Harriet Nakalyango sells water and farms a small plot of land to make a living on the outskirts of Kampala, Uganda’s capital. After she married at age 16 and had four children, her husband “started boozing and beating [her] from morning to evening,” she says. The physical violence took an emotional toll. “I was sincerely sick. I was crying every day. I was not eating. I wouldn’t let my kids go out,” she says. “They used to cry and I used to cry. I wasn’t working and stayed at home. I was almost dying with kids. That was the end of me.” Nakalyango fell into an eight-year depression.
In 2015, a friend told Nakalyango about StrongMinds, a US-based nonprofit that launched its pilot program in Uganda in 2014. StrongMinds trains mental health facilitators to lead peer-group therapy sessions for women with depression in poor communities in Kampala.
According to the World Health Organization (WHO), depression affects 322 million people worldwide and is also the leading cause of disability globally. But fewer than half of the people suffering from it receive treatment—especially in countries lacking a solid understanding of mental health. In developing countries like Uganda, up to 90 percent of people who suffer from depression don’t seek treatment. Social stigmas and lack of awareness, resources, and health-care providers are just some of the barriers they confront. In Africa, people with mental health issues are often ignored or ostracized, and resort to being “treated” by witch doctors. In Uganda, where less than 1 percent of GDP goes to mental health care, reports estimate that approximately 30 psychiatrists exist among a population of more than 44 million.
Discouraged by the lack of options for people with mental health issues in Africa, Sean Mayberry founded StrongMinds in 2013. Mayberry had worked in Africa for a decade on implementing AIDS/HIV and malaria programs. Prior to starting StrongMinds, he was country director for Population Services International in Democratic Republic of the Congo. He also served as chief operating officer of VisionSpring, an eye-care nonprofit serving developing countries, and as chief executive of FXB, a global poverty-alleviation nonprofit based in New York City.
A life-changing encounter in Uganda with an “adolescent boy with a mental illness,” Mayberry recounts, “finally galvanized me to understand that someone had to do something about creating mental health access in Africa. If I didn’t do it, who would?”
He continues, “I worked in the Congo for years to improve physical health—in malaria programs, HIV prevention, and clean water. I saw over and over my African friends, colleagues, and clients who suffered from mental illnesses [unable to] access care—and I could do nothing as a leader of a public health organization to help them. … I found this incredibly frustrating.”
Mayberry also had a personal connection to mental illness. “I grew up with parents suffering from depression, and I have very close family members today who suffer from depression,” he explains. “I understand what depression does to individuals, to mothers, to children, to families—I understand that depression is truly a debilitating disease that, left untreated, tears people down and in many ways stops them from living to their full potential.”
The Strongminds Model
StrongMinds uses the interpersonal group-therapy technique—also known as group interpersonal psychotherapy (IPT-G)—to help group members identify and manage their problems without medication. During weekly sessions of approximately 90 minutes over three months, groups of about a dozen women talk through their problems with a facilitator trained in IPT-G. The first few sessions focus on building rapport with group members to establish trust and emotional comfort. In the second of the program’s three phases, women make suggestions to one another and begin to understand the triggers of depression. In the third phase, facilitators teach them to recognize and respond to those triggers. Women who want to join StrongMinds take the PHQ-9 survey, the standard patient questionnaire used to assess depression, to receive a preliminary diagnosis. Those found to be severely suicidal are not a good fit for peer-group therapy and are referred to clinics with mental health facilities.
StrongMinds focuses on women—who suffer unipolar depression at twice the rate of men, according to WHO’s report on gender disparities and mental health. Potential causes for this difference include gender-based violence, and economic and social inequalities. In Uganda, these range from poverty to women’s shouldering the responsibility of caring for their children and families. StrongMinds also piloted programs for men, but, because attendance was low, the programs were subsequently cancelled.
