Lifting the Fog of Depression in Vietnam

In the two years since Long’s wife died, he slowly drifted away from his life as a farmer in his small Vietnamese village. He wasn’t able to work. He couldn’t get out of bed. Neighbors worried that his two young children were being neglected.

Long had become an alcoholic, but his underlying depression wasn’t diagnosed until a community health worker, concerned about his isolation, took him to the community health clinic to get assessed for depression. A nurse trained in the symptoms of clinical depression referred him for counseling through the Vietnam Multicomponent Collaborative Care for Depression (MCCD) program, which launched in 2009.

Victoria K. Ngo, Ph.D., the program’s lead director and Associate Professor of Community Health and Social Sciences at CUNY SPH, was supervising staff when Long came in.

“At first he wasn’t interested in treatment at all,” Ngo said. “He said he didn’t have the time.” But together they calculated that depression had cost Long several thousand hours of productivity over the last few years and that treatment would only take about ten hours of his time over six weeks.

“When we put it that way, it changed his mind,” she said. “I remember it was a profound moment for him, how he was stuck, and nothing was working for him, and here was an alternative to make a change. It opened him up.”

For Ngo, community mental health care is personal. Her motivation comes from her own family’s suffering from depression, anxiety, and the trauma of being refugees.

“When I was two, after the war, we left Vietnam in the middle of the night,” she said. They were stranded at sea for days until an Argentinian boat deposited them in a refugee camp in the Philippines. They spent six months there before landing in Los Angeles.

“Many Vietnamese who fought on the American side were put in re-education camps, which was prison basically, and my father didn’t feel he could live like that,” Ngo said. “Dad had never been more than a few miles off the shore but knew he needed to get on the boat and go. For refugees you take what you can. Two items of clothing and one bag of rice and hope you make it.”

The oldest of four children, Ngo found ways to support immigrants while she was in college, which led to work on community mental health issues. She went on to earn her master’s and doctoral degrees in clinical psychology from Vanderbilt University. She has expertise in developing, evaluating, and implementing evidence-based treatments, such as cognitive behavioral therapy, for depression, anxiety, and trauma in diverse communities in the United States and abroad. Since 2000, she has worked to develop research and clinical training capacity and infrastructure in Vietnam.

“Effective treatment for depression exists and yet there’s a huge treatment gap in Vietnam and other low- and middle-income countries,” Ngo said. “People don’t understand what depression is or how to deal with it. There’s no place for them to turn.”

Screenings and non-drug treatment options for common mental health disorders were virtually nonexistent in Vietnam just a handful of years ago, at a time when the World Health Organization estimated that as many as 99 million people worldwide suffered from depression.

Ngo’s MCCD team started with a three-year demonstration project in twelve sites in Da Nang and Khanh Hoa provinces, then conducted ongoing adaptations and studies. They are wrapping up an innovative project funded by Grand Challenges of Canada that integrates depression care with microfinance services in March 2019 and are currently funded by NIMH to compare models for depression care scale up for 54 communities throughout the country.

The program needed to address the shortage of mental health professionals and the lack of access to treatment, Ngo said. She integrated mental health care with primary healthcare at the community level, and introduced task shifting, in which nurses and doctors who generally treat lacerations or administer immunizations are established as care managers who oversee treatment, provide mental health screenings, psychoeducation, problem-solving therapies and behavior activation, and coordinate care.

The general practitioners are responsible for diagnosis, medication assessment, and treatment, according to Ngo. A visiting psychiatrist provides weekly supervision on site. Individuals with more severe mental illnesses are seen by a psychiatrist or referred to the psychiatric hospital. Community health workers provide community education, follow-up care, and sometimes provide the brief depression therapy.

Within the first year, the MCCD team recognized their patients were being held back by a general lack of information about mental illness and the cultural bias against seeking help. To overcome these hurdles, they enlisted community partners, organized public awareness campaigns, invested time with medical staff to ensure their commitment to supporting the new program, and allowed word-of-mouth to build trust in their program.

Ultimately, a randomized controlled study of 475 participants comparing MCCD to treatment with antidepressant medication alone showed the MCCD to be “very effective,” Ngo said, “with very large gains in the reduction of depression over time.” She said the results overwhelmingly support the more comprehensive approach to mental health care favored by MCCD, namely the focus on psychoeducation, behavioral and problem-solving skills, and the ability to self-manage one’s mood. The program resulted in improvements in depression symptoms, functioning, and healthy behaviors.

MCCD is being implemented in three provinces with studies underway focused on how best to support the local healthcare providers. The emphasis now is on implementation science, Ngo said, not just on what is effective in the treatment of depression but how to support implementation and sustain programs.
“There’s a seventeen-year gap between the research showing a treatment is effective to it actually being implemented in the field,” she said. “Isn’t that crazy?”

MCCD spawned another successful program that targets women with depression who are at or below the poverty level, both high-risk groups. The Livelihood Integration for Effective Depression Management (LIFE-DM) project was developed by Ngo and two other Vietnamese colleagues, Dr. Trung Lam and Tam Nguyen, who has worked with Ngo, the co-principal investigator, on community projects since 2006.

“Vicky is good at bringing knowledge in,” Nguyen said. “The next step is to transfer what works, scale it up and roll it out.”

