Dominic Velasco, MD, MBA – Brain Blogger Health and Science Blog Covering Brain Topics Wed, 15 Aug 2018 15:30:18 +0000 en-US hourly 1 Friendship Bench—A Model for Accessible Mental Health Care Mon, 13 Aug 2018 15:30:17 +0000

In 2017, Mental Health America reported that one in five adults with mental illness say that they are not receiving the mental health care that they need. (Mental Health America, 2017) The reasons for this are the following:

    • (2) they do not have enough money to pay for the service
      (3) mental health care providers are lacking
  • There is one mental health care provider for every 529 individuals in the US. This gap widens significantly for specialized mental health care. Only 20% of children with mental health problems receive some form of mental health services. The reason is that there are only about 8000 child and adolescent psychiatrists practicing in the US. In San Francisco alone, the Center for Disease Controls and Prevention (CDC) reports that there are about 32 child psychiatrists and 88 child psychologists per 10,000 children ages 0 to 17 years old.

    There is a need for re-imagining the delivery of mental health care. One such method is known as the Friendship Bench Intervention (see video). The friendship bench has been undergoing development for more than 20 years in Harare, Zimbabwe where the Harare City Health Department in collaboration with the University of Zimbabwe Medical School sought to solve a major cause of disability from non-communicable diseases in the region, mostly common mental disorders such as depression and suicidal ideation.

    The Friendship Bench is a task-shifted brief intervention and problem-solving therapy for common mental disorders which is provided by female lay health workers trained in specific aspects of cognitive behavioral therapy, particularly in problem-solving therapy and behavior scheduling. 

    In short, the Friendship Bench mitigates common mental disorders such as depression by utilizing female lay health workers who are trained and supervised by clinical psychologists and psychiatrists to perform problem-solving therapy in a primary care setting.

    The problem-solving approach starts with the patient identifying the cause of his mental illness. For example, unemployment. Interestingly, this approach deviates from the conventional where experts aim at diagnosing the patient from the symptoms that they present. Problem-solving therapy aims to provide a positive orientation of the patient towards resolving these identified problems. This makes them realize that they can have control in overcoming their mental illness.

    The lay workers follow a script and conduct 6 sessions lasting from 30 to 45 minutes for each patient. The first session involves three components: (1) Opening the Mind or kuvhura pfungwa, (2) Uplifting or kusimudzira, and (3) Strengthening or kusimbisa. The first session aims to let the patient open their mind and identify their problems. They would then be allowed to choose only one to work on. The lay worker and the patient will then identify how to solve this problem realistically and formulate an action plan. This is an iterative process where the subsequent sessions will develop based on the first session.

    Common mental health disorders that the Friendship Bench aims to treat are the following: depression, anxiety, panic disorder, post-traumatic stress disorder, cognitive disorders, and substance abuse.

    Hiring and training lay workers from the community can significantly increase the mental health workforce. The requirement for the adult female trainees in this program is an educational background with at least 8 years of formal schooling (secondary schooling may suffice). The average age of the trainees is 58-years old. The training can be easily implemented, and it is cost-efficient at only $200 per health worker.

    Figure 1. An Example of a Theory of Change Framework Output. LHW = Lay Health Workers

    Community engagement is a key process in the development of the Friendship Bench. The goal is to bring community members, experts, researchers, and other key stakeholders together and become equal partners in the program. They engage in a workshop to develop a theory-driven framework known as the Theory of Change. Members hypothesize the best treatment initiative plan for the community’s patients and form a theory of “how and why an initiative works?”. Variables are identified and constantly measured for every cause and effect pathway. This illustrates proof that an initiative has a positive or negative impact. The theories are continuously measured, challenged, and changed until the desired impact is formulated (see Figure 1).

    The success of the program is heavily reliant on the training method, the translation of the manual to the local language, and the integration of the program with the culture of the community. Lay workers must also learn how to translate and utilize tools used in common mental disorders such as the 20 item Self-Reporting Questionnaire (SRQ-20), General Health Questionnaire (GHQ-12), Hospital Anxiety and Depression Scale (HADS-D), and Patient Health Questionnaire – 9 Depression Test (PHQ-9). These are the basic metrics used to determine if the therapies are working.

