terms of our staff employees who can run groups in Uganda, we have roughly about 60. So we're getting better and better at training more types of people to run these groups.

SPENCER: Okay, so someone comes to the group sessions once a week, and what are they going to experience during this?

SEAN: Well, before you even come to the group, let's say you're one member of the 10, you're already going to have sat down with the group leader at least once or twice individually. That's an opportunity for us to screen you using the PHQ-9, the depression diagnostic tool, to really understand if you are depressed. It's a chance to go deeper to understand and to really collect, you can think of it as a case history. What are your triggers, what's going on in your life? So that when you sit down in the group in week one, the group leader knows who you are, knows your story, and knows how you can fit into this group. And then for the next eight weeks, we break this into phases. There's the introductory phase, the middle and the ending phase. Ultimately, what it is, is trying to help people understand what their triggers of depression are (we talked a little bit about triggers already) and what they can do differently in their lives to reduce triggers. And by turning down a trigger or reducing a trigger, you thereby reduce depression.

SPENCER: Could you give an example of a trigger?

SEAN: Sure. So, if a trigger is you're having disagreements, so disagreement is a trigger. Let's say I'm a young woman, and I grew up in Uganda — typically, we focus on treating women — and I'm having disagreements with my spouse as to how to spend the limited amount of income we have. We're probably living on maybe $2 - $3 a day. I, as the mom, want to spend it on my children on school fees, on food, normally. The husband may want to be spending that money on something maybe less useful to the family, maybe something for entertainment for him. So I'm having lots of disagreements with my husband over how to spend this. And ultimately, that has led to depression. Because of the ongoing arguments, you're feeling maybe that you're not taking care of your children well enough, being a good mom, et cetera, et cetera. So then in the group, what we're doing is — and it's not these group leaders that we have telling someone not to do — it's really facilitating the group, and getting the other group members to make suggestions. In this case, to me, the Ugandan mom, on how I can deal with my disagreements with my husband differently, and thereby reduce those disagreements and reduce the trigger. So, you could have people in the group who literally are coming to you with hundreds of years of combined life experience making suggestions on how I can negotiate with my husband differently, how I can talk to him differently, how I can reduce those disagreements, reach agreement on spending those funds, thereby reducing my trigger and reducing my depression.

SPENCER: So put that way, it seems like there's an aspect of problem solving and also an aspect of learning social skills that may be helpful for navigating tricky social situations and things like that. Is that right? Or how would you put it?

SEAN: No, those are certainly some skills that we're helping people to understand. It could be that those people have those skills, and they just haven't been successful in using them. But it is giving them the life skills to be able to reduce that trigger. At the next level up, it's really about helping the individuals in the group to understand that depression is a manageable illness. There are reasons for it–triggers. It's taking away kind of the mystery around depression and the stigma, and giving the individual sufferers the understanding that they have it in their control to understand there are triggers, that they can change those triggers, and that their depression is linked to events in their lives. So it gives them the skills to understand depression, to influence depression, not just in this case, but also down the road once they've left a StrongMinds group, after six months or two years later. I gotta tell you, Spencer, having done this for nine years in Uganda and Zambia, and now we just launched in Kenya, I've had so many depressed moms in Africa come to me and say they thought they were the only person, they thought they're the only ones suffering from the symptoms of depression. And really in the groups, it's helping them to understand that it's a common manageable illness, which I think is one of the most important things we're doing as an organization.

SPENCER: That reminds me of something that Kristin Neff (who's on this podcast previously) who talks about this idea in self compassion, that often people feel like they're suffering alone when they're dealing with difficult situations. And by realizing that many other people have experienced the same thing, it gives them kind of a sense of shared unity, and that actually can help people a lot.

SEAN: Exactly. I would say, it is really, in a way, you're normalizing this. When these women say, "I thought I was the only one," but then they show up on day one of week one of the group, and they find nine or 10 other women, many of whom are neighbors that they didn't even realize who are also suffering depression. It makes them feel not alone, and it normalizes what they're feeling. And it also just creates a very strong social bond among those group members that goes to the loneliness factor.

SPENCER: Besides social challenges, what are the other kinds of problems people come with?

