To alleviate the impact of mental illness on the Zimbabwean population, the Friendship Bench project was created to provide a community-based approach to mental health care, providing safe spaces and a sense of belonging outside of primary healthcare settings.

Using over a decade of research on the delivery of mental health including King’s research, the Friendship Bench was founded by Professor Dixon Chibanda at the London School of Hygiene & Tropical Medicine (LSHTM). The Friendship Bench clinical team trains lay community health workers to deliver a basic Cognitive Behavioural Intervention with an emphasis on Problem Solving Therapy, activity scheduling and peer-led group support.

The therapy is delivered outdoors, in the grounds of government primary health care clinics. Community health workers, who are mainly grandmothers, sit with their clients on wooden benches in discreet, safe community spaces, delivering up to six one-to-one counselling sessions. This is provided to people with mild to moderate mental health disorders such as anxiety and depression, known locally as ‘kufungisisa,’ which translates to “thinking too much.” Referral pathways are also provided for cases in which a client is considered to have a higher level of need.

Working with communities to improve mental health outcomes

Professor Melanie Amna Abas, psychiatric epidemiologist and Professor of Global Mental Health at the IoPPN, has researched culturally appropriate measurement and treatment of depression in Zimbabwe and its social origins extensively. In a randomised controlled trial conducted by the University of Zimbabwe, IoPPN, and London School of Hygiene and Tropical Medicine in 2016, brief psychological treatment delivered by Zimbabwean community health workers on Friendship Benches dramatically improved mental health symptoms.

The trial, supported by the Government of Canada through Grand Challenges Canada and published in JAMA, found people with depression or anxiety symptoms who received problem-solving therapy through the Friendship Bench Programme were more than three times less likely to have symptoms of depression after six months, compared to patients who received standard care (14 per cent of participants in Friendship Bench group depressed at follow-up compared to 50 per cent control participants). They were also four times less likely to present anxiety symptoms and five times less likely to have suicidal thoughts than the control group after follow-up.

As co-author of the study, Professor Abas said at the time that Friendship Bench was “set to become the largest mental health programme for depression in any low-income African country, being feasible to scale-up, low cost and culturally acceptable.”

Using Friendship Bench to tackle co-morbidities

Most recently, researchers at the Centre for Global Mental Health, a collaboration between the IoPPN and LSHTM, conducted a study analysing the impact of Friendship Bench on HIV disease control, in people living with HIV and co-morbid common mental disorders. The study in Zimbabwe was the first of its kind to assess whether the community-based therapy could improve outcomes for those managing a long-term illness alongside depression or anxiety. These mental conditions are among the most common co-morbidities recorded for people living with HIV, and lead to poor adherence to antiretroviral therapy (ART). ART is essential for decreasing the level of HIV virus in the body, and poor adherence caused by depression is a key reason for poor viral control and progression to AIDS in people living with HIV.

This study recruited 700 participants aged 18 and over across eight HIV care clinics in Harare. Patients at six of the clinics received therapy through the Friendship Bench programme, while those at the remaining two clinics received usual care. Blood tests to measure viral load and mental health assessments were taken at the start of the study and followed-up after six months of treatment.

Published in PLOS Global Public Health in January 2024, the study found people living with HIV and common mental disorders who received the Friendship Bench were three times more likely to maintain HIV viral suppression, compared to people who did not receive the Friendship Bench. This important finding shows how improving mental health in countries like Zimbabwe with a high HIV burden is a route to accelerating progress towards ending the AIDS epidemic.

Expanding the reach of Friendship Bench

The Friendship Bench programme has now been running for over 10 years in Zimbabwe, to marked success. It has been successfully scaled up to all 10 provinces of the country, covering a population of approximately 16 million. In 2023, over 220,000 people received therapy from over 2000 community health workers across the country, and Friendship Benches are now also present in six countries around the world including the US, Vietnam, Malawi, Kenya, Zanzibar and Jordan.

Professor Chibanda, Professor Abas, and other researchers are also exploring a pilot Friendship Bench in London, and testing an enhanced form of the Friendship Bench called TENDAI for people living with depression and poorly controlled HIV.