    Adding to the workforce, competent lay mental health workers in the primary care setting can offset the gap in mental healthcare delivery in communities. Its success in first-world countries is more likely because its growth can be sustained by leveraging readily accessible financial resources allocated each year by public health organizations. Its robust infrastructure, particularly in primary care clinics and information technology such as telehealth services, can boost the Friendship Bench programs. A limitation of the Friendship Bench is that it is designed to treat adult common mental disorders. To emulate this program so that it can suit the need for pediatric mental health disorders is of importance.


    Abas, M., Broadhead, J. C., Mbape, P., & Khumalo-Sakatukwa, G. (1994). Defeating Depression in the Developing World: A Zimbabwean Model. Brittish Journal of Psychiatry, 293-296. doi:10.1192/bjp.164.3.293

    American Academy of Child and Adolescent Psychiatry. (n.d.). Workforce Issues. Retrieved May 15, 2018, from American Academy of Child and Adolescent Psychiatry:

    Blakely, T. (2003). Unemployment and suicide. Evidence for causal association? J Epidemiol Community Health, 57, 594-600. doi:10.1136/jech.57.8.594

    Center for Disease Controls. (2015). Behavioral Health Services Providers by County. Retrieved May 15, 2018, from Centers for Disease Control and Prevention:

    Chibanda, D., Mesu, P., Kajawu, L., Cowan, F., Araya, R., & Abas, M. A. (2011, October 26). Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. DMC Public Health, 11, 828. doi:10.1186/1471-2458-11-828

    de Silva, M. J., Breuer, E., Lee, L., Asher, L., Chowdhary, N., Lund, C., & Patel, V. (2014, July 5). Theory of Change: a theory-driven approach to enhance the Medical Research Council’s framework for complex interventions. BioMed Central, 15, 267. doi:10.1186/1745-6215-15-267

    Mental Health America. (2017). 2017 State of Mental Health in America – Access to Care Data. Retrieved May 5, 2018, from Mental Health America:

    Munets, E., Simms, V., Dzapasi, L., Chapoterera, G., Nyaradzo, G., Gumunyu, T., . . . Chibanda, D. (2018, February 8). Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study. BMC Public Health, 18, 227. doi:10.1186/s12889-018-5117-2

    Shamu, S., Zarowsky, C., Roelens, K., Temmerman, M., & Abrahams, N. (2016). High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe. Gen Hosp Psychiatry, 38, 109-114. doi:10.1016/j.genhosppsych.2015.10.005

    van Ginneken, N., Tharyan, P., Lewin, S., Rao, G., Meera, S., & Pian, J. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev, 11, CD009149. doi:10.3109/01612840.2015.1128299

    Image via Pexels/Pixabay.

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    Virtual Reality for Reducing Pain Thu, 09 Aug 2018 15:30:41 +0000 Falling Through the Cracks in Pain Management

    Pain and Opioids

    Chronic pain is debilitating, and it can cause patients to “fall through the cracks”. Health care institutions struggle to find ways to create “nets” and catch these patients. Pain medications include opioids which are used to treat chronic pain. Opioids often fail to treat the patient’s primary medical condition. As time goes by, patients tend to be unsatisfied with the results.

    Also, there is a good chance that some of these types of pain medications will be abused. In fact, pain medicines such as opioids are part of the United States opioid crisis. According to the Centers for Disease Control (CDC), every day, more than 115 people in the United States die after overdosing on opioids. (CDC/NCHS, 2017) The opioids include prescription drugs, including fentanyl, and synthetic street drugs such as heroin.

    It is estimated that the total economic burden of prescription opioid misuse in the United States is $78.5 billion a year which includes the costs in health care, lost productivity, addiction therapy, and criminal justice involvement. (Florence, Zhou, Lou, & Xu, 2013)

    Pain and Mindfulness Meditation

    To overcome pain, another task which demands higher controlled attention must be pitted against it.

    Other forms of therapies were introduced to manage chronic pain.