SEAN: Disagreement is one trigger, life change is another trigger. When you think of life change, again, it can be a number of factors. Many times we see people (as we've already spoken today), moving from rural settings to the urban settings. It's a huge life change. People who are getting fired from jobs, people are having children, people are losing loved ones, any kind of life change can drive symptoms of depression. Social disagreement, as well. So, for us, it's all about really understanding what these different triggers are and then helping people to cope.

SPENCER: So does it teach cognitive behavioral therapy skills, or would you say that it's really doing a different thing?

SEAN: No, no, no. This is Group Interpersonal Psychotherapy, which is IPT. Very separate and distinct from CBT. On IPT (Interpersonal Psychotherapy), it's less about what someone is thinking to themselves or telling themselves, it's really what it says on the interpersonal side. It's how people are interacting and exchanging with those around them. So when you think of life change, disagreement, social isolation, it's not what you are thinking to yourself, it's how you are responding and interacting to your local communities on the interpersonal side. On CBT, that's a little bit more on what is your internal dialogue, what is that conversation you're having with yourself. So CBT is more inwardly focused, whereas IPT is certainly more externally focused.

SPENCER: That makes a lot of sense. What about the behavioral piece of CBT? Because you got the C, and then you got the B, and for the B, there's a lot of aspects around, "Okay, the next time this thing happens, you're gonna change your behavior. Instead of just sitting at home alone when you're feeling down, you're gonna go be around people," things like that. I'm wondering, is there a behavioral component of the interpersonal treatment, or is it not so much focused on that?

SEAN: There's certainly a behavioral component. When you're helping someone to identify and understand and then change their trigger of disagreements, for example, really, what you're doing is giving them the understanding, and then the skills to change that behavior in the future. So if I was, again, going back to that mom, unable to negotiate with my husband over the use of our income, let's say it's because I was too shy, or I just didn't know the right way to kind of negotiate the give and take, what you're seeing happening here is giving the skills. And then when I come back and see an improvement, that I was able to negotiate with my spouse and things feel better, that is one step to change the behavior. And then I'll do it again. I'll negotiate with him better. I'll defuse another disagreement. And over time, that accumulation of change, of course leads to behavior change.

SPENCER: How do you get people interested in this program? Do you actually talk about depression, or do you use other words? And how do you actually get the word out? I mean, how do you advertise that?

SEAN: It's the hardest part we do, as you can imagine. There's different approaches because today, we're doing groups in person, we're also doing roughly about a quarter of our groups now are done on the phone, so remotely. That's because during the pandemic, we were able to transition everything to the phone. And now it's a mixture of in person and on the phone. But it really depends where we are. If we're in a community where we've been working for years, where we have deeper roots, we'll have just a great referral system of people who have graduated from our groups. And these individuals typically will bring back — they're very good at identifying others with depression — so they'll make referrals and bring to us their mother or their neighbor or sister who they think might be suffering from depression. So that's more of a forerunner of an organic approach of people we've already helped and are helping us in terms of finding other sufferers. If you're in a community where we're brand new, we don't have those roots, it's a slower, more difficult process. We work very closely in the community. Many of the communities we work, be it in Uganda or in Zambia, these local communities, many times in slums, just like a few city blocks, will have a community leader. There's not much of an analogy here in the United States of what that would be locally. But we work with the leader to help them understand what depression is, what the symptoms are, and how depression in their community is probably holding them back in terms of social cohesion, et cetera. So over time, we're creating awareness with the community leader. We'll do small community events where we're talking to 20 or 30 people, literally just explaining what depression is and what it's not to individuals. Now, those individuals who we've just spoken with will then go home, and the next day or so typically will bring back to us again someone who they think is suffering from depression based on what they learned from us. I don't think it's surprising to think or to understand that those who are really suffering from depression aren't going to come to our public forum, if you want to think of it that way. Just because of the symptoms of depression won't really allow them to focus and concentrate and to kind of be goal oriented, so we're going through intermediaries. And then over time, the groups are forming, we're getting more referrals, and that wheel kind of starts spinning more on its own in terms of finding new patients,

SPENCER: Do they usually speak English or their native languages?

