Fighting Depression, One Village at a Time
抗击抑郁症，社区诊疗先行

What is the most burdensome disease in the world today? According to the World Health Organization,  the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression.

当今世界最让人困扰的疾病是什么？根据世界卫生组织(World Health Organization)的统计数据，剥夺了多数成年人高产期大部分时光的疾病，不是艾滋病，不是心脏病，也不是癌症，而是抑郁症。

The disease is not merely a bourgeois problem. It is especially prevalent in places that have experienced war, disaster or crushing deprivation. Yes, in many poor countries the bonds between people are much stronger than they are in wealthier, more individualistic societies, and this is a good thing for mental health. But it can hardly counteract the fact that a lot of people have an awful lot to be depressed about. War and high rates of crime produce widespread post-traumatic stress. The constant worry that a crop failure or serious illness will throw a family into poverty is a source of extreme anxiety. Seeing your children go hungry creates paralyzing guilt.

这种病不仅仅是中产阶级的问题。它在那些经历过战争、灾难或是极度贫困的地方尤为普遍。的确，很多贫穷国家的人际联系要比富裕国家以及那些更崇尚个人主义的社会更加紧密，这样的状况对心理健康很有好处。但这并不能掩盖一个事实，很多人都有不计其数的烦心事。战争与高犯罪率，让很多人饱受创伤后压力的困扰。长年担心庄稼歉收或者严重疾病使得自己的家庭一贫如洗，是引发极端焦虑的原因之一。看着自己的孩子饿肚子，也会让父母的良心备受谴责。
 

According to the World Health Organization, three-quarters of the world's neuropsychiatric disorders are in low-income or low-middle income countries.

世界卫生组织的数据显示，世界上四分之三的神经和精神紊乱都发生在低收入或者中低收入国家。

In troubled places, depression's impact is more severe. Most families have no cushion or safety net - they are running very hard just to stay in one place. A parent who is too depressed to work can bring a family to ruin.

在动乱地区，抑郁症的影响更为严重。多数家庭都没有“减震垫”或“安全网”——他们努力奔忙只是为了能在一个地方停留。如果家长因为过于抑郁而不能工作，这个家庭就有可能走向败落。

Yet attention to mental health in poor countries has been close to zero. The conventional wisdom is that treating depression in countries where there are myriad other problems is a luxury. Besides, how could it be done? Drugs are expensive, and the vast majority of poor countries have virtually no psychiatrists or psychologists outside of private clinics.

然而，贫困国家人民的心理健康几乎未曾得到任何关注。传统观念认为，在国家面临大量其他问题的时候，治疗抑郁症是一种奢侈。此外，治疗该如何实施呢？药物很贵，更何况，大多数贫穷国家压根儿就没有公共的精神医生或心理医生，只有私人诊所里有。

Today, however, not only is mental health getting global attention, but mental health care is also successfully expanding. The strategy is the same one that employs nurses and clinical officers to do the work of doctors in treating AIDS in Africa and that relies on barely literate women to improve the health of their villages: task shifting. "It became very clear it was possible to train lay members of the community to do fairly specific things and do them well," said Harry Minas, a psychiatrist who directs the Center for International Mental Health at the University of Melbourne.

不过，到了今天，心理健康得到了全球性的关注，心理疾病防治的覆盖范围也得到了成功的扩展。防治方法与非洲的艾滋病防治相同，名为“任务移交”，亦即通过雇佣护士和临床医务员来履行医生的职责，并且依靠几乎目不识丁的妇女来改善她们所在村落的健康状况。墨尔本大学(University of Melbourne)国际心理健康中心主任、精神病学家哈里·米纳斯(Harry Minas)说，“非常明显，我们可以训练当地的非专业人士，使他们有能力圆满完成比较具体的任务。”

Amadi was inside her hut, sitting in the semidarkness, when a local woman named Christina Nanyondo came to her door to invite her to do something that would have been unheard-of in her Ugandan village before:   join a therapy group for depression.

阿马迪(Amadi)坐在自己昏暗的小屋中，这时，一位名叫克里斯蒂娜·南永多(Christina Nanyondo)的当地妇女来到了她家，邀请她参与一件在这个乌干达村落前所未闻的事情：加入一个抑郁症治疗小组。

Amadi (a pseudonym) was 59, and had lost five of her nine children in the last 10 years, three of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden, or do her mat-weaving. "All the treatment in the world won't bring my children back," she told Nanyondo But at Nayondo's urging, she joined the group of eight women. The sessions, part of a study designed to test whether interpersonal psychotherapy could work in 30 rural villages, began with Nanyondo as facilitator. They met weekly, first spending their time describing their problems, later comforting one another and suggesting steps to take. Together they held a formal mourning service at the graves of their loved ones.

阿马迪(化名)时年59岁，在过去10年间，她失去了9个孩子中的5个，其中3个都死于艾滋病。她显得呆滞漠然，悲伤而又急躁，没有能力照顾家庭、做园子里的活计，也没有能力织毯子。她告诉南永多，“世界上任何的治疗手段都不能让孩子们回到我的身边。”但是，在南永多的鼓动之下，她加入了那个由8名妇女组成的小组。治疗活动随即开始，由南永多担任协调员。这一系列治疗活动是一项研究的组成部分，该研究覆盖30个村庄，旨在测试人际心理治疗是否有效。小组成员每周见一次面，以讲述各自的问题为开端，之后相互安慰，然后再彼此建议应该如何解决问题。在自己亲人的坟墓前，她们一起举行了一个正式的悼念仪式。

All the women, including Amadi,  gradually got better. Eighteen weeks after starting therapy, Amadi had no more symptoms of depression. Her husband said she had been a fierce, strong, loving woman. Now she was again.

