Thanks so much to everyone that took the time to ask me questions and participate in this AMA. It was really refreshing to speak to so many people that are curious about our work. Many of the questions got me thinking about how we work and the ways we can do a better job moving into 2023. I appreciate all of your thoughts, ideas, and support! 

Great questions! I should probably do a bit more reading on both topics before making a definitive statement, but just like the emphasis on well-being from Happier Lives Institute, I think considering the suffering risk of populations is a high moral priority. Mental health is an investment in the betterment of all areas of life. We see it can increase productivity, the number of meals a family eats, and the amount of school children attend. It impacts all areas of life and health, and similarly, restoring mental health creates thriving communities and stronger economies. From the longtermism philosophy, I think there is much to consider outside of simply eliminating existential threats and improving humanity. The results of climate change are already devastatingly impacting some of the communities we work in, which has serious implications for mental health and overall well-being. If we genuinely wish to eliminate suffering, we must address the crises and unrest at the root of the depression triggers. 

Hi John! I have not forgotten this question. I aim to have an answer for you by the end of the week. I wanted to wait until our CFO had the opportunity to review to ensure we have the most recent figures for you. I'll be back in touch on this very soon. Thanks for your interest! 

Thank you! I appreciate your curiosity, and I'm not put off by the questions or anything; it's just many of them are not in my area of expertise, and this happens to be a pretty busy time of year at StrongMinds. It may take some time to fully gather what you're asking for. We aren't a large research institute by any means, so our clinical team is relatively small. Additionally, some of the work you are referencing is nearly a decade old, so we have shifted some of the ways we operate to be more effective or better based on our learnings. That said, I will dig back in when I can to help answer your additional questions via email or direct message. 

To answer the remaining four from your original note to close the loop:

5) Since HLI generated the $170 figure, they have the best information on that particular breakdown, but I am collecting the most recent info on our CPP for another question, and I will share that with you later this week when I have the updated numbers. 

6) As mentioned above, we are currently in the process of assessing the right questions and framework for an RCT looking at the results and impact of our therapy model. We are hoping to be able to launch the RCT late in 2023. 

7) We switched our model to teletherapy to continue to treat clients during the pandemic lockdowns. It was not ideal, but we wanted to continue reaching as many women as possible despite the challenges. Though it proved tricky in some cases to reach our target demographic, we did find that some women preferred the flexibility teletherapy offered them. For the most part, we have switched back to our original model, but we still see some groups via teletherapy in Uganda. All research shared publicly from our initial year using teletherapy can be found here.

8) We track individuals that attend most of their therapy sessions, as we saw that the effects of therapy were still statistically significant and that attending additional sessions did not produce incremental impact. Due to the individual roles and responsibilities of the women that attend, it's sometimes challenging for them to make it to all 12 sessions. 

Thanks again for the questions!

I agree that based on all of the barriers and life challenges that it seems like it would be harder to treat depression in Kampala. As mentioned in some of the other answers, I think the model itself, being culturally appropriate and community-centered, as well as the interpersonal bonds, play a significant role in the program's success. Also, the fact that we work where the women are, in refugee camps, slums, or schools, to deliver our services. 

Thanks for these questions! I appreciate the time you took to really look at our data, and I think some of the questions will help us ponder what we need to be looking at next within StrongMinds. Please note, as the Founder, I'm not a researcher or clinician by trade, so my answers may not be as granular as you would hope, but I'll do my best to respond. I'm going to tackle the first four tonight.

1. a. The NNTs could be different due to a variety of theoretical factors. NNTs are really only as good and accurate as the data provided. We are planning an RCT for 2023, so hopefully, we will have more to consider and dig into once those numbers are available. b/c. Yes, the numbers are surprising. As I've mentioned in some of the other responses, I largely think the success has to do with the interpersonal nature of IPT and how it works within the community-centered culture of Uganda and Zambia.
2. I believe the 10% figure is part of the HLI analysis, and I am not an expert on that, so I'll let their team speak to that or let the numbers speak for themselves. 
3. An RCT certainly could have been done as a pilot, but they are pretty costly to complete, and at the time, StrongMinds was just finding its footing and searching for funders. I was working as a volunteer at StrongMinds for the first 18 months of operation. 
4. Our facilitators are all lay community members. In Uganda, 100% of our facilitators are Ugandan. In Zambia, they are all Zambian. They don't need to have a college degree in Psychology; in fact, they don't even need to have a high school degree. The most critical factor when we are interviewing potential facilitators is their empathy level. We have found that the higher their empathy level, the better they are as facilitators. 

