StrongMinds: Treating depression in Uganda

Uganda has about 30 psychiatrists. New York City and its suburbs have about 41,000. So depression in Uganda can’t be treated the way it is in New York.Turns out, that may be a good thing.StrongMinds, a fledgling nonprofit founded in 2013, organizes self-help groups to treat depression among poor women in Uganda. Its approach costs about $48 a person, which buys 20 minutes with a shrink in Manhattan, if that. Yet its self-evaluations find that more than two-thirds of the women report being free of depression, when surveyed 18 to 24 months after their treatment. Those are impressive results--better, in fact, than the outcomes reported for antidepressants or talk therapy in the US.“We have simple, proven effective solutions for mental illness,” says Sean Mayberry, the founder and executive director of StrongMinds,Of course, self-evaluations are….self-evaluations. What seems to work in Uganda may not work in the US. That said, StrongMinds appears to be alleviating suffering at a low cost in a place where the needs are great.“Africa is the last place on earth you want to be a depressed man, woman or child,” Mayberry said in a 2015 TedX talk.To learn more about StrongMinds, I called Mayberry last week. He told me that, to the best of his knowledge, neither big NGOs, nor major foundations, nor governments are paying much heed to the mental health needs of Africans. “There’s just no money for it,” Mayberry told me.This, despite the terrible cost of the disease. In a 2014 editorial, the scientific journal Nature wrote: “Measure by the years that people spend disabled, depression is the biggest blight on human society -- bar none.”So how did Mayberry get StrongMinds off the ground? Importantly, which funders took the risk of supporting an unproven startup?Mayberry, who is 50, has an eclectic background. He worked in government, as a foreign service officer with the US state department, working in East Africa in the late 1980s and 1990s. He earned an MBA and did a five-year stint at Intel. He held executive jobs with Population Services International, a big global NGO, in the Democratic Republic of the Congo and in India, and then led a smaller NGO, VisionSpring, which provides eyeglasses to the rural poor in Bangladesh.Mayberry started StrongMinds because he has seen the toll depression can take in his professional and personal life. “I have spent my entire life surrounded by this disease,” he says. He learned about a randomized controlled trial (RCT) done in Uganda in 2002 by researchers affiliated with Johns Hopkins, Columbia and WorldVision, in which people suffering from depression were given group therapy in weekly 90-minute sessions for 16 weeks. The study, which was published in the Journal of the American Medical Association, found that that “group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction."“The RCT was incredibly helpful,” Mayberry said.The first foundation to invest in StrongMinds was the Mulago Foundation, which funds organizations that serve the extreme poor and has an impressive track record of doing so.By email, Kevin Starr, who leads Mulago, told me why Mulago backed StrongMinds:

a) depression is #1 cause of suffering and no one was doing anything very effective or scalable about itb) sean was iterating on something already shown to work per RCT. we loved that.c) we knew sean from his stellar work at visionspring, so we believed he could deliver.

Mayberry became a Mulago fellow, and got a $50k grant for StrongMinds. Just as important, he was introduced to a network of like-minded funders known as Big Bang Philanthropy, who share ideas and due diligence as they seek out nonprofits that serve the poor. Other foundations affiliated with Big Bang, including the Peery Foundation ($35k), the Jasmine Foundation ($50k) and the DRK Foundation ($50k), gave early-stage support to StrongMinds.

Venture philanthropy

These small-to-midsize foundations play a crucial role in the philanthropy ecosystem by providing early-stage capital to start-up nonprofits and social enterprises. It’s no accident that the DRK Foundation is the philanthropic arm of a Silicon Valley venture capital firm. Mulago and Peery are also based in the Bay Area. Their portfolio companies are then expected to test out and refine their programs, which is exactly what StrongMinds did.In 2014, StrongMinds launched a pilot program that treated about 500 women in Uganda. The findings were encouraging: “During the 16-week intervention, self-employment increased by 22%, unemployment was reduced by 67%, the number of women who were able to save part of their income increased by 63%, and women eating three meals a day increased 245%.” A second impact evaluation tested the effects of a shorter, 12-week intervention, and found positive results.Strong Minds continues to test approaches that would reduce costs, without reducing effectiveness, and thus enable the organization to treat more women. Some peer groups are now led by women who have been through the process, and volunteer to work with others, an approach that resembles the model of Alcoholic Anonymous.The key to success seems to be the connections created by the peer groups. “They create incredibly strong social bonds,” Mayberry says. “The women rely upon one another.” The vast majority of the groups continue to meet after the formal treatment is over. Absent the groups, depressed women tend to be isolated or shunned.Since its inception, StrongMinds has treated about 20,000 women. It aims to treat a total of 100,000 by the end of 2019, which will require another $6m in funds in 2018 and 2019, Mayberry estimates. This year, StrongMinds has a budget of about $1.8m.Fundraising has been a challenge.One problem, Mayberry says, is that mental health services are just not on the radar of big funders. “They still think that solving mental illness is very complicated, that you need a psychiatrist and nurses, that you need hospitals and medications,” he told me. “They won’t even go there. They think it’s an intractable problem.”Besides that, he says: “Like it it not, there’s still tons of stigma around mental illness.” Compare the funding for depression with the billions of dollars spent to prevent and treat malaria, smallpox or polio.For StrongMinds to grow, Mayberry will have to garner support from big foundations or governments, or perhaps from high net-worth donors with an interest in depression. His biggest funder this year is Unorthodox Philanthropy.“Raising money for mental health is hardest the thing I’ve ever done in my life,” he says. “Doing the mental health in Africa is actually the easy part.”