Objective: To assess if eight counseling sessions conducted by women minimally trained as community counselors could reduce the mean level of anxiety and/or depression in women of their own community. Design: A randomized controlled trial. Setting: A lower-middle-class, semi-urban community in Karachi, Pakistan. Participants: 366 anxious and/or depressed women providing informed consent. Method: Through systematic sampling, 1226 women were screened using an indigenous instrument. Out of these, 366 women were found to have anxiety and/or depression and were randomized to intervention and control groups. Women from the same community were trained in 11 sessions as counselors. Subjects in the intervention group were counseled once weekly for eight weeks by the trained community counselors. After the 8th session, the screening questionnaire was re-administered to both the groups. Results: A significant reduction was found between the mean anxiety and depression scores of the two groups (p value = 0.000). Conclusion: Counseling by minimally trained community counselors reduced levels of anxiety and/or depression in women of their own community.
An enormous universal burden of mental disorders has been reported in several recent studies (1-8). Two thirds of those affected are in the developing countries, and their number is likely to increase due to rapid population growth, urbanization, and strong links between adverse socio-environmental factors and prevalence of mental illness (9, 10). Pakistan is a developing country with an estimated population of 140 million, of which 70% live in rural areas and depend on agriculture for their livelihood. Persisting drought has forced people to migrate to urban areas in search of employment (11). Karachi is a port, a business hub, and a mega-city that is subjected to continuous immigration. It has a population of more than 14 million, of which 40% live in overcrowded squatter settlements plagued by poor sanitary conditions, unemployment, and inferior social services. Women are in greater jeopardy because of their gender, illiteracy, domestic violence, and loss of extended family (12).
Anxiety and depression are responsible for over 90% of mental disorders found in the community and comorbidity is common (13). Their combined prevalence is taken as a measure of the magnitude of mental illness in a community (14). A high prevalence of anxiety and depression in the general population with more than double the prevalence in women has been reported in local studies (15, 16).
Generally, the psychiatrist/population ratio for developing countries is reported as 1:50,000-100,000 (17). Pakistan falls in the 1:50,000 group (18). Addressing this issue of accessibility and affordability, the World Health Report 2001 recommends community-based programs for promotion, prevention, and treatment of mental and behavioral disorders (1). However primary care professionals and primary health care systems have their own limitations in these countries, as some of these allocate less than 1% of their budget to health (19). In Pakistan only 0.8% of the budget is allocated to health and within this, mental health has the lowest priority (20).
Although antidepressant medication is both convenient and effective, there is considerable demand from patients for psychological treatment (21). Widespread stigma is one of the barriers to seeking psychiatric treatment (22), and Pakistan is no exception as patients with mental disorders are still taken to faith healers or exorcists. In this setting, we hypothesized that informal social support in the form of counseling would be more acceptable and affordable than seeing a psychiatrist.
If the counselors are from the same community, they are more easily accessible, have frequent contacts, and greater opportunities to initiate and to provide continuity of care (23). Randomized controlled trials showing the benefit of counseling by accredited counselors (24, 25) are available, but none could be found on assessing the benefits of counseling by minimally trained community women. …