SEAN: We don't see a lot of English. In Uganda, which I think at the last count I had has 42 languages. In Uganda, almost always these groups are in their own language. Also, there's well over a million refugees in Uganda. It's really the refugee crisis center of Africa, where we'll have different languages. People coming in from Sudan and the Congo. Sometimes for the refugees, their most common language actually is English, just because if you think of Sudanese or the Congolese, they won't have a native language that is in common. So typically, very rarely, have I ever sat in a group that is just an English,

SPENCER: Is there a challenge with language where there may not be an easy way to kind of interpret the word depression in their language, or they just think of it differently?

SEAN: Well, if you were in a group, and even in the English version in Uganda, we typically aren't using the word depression. There is no translatable equivalent. There are local terms that equate to depression that we can use, so that we're really literally speaking the same language. In some of the local dialects, there is just no word for depression. You really just have to kind of explain the symptoms for a little bit, so it's a longer way to kind of communicate your point. But ultimately, we're able to be effective communicators, speaking in the local language and getting the point across so that we're all on the same page.

SPENCER: It's interesting to think about how hard it would be to identify something if you didn't have a word for it, right? If you know this thing depression exists, you can be like, "Mmm, maybe I have depression." Whereas, if there's literally no word for it, you're like, "Hmm, I feel this, I feel that." But you may not connect those things together (those different symptoms) and think of them as a unified thing. And then you may not even know how you would seek out help with that, because you don't think of it as something that's unified or has a name,

SEAN: Oh, you hit the nail on the head just with that observation, Spencer. That's a lot of the problem. What you're describing in terms of having the right word, for me, it comes down under the umbrella of just that lack of awareness. So by not understanding, it takes more of our time to just communicate and explain what depression is, what it's not, helping people understand the symptoms, and then getting them to either come for treatment or to bring their friend or neighbor who is suffering with those symptoms to treatment. You think of here in the United States, everyone understands depression. If you say you're having a depression group or something like this, you're already 10 steps down that journey that we start at in Uganda at step zero, so it's a huge impediment. Something that's become quite normal to us. I think we're very strong, all of our team, in terms of how we communicate and talk about something that most people thought they were the only one suffering from. So, it's a huge challenge.

SPENCER: What percent of people go to the program would you say improve in their symptoms?

SEAN: It's a hugely successful program. At least on average now, over the last nine years, be it in person groups or teletherapy groups, we see on average 80% of the people come out of the group at a level that we call as depression free, which (to get in kind of the details) is a score of one to four on the Patient Health Questionnaire-9. But those remaining 20%, as well, typically have seen a significant reduction in their PHQ-9 score or their overall symptoms as well. So for the most part, everyone benefits. It's the question of to what end they are benefiting. But for us, to be having consistently hit 80% people becoming depression free, now as we approach 200,000 individuals, I think is a huge testament to Group Interpersonal Psychotherapy. I think it's a huge testament to our team, who really over nine years have been able to operationalize how to deploy group talk therapy in really difficult environments of Africa.

SPENCER: That's an astounding number, 80%. I mean, that's substantially better than the numbers for antidepressant medication, for example. Have you been able to run a randomized control trial on your work? And I'm wondering what the details of that are, if you have one.

SEAN: We haven't run a large formal one, because we're based off of an RCT from 2002 that really, for us, I think, makes us feel confident that what we're doing is valid. I think more recently, as well, about two years ago, the World Health Organization came out and formally recommended Group Interpersonal Psychotherapy as an effective treatment, frontline treatment, for depression in developing and lesser income countries. So for us, between the original RCT, the WHO's endorsement, we see ourselves using a valid and proven model to treat depression.

SPENCER: Got it. Because obviously, a tricky thing with this is having a control group and knowing what percentage of people would improve otherwise. I think especially it gets tricky with life events, or something like moving to a new city, or having a fight or something like this, because obviously those things tend to be hard in the beginning, and they tend to get easier. I don't I don't know if you have any thoughts on that?