When StrongMinds launched in Uganda, people were suspicious of a new organization coming into their community. Some feared it was a religious cult. Some women who wanted to join faced resistance from their husbands and other family members who did not want them to talk to others about their problems. To overcome these barriers, mental health facilitators spent time with community leaders and held public events to raise awareness about depression and explain their work. Mental health facilitators stress confidentiality, even though women often come from different nearby communities and don’t necessarily know one another. According to Dena Batrice, executive director of StrongMinds Uganda, about 20 percent of women drop out of the program, although she says the reasons for this rate remain unclear.
For Juliet Nsubuga, the facilitators’ continued presence in her community convinced her to join a meeting after she originally dismissed the program. Nsubuga was married at 14 and then widowed after having seven children. Her deceased husband’s family took most of her property and told her to remarry. Instead, she eked out a living as the owner of a small shop, but thieves robbed the store and took everything. She reached a breaking point when her 27-year-old son died in an accident and her three daughters—ages 17, 15, and 13—became pregnant. Nsubuga used to serve as an informal leader in her community, but her daughters’ unplanned pregnancies made her feel ashamed and caused her to withdraw and fall into depression. “I hated myself. I thought my life was over,” she says.
In Nsubuga’s group, women talked through their problems. One woman was distraught because her husband harassed her because she couldn’t get pregnant. Lack of money was a common challenge among the women. Group discussions covered possible financial solutions, including earning money from selling vegetables and braiding hair. In therapy, Nsubuga admitted she “hated her children,” but the group encouraged her to resume communication with them.
Nakalyango’s experience is similar to Nsubuga’s. By sharing their own stories of depression, the women in her group affirmed that she wasn’t alone in her struggles. She learned to communicate better with her husband, which improved her relationship with him. Nakalyango recalls something the facilitator told her group: “One stick is easy to break. But many sticks together are difficult to break.”
After their sessions ended, both Nsubuga and Nakalyango completed 14 weeks of training from StrongMinds to become volunteer peer facilitators. “I was in the deep,” explains Nakalyango. “If I [hadn’t gotten therapy], I’d be dead now. I know many people who are suffering. It was medicine for me. What they did for me, I also have to do it.”
Two Million Women by 2025
Starting StrongMinds was no easy task. Because mental health is more difficult to quantify and explain than physical health interventions, such as vaccinations, Mayberry faced the initial challenge of attracting donors, who were more focused on highly visible health crises like HIV/AIDS and malaria. “Until StrongMinds started, mental health programs and illnesses were viewed as complex, complicated, slow to work, and even mysterious,” Mayberry says. “Donors thought treating them would take years and massive investments in hospitals, doctors, and nurses, and that even then there would be no clear deliverables.”
Mayberry launched StrongMinds with family savings and worked unpaid for the first two years. Today, financial support for StrongMinds comes from private donors and philanthropies such as Mulago, CRI Foundation, Elmo Foundation, and Draper Richards Kaplan Foundation.
“Our first donors came on board because I knew them—they supported VisionSpring, so they knew me and believed in me,” says Mayberry. “They also were forward-thinking and understood that mental health was a neglected health area that needed support.” Kristin Gilliss, a senior investment partner at Mulago, explains that Mayberry is “a proven implementer—he built teams and scaled operations for organizations ranging from Intel to VisionSpring across Asia and Africa. We look for people who are irrepressible.”
Both StrongMinds’ effectiveness and its future expansion plans are due to its group-therapy model, which is inexpensive to scale. In its first year, 514 women in Kampala participated in group therapy. In 2017, more than 15,000 women were treated. Since the 2014 pilot program, more than 25,110 women have successfully gone through StrongMinds treatment, and approximately 86 percent of those who completed the program say they are no longer depressed. StrongMinds also reports that about 80 percent of groups continue to meet informally after their program’s conclusion.
The nonprofit now aims to reach two million women by 2025. It wants to expand to other countries in Africa and work with governments and big NGO partners to meet its ambitious goals. Mayberry sees this objective as integral to development in general. If women are struggling with depression, they “are held back, and development efforts are wasted,” he says. “By reducing and eliminating depression in Africa, we pave the way for all other behavioral change efforts to be more efficient and impactful.”