    One such therapy is known as mindfulness meditation. Mindfulness meditation is: “the intentional self-regulation of attention from moment to moment”. (Goleman & Schwartz, 1876) This method has been used for quite some time. A study done in mindfulness meditation by Dr. Kabat-Zinn has reported that 65% of patients have exhibited a reduction of pain by more than 33% and about 50% of patients have reported a reduction of pain by 50% over a 10-week period of therapy. (Kabat-Zinn, 1982)

    Some studies performed in mindfulness meditation have reported patients with strong feelings of anger towards their pain condition while others report some anxiety while undergoing mindfulness therapy. la Cour and Petersen point out that meditation therapy requires a learning curve for the patient to access the more important personal “inner space”. (la Cour & Petersen, 2015) This can be an exciting learning experience of discovery for some patients while other patients may see this as a constant battle that in itself can be a painful experience.

    The next question to consider therefore is to find out which patients benefits the most from mindfulness meditation and which are not, and then find out what other therapies we can use in these patients.

    Enter Virtual Reality: Pain and Attention

    Recall a recent injury. Ever wonder why after a trauma or injury has occurred, there seems to be a delay in which actual pain is produced? Pain has to first gain access to consciousness and demands central attentional resources by interrupting all other current brain processes such as worry, fear, or desire. It does so easily because of its noxious nature. (Eccleston, 1995) Pain, therefore, can be considered as a controlled task. To overcome pain, another task which demands higher controlled attention must be pitted against it.

    The characteristics of pain such as intensity, quality, and/or pattern affect the probability of capturing attention. In chronic pain, for example, the characteristics of the pain and its intensity are important for pain processing. This may explain the reason why there are “good” days and “bad” days for patients with sciatica, multiple sclerosis, and other causes of chronic pain. Persistent pains with unpredictable sensory qualities that fluctuate in intensities are more likely to be processed. (Eccleston, 1995)

    Finding the perfect distractor with the ability to interrupt persistent pain stimulus processing is key to coping. Virtual reality (VR) systems offer computer-generated sensory inputs that involve sight, sound, and touch. These inputs make it essentially difficult for the brain to ignore especially if the VR program is immersive. Immersive VR is an experience that gives a perfect illusion to the patient that is in the virtual world. The strength of the illusion of the presence of the virtual world reflects the amount of attention drawn into the virtual environment. (Hoffman, Doctor, Patterson, Carrougher, & Furness III, 2000)

    Virtual reality may not replace the conventional pain management anytime soon. Once the patient comes out of VR, they will soon feel pain once more. Pharmacologic therapy remains the mainstay of pain management. But the problem of using pharmacologic treatment for pain remains a challenge. Undermedication is a problem of pain management failure. But higher doses of opioids poses a serious risk such as respiratory failure and encephalopathy. Therefore, the application of pain relief using VR may be for the use of procedural pain management such as minor surgical procedures, wound cleaning and debridement, and escharotomy in burn victims.


    CDC/NCHS. (2017). National Vital Statistics System, Mortality. (US Department of Health and Human Services, CDC) Retrieved May 21, 2018, from CDC Wonder, Atlanta GA:

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    Florence, C., Zhou, C., Lou, F., & Xu, L. (2013). The economic burden of prescription opioid overdose, abuse, and dependence in the United States. Med Care, 54(10), 901-906. doi:10.1097/MLR.0000000000000625

    Goleman, D., & Schwartz, G. (1876). Meditation as an intervention in stress activity. J Consult Clin Psychol, 44, 456-466. doi:10.1037/0022-006X.44.3.456

    Hoffman, H. G., Doctor, J. N., Patterson, D. R., Carrougher, G. J., & Furness III, T. A. (2000, March 1). Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain, 85(1-2), 305-309. doi:10.1016/S0304-3959(99)00275-4

    Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psych, 4, 33-47. doi:10.1016/0163-8343(82)90026-3

    la Cour, P., & Petersen, M. (2015, April 2). Effects of mindfulness meditation on chronic pain: a randomized control trial. Pain Medicine, 16(4), 641-652. doi:10.1111/pme.12605

    Image via Pexels/Pixabay.

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