SEAN: Yeah, it's tricky, but not impossible. We do hope to actually do an RCT in the next one to two years. It is difficult when you think on the control group side, you really can't hold someone who's depressed in a control setting by withholding treatment from them for a very long time for moral reasons. We've done some small RCTs in the last few years, very small, very specific. The longest that we've been able to have individuals who are depressed in a control, who are having treatment withheld, is one year. And that's the most that institutional review boards have agreed to. So it doesn't slow down the RCT, but it does make it a complicating factor. We're really optimistic that in one to two years, we can do a larger RCT based on all of the impact that we've been seeing that could really inform us and help. There are still, I think, some people who doubt what we're doing for whatever reason. I think, more relevant and recent RCT in the next one to two years would be very beneficial.

SPENCER: You mentioned that you tend to focus on women. What percentage of the participants are women, and why make that choice?

SEAN: We focus on women because depression affects women at a much higher rate than men. So for us, when we were starting strong minds, and even to today, it was really about mindful of the fact that funding — and we're a nonprofit, so we're entirely funded by either aid or philanthropy — that mindful of the very limited amount of mental health funding available in Africa, that we would really have to do everything we could to just maximize our impact, how do we get the greatest return on investment. So with that scarcity of funds, we decided that the greatest impact is focusing on women who suffer more from depression than men, and focusing on women who are typically the backbone of the family, in terms of helping the children and getting them to school, feeding them, etc. So we felt that given a choice, if we had $1 to spend helping a depressed woman to become depression free would have a greater social impact than helping depressed men. Now, if we had all the money in the world, of course, we'd be treating men and women equally, but we don't have all the money in the world. In the early days, we were almost exclusively all women 100%. Today, that rate is about 75% women 25% men, and that's mostly because other ways that we're finding patients that we didn't discuss earlier, we're also finding them not just by walking through communities, but particularly when hit by the pandemic, we're finding a lot more people on social media, just doing radio spots. So we have a number of people in the community who can just call us. And we can't really target our radio spots or social media just to females. So if a depressed man calls us, we feel it's our obligation to respond and to treat him. We don't push him away or deny him treatment. And that's why that number of men treated has gone from 0% up to about 25% today.

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SPENCER: One thing that I find confusing about mental health statistics is that the United States tends to be reported as having especially high numbers. For example, depression in the United States, the statistics I've seen shows it being one of the higher ones in the world, higher than I think many countries in Africa. And I'm wondering if you agree with that statistic, and what you attribute it to?

SEAN: I attribute it to there's a lot of just incorrect data out there. I don't even know what numbers you see in the US. I see depression in the US typically reported anywhere between eight and 10% of the population. Is that what you're seeing?

SPENCER: Yeah, that's compatible with the numbers I've seen. I think it varies depending on the estimate, but yeah.

SEAN: And then you can glance through all sorts of World Health Organization or other international data on depression rates in Africa, and typically, you're seeing maybe 2, 3, 4 or 5%. I don't know if that's what you're seeing as well.

SPENCER: Yeah. And it just sort of APR seems very surprising, right? Because people in the US tend to have a lot more material abundance. In some countries in Africa, people are dealing with really difficult situations like poverty and war and so on.

SEAN: Well, there's a couple things in what you said. One is, I don't know if you're saying this, but poverty or not being poor can exacerbate or influence depression. Poverty is not a cause of depression.

SPENCER: It's not?

SEAN: Poverty does not cause depression, it does not. That's a huge misunderstanding, something I've been trying to explain to people for the last nine years. If poverty causes depression, so when we're in the slums of Uganda and we're walking through a normal slum, we'll see depression rates up to about 25%, one in four. Now, if poverty was causing depression, then that rate to me should be much higher. Why will this one poor woman be depressed, but the three others next to her won't be depressed?

SPENCER: I think we use the word cause differently, because I think of causes as a factor that makes something more likely in a causal way. For example, carrying heavy backpacks causes back pain. It doesn't mean it gives back pain to everybody, but it means it increases the probability in a causal way.

SEAN: Well, that's a good definition. I think it comes down to how others are using 'cause' as well. There's many people that I work with (funders, etc,) who are actually shocked to learn of our experience in Uganda and Zambia, and our belief that poverty is not causing depression. You see this as well. And I think there's been some great writings, particularly from the World Health Organization, helping people to understand as well that poverty can exacerbate depression, increase some symptoms. Going back to that example, if I'm a depressed mom disagreeing with my spouse over how to use the $1or $2, well, we only have $1 or $2 because we're poor. But I think the flip side is, well, there's three other families who aren't having these disagreements, and they have the same level of income.