Nguyen is also the Country Director of BasicNeeds Vietnam, the main implementation lead for LIFE-DM. BasicNeeds is in charge of building capacity, implementation, raising public awareness, and advocacy for the project.

LIFE-DM is active in two of Vietnam’s 63 provinces—Thua Thien Hue province and Da Nang city—and is shortly moving to three more, also with help from grantors NIMH and GCC. Nguyen laughed as she recognized they have a very long road ahead but continued with her sober message.

“Most of our patients are so poor, so poor,” she said. “Their priority is what to eat tonight, not is their depression treated.”

The women in LIFE-DM are eligible for a $150 loan, a small sum that is meant to provide an exercise in budgeting rather than a cash infusion.

“Getting into debt is anxiety-provoking,” Ngo said. “We wanted this loan to be a trial, a way to practice financial skills.”

Together, Nguyen and Ngo worked to simplify the psychotherapy approach to treat depression and also used Ngo’s background in problem-solving skills to empower the women in the program to change their behavior, learn coping and communication skills, and overcome barriers to moving forward. The activities include mood monitoring, activity scheduling, and engagement in pleasurable and healthy activities. They repackaged depression care into a life- and family-focused program, which made it more acceptable.

“When we did that, we saw a huge need and a huge waiting list,” Ngo said. “The engagement was really remarkable. We were all floored by it. The results were even better than expected,” she said, citing an 80 percent reduction in depression and sustained increase of $50 a month over an average baseline monthly income of $95 at the start of the program.

Ngo supervised the first group and interviewed patients at six and twelve months. Additional sporadic visits allow her to see progress. “In the first group they don’t speak to each other, they’re nervous, teary, emotional, and resistant to being there. They don’t understand what depression is.

“We educate them in our first contact,” Ngo said. “If they are achy, if they can’t sleep or have a lack of motivation to do things, lack of concentration, that is what we call depression. We tell them it can impact how they function, family, work, health. Then they start sharing how hard it’s been.”

Once the women hear that they will learn skills for making a living and they get a loan, they are very interested, Ngo said. “But when they really start learning, they understand what they got is way more valuable than the $150.”

Participants interviewed after treatment report that the social support during group therapy is key to their success.

“They realize they are not alone,” Ngo said. “They thought they were lazy. They didn’t understand why they weren’t getting out of bed. But they felt guilty to want to do anything for themselves.”

“People don’t see the value of getting treatment if they need to be in the fields or make money to feed the family,” Ngo said. “It’s seen as a luxury to be happy. They don’t understand the link between emotional health and physical health.”

For instance, she said, Mai always wanted to learn how to dance though she could barely will her body out of bed in the morning. Married to an alcoholic and struggling to feed her family, she had no idea she was depressed. Within a few weeks of beginning the LIFE-DM program, she started watching YouTube to learn dance moves and convinced a group of her girlfriends to join her. Now the 30 or so women wear matching T-shirts when they appear in flash mobs and community events, and volunteer at orphanages and hospitals.

Even Mai’s husband, Thanh, has benefited from his wife’s success. He uses the car they bought with her loan to provide rides to tourists. Ngo hired him during her last trip to Vietnam. “He said the family is so different now, in such a better place because of the skills she learned and shared with him.”

“The changes in people’s lives are real,” Ngo said, “not just numbers.”

Phuong used her loan to buy coconuts and sell them in front of her home. She used money she earned to have her husband pick up more coconuts wholesale, then bought a cart for his motorcycle so they could sell even more. They became local distributors for other stands. Now they have a new car and are selling to restaurants and employing other people.

After Vuon’s daughter was kidnapped fifteen years ago, she believed she was a useless person. Her husband blamed her for the disappearance and didn’t understand his wife’s sense of loss. Eventually diagnosed with depression, she joined the LIFE-DM group and felt better for sharing her story. Her communication with her husband has improved and he has become supportive, even washing dishes so she can attend group meetings. She used her $150 loan to raise chickens and sell garden vegetables.

“This program is my heart,” Ngo said. “It’s so beautiful, and the women who are part of it are so inspiring. They recite their lessons, they know they should do things even when they’re not in the mood, they know the activities give you the energy you need, that the moment you want to withdraw is when you need to reach out and get help.”

For now, Ngo’s focus is on improving the quality and availability of mental health care, which includes her work with ThriveNYC, an $850 million initiative in New York City created by First Lady Chirlane McCray, the wife of Mayor Bill de Blasio. Ngo is Deputy Director of the Center for Innovations in Mental Health at CUNY SPH, the academic arm of ThriveNYC that helps with research and evaluation.

“I’m trying to make connections between the work I’m doing overseas and here, using task-shifting again,” she said. “We’ve already seen success with teachers, community leaders and peer advocates, pastors and in the criminal justice system.”

And everything she’s working on now reinforces her commitment to CUNY and her new role in public health. “I love that we are one of the largest agents of social mobility,” Ngo said, citing a 2017 study of tax returns that revealed the City University system launched almost six times as many low-income students into the middle class and beyond as all eight Ivy League campuses, plus a handful of other top-tier schools, combined.

“CUNY really fits with my values and what I do,” Ngo said, “being focused on immigrant communities and the underserved.”