"Making Patients" in Postwar and Resource-scarce Settings. Diagnosing and Treating Mental Illness in Postwar Kosovo

Exploring the impact of a complex intervention for women with depression in contexts of adversity: A pilot feasibility study of COURRAGE-plus in South Africa

BACKGROUND

Depression is a leading cause of disease burden worldwide but is often undertreated in low- and middle-income countries. Reasons behind the treatment gap vary, but many highlight a lack of interventions which speak to the socio-economic and structural realties that are associated to mental health problems in many settings, including South Africa. The COURRAGE-PLUS intervention responds to this gap, by combining a collective narrative therapy (9 weeks) intervention, with a social intervention promoting group-led practical action against structural determinants of poor mental health (4 weeks), for a total of 13 sessions. The overall aim is to promote mental health, while empowering communities to acknowledge, and respond in locally meaningful ways to social adversity linked to development of mental distress.

AIM

To pilot and evaluate the effectiveness of a complex intervention - COURRAGE-PLUS on symptoms of depression as assessed by the Patient Health Questionnaire (PHQ-9) among a sample of women facing contexts of adversity in Gauteng, South Africa.

METHODS

PHQ-9 scores were assessed at baseline, post collective narrative therapy (midline), and post social intervention (endline). Median scores and corresponding interquartile ranges were computed for all time points. Differences in scores between time points were tested with a non-parametric Friedman test. The impact across symptom severities was compared descriptively to identify potential differences in impact across categories of symptom severity within our sample.

RESULTS

Participants' (n = 47) median depression score at baseline was 11 (IQR = 7) and reduced to 4 at midline (IQR = 7) to 0 at endline (IQR = 2.5). The Friedman test showed a statistically significant difference between depression scores across time points, χ2(2) = 49.29, p < .001. Median depression scores were reduced to 0 or 1 Post-Intervention across all four severity groups.

CONCLUSIONS

COURRAGE-PLUS was highly effective at reducing symptoms of depression across the spectrum of severities in this sample of women facing adversity, in Gauteng, South Africa. Findings supports the need for larger trials to investigate collective narrative storytelling and social interventions as community-based interventions for populations experiencing adversity and mental distress.

The Politics of Trauma: Gender, Futurity, and Violence Prevention in South Africa

In this article, I consider the framing of trauma as an epigenetic exposure that warrants intergenerational interventions. I draw on ethnographic research conducted in Khayelitsha, Cape Town, South Africa in 2014-15 to illustrate how violence prevention in this context is increasingly framed in epigenetic terms. I show that, in contrast to the anticipatory logic of a programmatic focus on maternal investment as a means to arrest intergenerational cycles of violence, violence produces different infrastructures of anticipation and effects on intergenerational relations. I argue against the speculative conflation of trauma and intergenerational epigenetics, to resist a newly biologized view of the bodily manifestations of apartheid history-in itself a re-inscription of damage, and a form of violence. Drawing on Murphy's concept of distributed reproduction (2017b), I argue for collectivized forms of intervention that aim for accountability and social justice.

The anthropology of health systems: A history and review

Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.