Hi, harriet! Thanks for the questions! Yes, there are advantages and disadvantages to both individual and group therapy, and as you mentioned, cost certainly favors the group model. We can offer a woman an entire course of treatment for $105. In terms of patient outcomes, StrongMinds doesn't utilize individual therapy, but some studies have shown that effectiveness overall is pretty similar, and it really comes down to individual (and sometimes cultural) preferences to determine what type of therapy is best. I hope that helps!

In terms of SSRIs, yes, they can certainly be effective. In some cases where we think the client is a risk to themselves or others during therapy pre-screening, we refer them to where they have access to other methods, including SSRIs or other prescription options. That said, there are some significant challenges with the availability of SSRIs, given the treatment gap and the fact that everyone may not have the access needed to get to a trained psychiatrist/psychologist or nurse to prescribe them. This is one of the reasons the WHO recently cited and recommended community-based models and methods using lay community workers rather than trained mental health professionals as a key way to meet the growing need for services. 

In terms of cost-effectiveness, prescribed medication is reasonably affordable, but the cost can add up over a lifetime of use. For $105 USD on our end (and entirely free for the women we treat), we can provide long-term depression-free rates. Our results show that for every woman who restores her mental health, four additional members of her family feel the benefits. The HLI cost analysis looks at the benefits for the whole family as well as some of the long-term impacts as well, which is what makes our model so cost-effective. 

Currently, StrongMinds is actively looking to hire for a few positions listed here. We are growing and are always looking for smart, ambitious, and creative people to join our team. We encourage everyone to follow us on LinkedIn for our most up-to-date job openings. At this time, we currently do not use volunteers. 

StrongMinds seeks to treat 300,000 women and adolescents between 2022 through 2024. To do that, we need to raise $30M U.S. dollars. To date, we've raised about $13M, which leaves us at a shortfall of $17M. So there is lots of room for more funding!

In 2022 we expect the cost to treat one patient will be $105 USD. By the end of 2024, we anticipate the cost per patient will have decreased to just $85. We will continue to reduce the cost of treating one woman even while our numbers increase. This is through effective scaling and continuing to evaluate where we can gain more cost savings. A donation to StrongMinds will be used as effectively and efficiently as possible. And when you think about what it costs for therapy in the United States, to spend just $105 and treat a woman for depression is a pretty incredible feat. 

Thanks so much for your kind words and for following our work! I appreciate your comment about the incredible impact mental health can have. We've certainly seen it change women's lives far beyond what we could have predicted, such as helping a woman's children eat more meals a day or even helping individuals with HIV adhere to their antiretroviral treatments more regularly. 

1. We completely switched to a teletherapy model during the COVID-19 lockdowns in Uganda and Zambia, which required a lot of creative thinking on a short timeline. This made it somewhat tricky to reach our target demographic since many women share a phone with their family or neighbors (and some don't own a phone at all.) Fortunately, the depression-free rates were comparable to in-person group therapy, and some ultimately preferred the flexibility it offered. We usually work in communities, offering therapy directly where the women live to make access easy (our motto was often to diagnose on a doorstep, treat under a tree.) We had to reach new clients using things like radio ads, social media, and a mental health WhatsApp-based chatbot to help ensure resources were available as often as needed. You can read more about our key learnings from the COVID-19 pandemic here. 
2. Like most in the mental health field, we saw a sharp increase in the need for services, particularly during the lockdowns. Unfortunately, since then, we have seen other climate-related humanitarian crises causing things like flooding and drought, undoubtedly worsening mental health conditions. Additionally, Uganda currently has some Ebola lockdowns in place, stressing already thinned health resources. StrongMinds has made ourselves available to support in these cases. We know mental health care is critical during high-stress times, and rates are only projected to increase in the coming decades. The good news, though, is, as you've eloquently stated, the interpersonal nature of group talk therapy enhances outcomes. We've seen that 72% of former clients we spoke to in Uganda were still in touch with their group mates. This extends years later in many cases. 
3. Absolutely! I've often said that the hardest part of our job is finding depressed individuals and getting them into a group. Depression can make simply getting out of bed a challenge, so this can be tricky. The group model works well to help with this scenario, though, because group members can hold each other accountable and check in on each other. Uganda and Zambia still have many stigmas associated with mental health, so advocacy and psychoeducation are critical to our work in-country. You can read more about the complete therapy assessment process and how we work to educate about mental health here in this Psychology Today article by our talented Uganda Country Director/Clinician, Tina Ntulo. 
4. Similarly, a small door-to-door study led by StrongMinds in Mukono District, Uganda, estimated that the prevalence of moderate to severe depression in adult women was about 20%. We also have about 85% of individuals with no access to other forms of treatment. IPT works particularly well in these settings and is currently a WHO-recommended first-line treatment for depression in low-resource settings. Other forms of community-based models using a rights-based approach are a great way to empower individuals to seek recovery and focus on the value of human rights within the mental health space.