Development of modified cognitive behavioural therapy for depression in Sri Lanka

Abstract

Depression is an important public health issue in Sri Lanka and an essential component of its treatment is psychotherapy. Standard Cognitive Behavioural Therapy (CBT), the most widely used psychotherapy in depression. originates in the West which has a culture and value system different from Sri Lanka. Despite multiple parallels and points of overlap between Buddhism, the majority religion in Sri Lanka, and CBT, the latter is underused in Sri Lanka.

This thesis aimed to design a culturally modified cognitive behavioural therapy for depression in Sri Lanka. The thesis was conducted in two phases. Phase 1 aimed to gather the necessary information to modify the existing CBT manual to suit Sri Lanka. Phase 2 aimed to evaluate the feasibility and effects of the modified CBT manual developed in Phase 1.

Phase 1 used a mixed methodology. A wide range of stakeholders including patients, carers, medical practitioners, psychologists, traditional healers and religious leaders took part in this phase of the study. The semi-structured interviews used were audio recorded, transcribed and translated. The data were analysed based on systematic content and question analysis by identifying emerging categories and themes. These results were used to develop a culturally modified CBT manual. Phase 2 was of an experimental prospective design. Patients with depression were recruited from Colombo North Teaching Hospital, Ragama, Sri Lanka, by convenient sampling. Participants were provided with 6 sessions of psychotherapy fortnightly as per the modified CBT manual and were followed up for 6 months. This was in addition to the usual treatment. Outcomes were assessed using the validated Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory II (BDI), and Global Assessment of Function (GAF) scales.

Briefer and fewer psychotherapy sessions, a more didactic style of therapy and greater emphasis on behavioural therapy, family involvement in therapy and use of local literature in explaining therapy, were identified as necessary modifications to standard CBT by the participants of Phase 1. Phase 2 saw the participation of 12 patients, the majority of whom were females. Their average length of treatment for depression was 3.1 years. Their HRSD, BDI and GAF scores improved significantly at weeks 10 and 26 with better scores at 10 weeks. All patients believed that psychotherapy was useful and practical. A majority (73%, 8/11) reported the modified psychotherapy as providing them something significantly different from treatment as usual. All the clinicians reported modified CBT as being ‘feasible’ and ‘easily deliverable’.

This thesis suggests that culturally modified CBT for depression is an acceptable and practical treatment option in Sri Lanka