SPENCER: Right, that makes sense. Yeah. So to put a kind of more formal flavor on it. My preferred definition of causality, like 'does X cause Y?' is, if you were to make X happen, would it increase the probability of Y? That's the definition I use. I think reframing what you said in the language I would use is that it's not extremely correlated with depression, or it doesn't fully determine depression. It's a factor that maybe increases its probability. Would you agree with that?

SEAN: I would totally agree with what you just said. And you're more eloquent at rephrasing in your own terminology than me. So thank you. The other part of the question we're talking about was the data, right? If depression rates, say in Africa, is 5% or so? That data on depression in Africa is woefully inaccurate and is doing a huge disservice to the planet, and is not helping us to understand that there is a depression — what I would call epidemic — in Africa. We are consistently seeing rates of depression up to 25%. Yet, international organizations are reporting rates of three, four or 5%. They're reporting that on incredibly small samples, and they don't have the right information. And as opposed to reporting that we don't have the right information, so there is no number here, they are really painting a picture that there's no problem here. And that's something that we're really trying to work with these international organizations using our data from 200,000 depression sufferers that we're consistently seeing that there is a depression epidemic in Africa up to 25%. So when you think of that 25% against that eight or 10% in the US, that's maybe changing the context that you had in your mind.

SPENCER: Yeah, that APR is more what I would expect. I've always been shocked by the statistics that are publicly reported. Do you know how they measure those? Because obviously, if you just ask people if they're depressed, it's gonna be a massive problem, if their language doesn't even have a word for it.

SEAN: I don't know. I know their sample sizes are super small. And we're open books, we've openly shared all of our data with the World Health Organization and others. I mean, they do great work. So don't hear me saying they don't do great work just based on the issue with the data. But again, if I had only looked at that data when I was creating StrongMinds, and if I had not lived and worked in Africa for like a dozen years, if I just looked at the data, I would have said, "I'm not launching in Africa, I'm launching in the United States or somewhere else where the depression prevalence is higher." If I had just looked at the data, I would have missed making a huge impact, where there truly is a depression epidemic, but no one really understands it. So it's really a disservice, and it's quite dangerous to public health.

SPENCER: I don't know if you would have a perspective on this, because I'm not sure if you've done work in, let's say, the United States or Europe. But I'm wondering, do you think that the way depression manifests is different in different countries?

SEAN: Well, how would you define manifest?

SPENCER: Well, either the cause of it or the symptoms of it? I'm just wondering if you think we should be looking for it in different ways, or are occurring with different side effects?

SEAN: Not that we've seen. It's interesting, we're about to launch here in the United States through another organization called StrongMinds America. We're actually launching in about two weeks in Newark, New Jersey. So we haven't treated individuals. I think, if you and I were speaking a couple of months from now, I'd be able to talk with more information based on what we're seeing in terms of the symptoms, prevalence, triggers, etc, on the American population. I can't speak to that now, but what we've seen across just different African countries is when we use the current diagnostic tool, the PHQ-9, it is quite accurate. It does come down to making sure that the different symptoms within the PHQ-9 (those nine symptoms) are understandable in the local context. It takes a little bit more explanation. But I think how it manifests and what those symptoms are, what I've seen so far, feels pretty consistent across countries. And I think of here, I live in New Jersey, I have four children, when we go for their annual physicals, they're filling out the PHQ-9 as well. I think it's a state law to be screening adolescents for depression. So, my kids are doing the same diagnostic tool that the 200,000 Ugandan and Zambian sufferers have completed. I think what you do see in some countries — I've read more about this as opposed to seeing it up close and personal — just different somatic symptoms. Sometimes depression sufferers in certain countries or communities will have similar physical ailments. Some may have more headaches or stomach aches or back pain. So, it tends to be just a somatic symptom that is resulting from a mental illness. I don't think somatic symptoms like this are completely understood yet as opposed to understanding why does this group of Congolese refugees who suffered from depression also have backaches. Where does that come from? Whereas another community of refugees from another country may have stomach ailments. So those are the only differences that I'm aware of across depression.