包括阿马迪在内的所有妇女都逐渐好转。开始治疗18周之后，阿马迪不再有抑郁症状。她的丈夫说，她曾是个充满爱心、性格刚强的烈性子，现在，原来的她又回来了。

Amadi's story was described by Lena Verdeli, an assistant professor of clinical psychology and director of the Global Mental Health Lab at Columbia University's Teachers College. (Amadi is not her real name.) By accident, the study did something unexpected and significant. The researchers had intended for the groups to be led by trained health workers from the Christian humanitarian group World Vision. "But they couldn't spare any," Verdeli said. "They said, 'don't worry, we're going to hire their younger brothers and sisters.'" Some, including Nanyondo, had only a high school degree.  They received only two weeks of training. Yet the treatment was overwhelmingly successful: Six months after beginning therapy, only 6.5 percent of the people treated still had major depression. It was proof that effective therapy for depression could be delivered in the poorest of settings, by lay people.

莉娜·韦尔代利(Lena Verdeli)是哥伦比亚大学师范学院(Columbia University's Teachers College) 临床心理学副教授、全球心理健康实验室(Global Mental Health Lab) 主任，她为我们讲述了阿马迪的故事。（阿马迪并不是主人公的真名。）因为意外情况，这项研究取得了一些预想之外的重要成果。研究人员原本打算，让基督教人道主义组织世界宣明会(World Vision)里一些受过培训的健康工作人员来领导这些小组，“但是他们腾不出人手，”韦尔代利说。“他们说，‘别担心，我们可以雇用他们的弟弟妹妹。’”包括南永多在内的一些工作人员都只有高中学历，培训的时间也只有两周。但是，治疗非常成功：治疗开始6个月后，接受治疗者当中仅有6.5%的人仍然有明显抑郁表现。事实证明，即便在最简陋的条件下，通过非专业人士，也能对抑郁症进行有效的治疗。

Other studies have confirmed this. In Goa, India, young local women took an eight-week course in interpersonal psychotherapy and proved very effective at treating depression. Even more impressive was a project in Pakistan. It gave community health workers - women who had completed secondary school - a two-day course in listening and basic cognitive behavioral therapy. They were shown how to integrate these things into their regular visits to pregnant women and new mothers. Even that brief training made a huge difference. A year later, only a quarter of their depressed patients were still depressed, compared to 59 percent of the control group.

其他研究也证明了这一点。在印度果阿，年轻的当地妇女经过8周人际心理治疗培训，就能非常有效地治疗抑郁症。巴基斯坦的一个项目更加让人印象深刻。该项目对社区的健康工作人员——中学学历的妇女——进行了为期两天的倾听和基本认知行为疗法培训，告诉她们如何在定期探访怀孕妇女和新生儿母亲的过程中运用这些知识。如此简短的培训也带来了巨大的变化。一年之后，只有四分之一的抑郁症患者仍有抑郁症状，而对照组中的对应比例则为59%。

Health systems are now starting to use task shifting for mental health. At the end of June, for example, India announced a new national mental health care plan, which will train a cadre of community mental health workers.

现在，医疗体系开始使用任务移交的方法来治疗心理疾病。例如，印度于6月底公布了一个新的全国心理疾病防治计划，旨在培养一批社区心理疾病工作人员骨干。

Several places that have expanded mental health care have done it by taking advantage of crisis. Sri Lanka and Indonesia's province of Aceh both had long-running civil conflicts that traumatized much of the population. But they started getting access to treatment for that trauma only after the tsunami of 2004. War had damaged far more people, but it was the tsunami that brought in money for mental health care.

有几个地方还把危机变成机会，扩大了心理疾病防治范围。斯里兰卡和印度尼西亚亚齐省都经历过长期的内部纷争，使很多民众遭受精神创伤。但是，直到2004年的海啸之后，他们才有机会接受精神创伤治疗。战争伤害的人远较海啸为多，但却是海啸为心理疾病的治疗引入了资金。

In the past, perhaps, international aid might have been used to enable doctors from outside to treat patients for a few months. Now, instead, most of the money was employed to build mental health care into the government's health system, using task shifting. The visiting psychologists and psychiatrists were there to train locals.

过去，国际援助兴许会被用于邀请外界医生，让他们过来对患者进行为期几个月的治疗。但是现在，通过任务移交，大部分资金都被用来在政府医疗体系中建立心理疾病防治机制。外界的心理医生和精神医生也会过来，但却只是为了培训当地的医护人员。

Lay people in Aceh learned to work with patients and their families in the community. Nurses were trained in psychotherapy. Doctors learned how to treat patients with a limited number of psychiatric drugs.

亚齐省的非专业人士学会了怎样与社区内的患者及患者家属合作。护士们接受了心理治疗培训，医生们也知道了如何用种类有限的精神病药物治疗病人。

This time nearly 85 percent of health centers in Aceh have some staff with mental health training, Miller wrote. Sri Lanka, which has a similar system, is now expanding it beyond zones hit by the tsunami.

米勒写道，这一次，亚齐省将近85%的卫生中心都有了一些经过心理疾病治疗培训的人员。拥有类似体系的斯里兰卡，正在将这项计划推广到海啸灾区之外。

If depression can paralyze people who have everything, how could we ever have thought that it didn't affect people who have nothing? "There's an assumption that after you bury five of your kids you get used to it, and it doesn't hurt as much," said Verdeli. "People don't realize you don't get used to it. You just give up."

既然抑郁症能对那些应有尽有的人造成困扰，我们怎么能认为，它对那些一无所有的人毫无影响呢？“人们认为，在掩埋了5个孩子的尸首之后，你就会对这种事习以为常，伤害就没那么深了，” 韦尔代利说。“他们没有意识到，你并没有习以为常。你只是放弃了希望。”

来源：好英语网