In resource-poor countries, one specialist doctor is responsible for around two million people, compared with 11,500 in industrialised nations. Simply increasing the number of training places for specialists cannot be the solution – it would take decades before sufficient capacity could be built. Treatment must therefore be delegated, under appropriate supervision.

The “Friendship Bench” in Zimbabwe is a prime example. Here, “community grandmothers” provide solution-oriented short-term therapy for people experiencing depression. Rooted in African culture – where important matters are traditionally discussed on benches in central places – the therapy takes place on benches at primary care centres. These centres are run by nurses with three years of basic training and no additional psychiatric qualification. Treatment is therefore brought directly to those affected and delegated to lay therapists. The results speak for themselves: significant improvements in both depression symptoms and quality of life.

Increasing access through training

Monika Müller, Assistant Professor of Psychiatry and Public Mental Health, is investigating a combination therapy that integrates the “Friendship Bench” approach with drug treatment for severe depression. “In our research project, we are following the logic of the ‘Friendship Bench’ and training nursing staff at health centres to prescribe antidepressants,” explains Müller.

In addition to increasing access to professional treatment, this care model is cost-effective – a key factor for sustainable implementation by governments. “In Zimbabwe, the public sector spends only about 0.25 US dollars per person per year on all mental illnesses,” says Müller. “That corresponds to just one percent of total government health expenditure. These figures alone show that highly specialised and costly care models would be doomed to fail from the outset.”

The link between poverty and mental health

Poverty has not only structural but also individual dimensions, as it is closely linked with mental health. Around 740 million people worldwide live in extreme poverty, two-thirds of them in the Global South. For those affected, this often means insecure jobs in the informal sector, unpredictable incomes, constant worry about meeting basic needs, cramped living conditions, and inadequate nutrition – all of which contribute to mental illness such as depression.

Conversely, mental illness can drive people into financial hardship, as social safety nets are largely absent in the Global South. When illness prevents people from working, it often leads to a loss of income and, in many cases, job loss for both the affected individuals and their families.

Focus on poverty

The vicious circle of poverty and depression must be considered when designing appropriate models of care. If the socio-economic living conditions of those affected are not addressed, there is a high risk that depression will recur.

Professor Müller’s research team is exploring innovative approaches as part of an SNSF Starting Grant project. “In a study involving almost 700 people with severe depression, we are testing a so-called ‘Cash Plus Programme’ in India,” explains Müller. This combines a short-term therapy similar to the “Friendship Bench” with an unconditional basic income. “We are treating depression both directly and indirectly – by addressing poverty as an important risk factor for the illness.”

Another advantage of this model is that it can be implemented not only through the health sector, but also via social welfare systems. “This enables us to expand access to professional treatment beyond the already overburdened healthcare system,” says Müller.

Innovative models for sustainable impact

The examples from Zimbabwe and India show that innovative, culturally adapted models of care can improve access to treatment even under extremely challenging conditions. It is crucial not to view mental health in isolation, but in connection with poverty, social security and everyday realities. Only by taking this broader view can sustainable improvements be achieved.

This article first appeared in German in the magazine Cogito.