SPENCER: For those who haven't heard of the PHQ-9 before, I'll just read a few parts of it. So it asks the patient: "How often have you been bothered by the following over the past two weeks?" And that it has statements like, "Little interest or pleasure in doing things," "Feeling down, depressed or hopeless," "Trouble falling asleep, or staying asleep or sleeping too much," "Feeling tired or having little energy," and so on. And there are nine such questions. And the answer scale is usually a four point scale: not at all, several days, more than half the days, nearly every day. And I have to say, I think the PHQ-9 is actually quite good overall. I think because it's very highly correlated with I think what we would call depression, and it has good sensitivity and specificity with regard to what psychiatrists would diagnose and so on. One of the things that's always bugged me about it is the answer scale, which I think is really badly designed. Because for example, the answer option 'more than half the day', it makes it seem like you're only supposed to choose that if it's more than four days. But then people's usage of the word several can differ. What do we mean by 'several'? People's usage of the word 'nearly every day' can differ. And so it seems to me it adds sort of a pointless ambiguity, where they could have just had more answer options. Like, how many of the last seven days have you experienced this? And it could be anywhere from zero to seven or something like that.

SEAN: No, you're absolutely right. It wasn't [inaudible] who came up with that scale. We see that in our own training in Uganda and Zambia. We're just training the StrongMinds America team, and we pretty much just converted that scale into this means this many numbers of days, and we quantify to make it easier because, yeah, 'nearly every day' what does that mean out of the four? And then even the fact that comes down to 14 days, it's a difficult scale in that sense. The scale overall works very well, as you said, but how it's quantified and rated is needlessly challenging.

SPENCER: So let's now change the topic of what the evidence says about how StrongMinds' interventions compared to existing interventions. Do you want to tell us, first of all, about the cost? What does it cost to administer this to one person?

SEAN: Yeah, today our cost is at about $90. So it's costing us $90 from beginning to end, when we find the individual and get them all the way through treatment. That $90 includes all of our overhead, from overhead costs in Uganda, Zambia, even here with our small fundraising office in the United States. So it's what you call a fully loaded cost of $90 to help someone become depression free. It's quite impactful.

SPENCER: Do you have an anticipation about what that will be when you launch the US version in New Jersey,

SEAN: It's going to be higher. When we think back to StrongMinds when we started, working on the ground in 2014, the cost was $400. And over the years has come down as those initial investments of hiring then get dissipated across a growing patient volume. In the long term, we forecast seeing the cost per patient in the America program definitely getting down into several hundred dollars over time. The lowest we've forecasted that is about anywhere between $100 and $150. And that just comes down to the big question being the patient volume that that program can imagine,

SPENCER: I find it surprising that the numbers are so close together, that the US numbers could come down to be within a factor of, let's say, two of the Africa numbers.

SEAN: Yeah, that's where the model in the United States is a little bit different, more patient flow going through. So an individual here, who clearly gets a higher salary would be seeing many more patients than we would be seeing in Africa, just in terms of the logistical challenges and things like that. That's what we're forecasting. And also, the model in America is more to be focusing with local partners. So, providing the depression treatment services on site at a local community center or something that's already existing. We don't have that kind of infrastructure that we're able to leverage in Africa. So a lot of times, we're kind of creating that infrastructure or being less efficient, because many times in Africa, we just literally have a group of people who just sit down where they are under the shade of a tree. But then when that group is done, the group leader has to get up and travel an hour to the next location, which is an hour not utilized treating individuals.

SPENCER: And what about cost effectiveness? How do you think about measuring the impact of what you're doing and kind of putting it in terms that can be compared to other interventions?

SEAN: Yeah, it's a great question. We've seen some great improvement on this. The Happier Lives Institute in the United Kingdom, just this year actually really helped us to understand our impact better, comparing it to others. When they came out, and they compared us to direct cash transfers from, I think the most notable organization there is GiveDirectly, and they went through all of our data and their data and really found that, for StrongMinds, our intervention is nine times more effective than cash transfer. We always felt that we were highly effective. We've been collecting the data for nine years, not just mental health data, but the data that shows when someone is no longer depressed, they go back to work, their productivity increases, their kids are better cared for, their whole life improves, and we have all this data. It was just very reaffirming for an outside entity to look at the data, and then compare it to cash transfers, which are, in the world of philanthropy, there's typically a lot of disbelief that cash transfers are very strong. And this report doesn't say that — it's not a competition — but in terms of the scheme of things, we're nine times more effective. I think it really goes to the fact that mental health is so important, and it's a huge lever in a person's life. I've done lots of different kinds of public health interventions in Africa, from HIV to malaria to sexual reproductive health. But for me, on the mental health side, it's just such a strong lever in the center. When the mental health of an individual is better, so much in their life improves. It's quite amazing.

SPENCER: When you're talking about cost-effectiveness here, what are you thinking about in terms of the outcome? Because if you think about giving people money, there's a lot of ways to look at how that benefits people. And similarly, if you're helping someone with depression, there's lots of ways to look at those benefits. So what's your preferred way to look at it? And when you're comparing it, say like GiveDirectly, what's that comparison based on?

SEAN: Speaking to their analysis, it's really looking at the secondary impact or the flow through, if you will. So if you give someone — I think leaving this case for GiveDirectly, it's typically — $1,000 cash outlay versus helping someone to become free from being depressed. And then looking later in their lives and on their family. For that $1,000, what will be different x period of time later in terms to the individual and the entire family compared to someone who's no longer depressed. And when you look at it, how I would have been looking at it, which is somewhat similar to HLI, in terms of looking at the entire gamut, it's understanding that when someone is no longer depressed. And we've seen this over the nine years with our own data that kids are going back to school, nutrition levels in the house are improving, the house itself (the physical structure of the house) is improving, and social connectivity is improving. And simply, when you look across a common basket of secondary impact indicators between better mental health or $1,000 in your pocket, HLI was able to see that the impact is simply nine times greater from the better mental health compared to having an extra $1,000.

SPENCER: I thought it was based more on thinking in terms of life satisfaction, or happiness self-ratings or something like that?

SEAN: No, I believe it's across a whole gamut of really understanding the entire circle of impact.

SPENCER: I see. And then trying to kind of come up with weights for how important each of those is, and then aggregating them together into some final number, like quality adjusted life years, something like that?

SEAN: That's certainly my belief. That's my understanding of the analysis.

SPENCER: Any other topics you want to touch on?

SEAN: I think we've hit a lot. I really enjoyed the discussion. I think, maybe just for the listeners sake to know, for StrongMinds, we're passionate about what we're doing. It's still a big challenge for us nine years into this program that we're still really the only organization in Africa working to really scale the depression intervention. For us, scale is getting into the millions. We're at 200,000 now. We still have a way to go, and that we're the only ones doing it. And we do it in a space where still funding for mental health is so limited. So if your listeners are able to help us to do that, we're always very thankful.

SPENCER: Sean, thanks so much for coming on. Really appreciate it.

SEAN: Spencer, entirely my pleasure. Thank you so much.

[outro]

JOSH: A listener asks: What untested hypotheses do you have about how personality works that you strongly believe are true?

SPENCER: Well, one thing that I think is true, although I haven't seen it tested formally, is that the way that human belief structures work is that we have certain beliefs that are nearly unchangeable in our belief structure, and others that are much more malleable. And that for all intents and purposes, if you're dealing with someone who has one of these sort of what I call 'anchor beliefs', it's unchangeable beliefs, that you're really better off just accepting that you're not going to change their belief on that topic. And so then when you're discussing things with them, keep that as a given that you won't change that belief and just think about beliefs around that, that you may be able to talk to them about that they may be more malleable on. So an example of this, let's say that you're talking to someone who their whole life they were raised in a certain religion and they deeply believe in it. Suppose you wanted to change their mind for some reason related to that religion, like maybe you thought it was having bad outcomes for them, it's extremely unlikely that you're gonna change their mind about the core tenants of that belief structure. However, if you think that their religion is leading to engage in harmful behavior, maybe you could work within scripture and you could find support from scripture from their own religion that supports behaving differently, and then maybe that's a much more likely way to achieve that because you're not dealing with one of these anchor beliefs.