Rio Center Stories: Interview with Professor Annika Sweetland, Mailman School of Public Health

September 30, 2016
Professor Annika Sweetland talks about her research on the correlation between depression and tuberculosis while in Rio. Photo: Maria Eduarda Vaz

Annika Sweetland, Assistant Professor at Columbia’s Mailman School of Public Health, is conducting a research in Itaboraí, Rio de Janeiro, to look for the correlation between depression and tuberculosis (TB) and effective treatment for both diseases. The two-year research project has already found important results. We sat down with Professor Sweetland to talk a little bit about her research while she was in Rio.


What brought you to Brazil?

I’ve been working with the topic of depression and tuberculosis for 18 years, actually. I started working at Peru in 1998 and I’ve noticed how difficult treatment was for them then. They have all sorts of challenges, not just the treatment, which had a lot of side effects, but also poverty, stigma, having been sick for many years, treatment wasn’t available before. And so, I started that topic way back, right out of college, and then studied social work, and I went back for a couple more years doing social work, then I’ve been at Columbia ever since for the past 12 years. So, I did my Doctorate and then a Postdoc in Sustainable Development, then I did another Post-Doc in Global Mental Health, and then now I just got a K Award – a career development award from National Institutes of Mental Health (NIMH).


But you’re so young! How did you have time to do all that?

(laughs) When I started my Postdoc in Global Mental Health in 2012, the way that it was structured - it was brand new - it’s called a T32 Fellowship, that’s an NIMH funded, it’s a Post-Doc meant to be a bridge between Doctoral and Junior Faculty. I was the first fellow in that program and they said “The way we structured is you have three choices: Brazil, Nigeria or Kazakhstan” because that’s where they had strong connections with the local universities to guarantee mentorship and since I speak Spanish, Brazil was a natural choice for me. So that’s why Brazil.


What were the biggest challenges you faced while working in Brazil? How did the (infamous) Brazilian bureaucracy influence your work?

So that’s a very easy answer: Ethics. So, I got Ethics approval in New York through Research Foundation for Mental Hygiene, it’s an institution that’s affiliated with New York State Psychiatric Institute at Columbia University and I got that in April of 2015, it was last year. And then in order to conduct research here in Brazil you have to have not just local Ethics approval, which makes sense, but also be affiliated to a local university.  I’m working with UFRJ. And so getting that permission through the Department of Psychiatry was actually fairly straightforward, it was about two months, but then because of its foreign funds you have to go through another level of approval, which is called CONEP, so that’s for foreign researchers, you have to get a national permission, federal level permission. And on the NIMH side, they wouldn’t disperse the money until I had this approval, so I was authorized to start last July, 2015, and I didn’t get to start until June this year. It was an 11-month process largely because of that process.

Once I got Ethics approval, everything got started, and my grant started in June. So, then we needed a partner institution here in Brazil that could be for the subcontract to administer funds. Historically, my mentor’s been doing research here in Brazil for 15 years and they had a partner institution that was no longer able to fill that role. So, since the Columbia Global Centers was established it was, to our understanding, to help facilitate Columbia faculties to do research here, it seemed like a natural fit. The challenge was trying to figure out how to do it, because it’s government money on the US side. How to do it in a way that everyone feels comfortable that they could withstand an audit from the US government. And also, because Columbia Global Centers had not done one like this before and neither had they. It’s exciting, but it’s also a little bit painful at each stage of the process.


Tell us a little bit more about your research.

First of all, the reason we do our work in Itaboraí is because my mentor’s been working there for 15 years, so we already have relationships there and there’s a lot of openness to research in this particular city. And they have a lot of history of wanting to do research in mental health and the TB program in particular is very exciting. In terms of Brazil, it is always a very attractive place to do health research because it has universal access to care, even if it’s not totally working. For example, working with mental health: you can’t treat mental health unless the person that also has TB treatment, for example, so there’s universal access to TB treatment, HIV treatment, or any other medical treatment, so it’s ethical to be able to conduct the research and there’s existing services, so that’s one piece. The second piece is that it’s a community-based model and the focus of our research group at Columbia is global mental health, and really trying to increase access to mental health care in low income settings, where they don’t have specialists. So, like Africa, for example, there’s no psychiatrist, no psychologist – There are only 9 psychiatrists for a country of 25 million people! We’re working with these psychiatrists and working with the government - we’re trying to do a community-based model there, so everything I do here in Brazil, I’d like to replicate ultimately in Mozambique and a south-south sort of transfer. And about the community-based model, we have evidence around the world that there are interventions that can be done where people, who are not specialists, can be trained and deliver mental health treatment. There are examples that worked in Uganda, Pakistan, Chile and lots of low income settings, but they’re case studies, they know it can work but we don’t know how to do it in systems of care. So, Brazil is attractive because it has this community-based outreach approach to health care where there is the desire for care to be disseminated, to be spread out, community-based outreach oriented with test shifting, which is term used to describe delegating different levels of care. This model is like one doctor, two nurses, five to seven health workers and they work in a way that the community health workers are the ones going from house to house, identifying and bringing triage to the nurse. Then the nurse does what’s in their capacity and often most of the work is seen or overseen by a doctor. So that’s how we’re gonna need to do global mental health, it’s gonna have to be community health workers doing identification, and in different levels of care is gonna have to require very close supervision by specialists. When you only have one specialist you need to really optimize and maximize the use of their time, and Brazil is set up for that; it has universal access to care, it has a community-based model and is extremely innovative, known for being innovative in terms of disseminating something that works in the whole country. They’re leaders in HIV, responding to HIV, they’re one of the first countries, if not the first, to offer universal access to HIV treatment, so that’s also very exciting. There’s a lot of factors that make it a very appealing place to do this research. And Itaboraí is even beyond. It’s a very interesting place because in the mid 2000’s it was, for most Brazil and for other countries, as a model TB treatment program. But then they had a series of political shifts where they had four secretaries of health in the course of one year and the programs sort of fell apart a little bit and they’re still recovering for that. It’s still a very good program but there’s some gaps that they’re trying to fill yet, and they’re very motivated to get back up to that status (of being the best program in the world). And also, and we didn’t know this at the time, but Petrobrás, the oil refinery, was in Itaboraí, so for my mentor that had been working for ten years before that came up and it was like “oh, that’s gonna be a really interesting social experience” because all of a sudden it’s gonna change dynamics, it’s gonna bring lots of people from outside, it’s gonna change disease dynamics, more health challenges. As as it turns out, different types of social change happened when they were shut down, and 30.000 people in Itaboraí lost their jobs overnight. At the same time, it coincides with the Olympics, where they’re pushing the drug dealers out of the “favelas” into Itaboraí, on a periphery of the metropolitan city and so now they have this huge drug problem and neighborhoods that are extremely dangerous. It´s a representation of the situation in Brazil right now in a lot of ways and it’s kind of a perfect laboratory, however unfortunate that is. On the positive side it means that if we can make something work there, we can make it work anywhere.


Regarding the specifics of TB and depression, what is the correlation and, is it between other diseases such as HIV? Would the treatment be the same, would the approach be the same? How does that happen, do you treat them mentally and then you give them the medicine…?

People with depression and TB are less likely to come for care right away, so they’re more likely to be sicker by the time they come. They’re less likely to take all of their medications, so they’re more likely to develop drug resistance. They’re less likely to finish treatment, so they’re more likely to fail treatment or die and they’ll be contagious in the community for longer periods of time, consequently transmitting it in the community. Depression is associated with all negative outcomes and is extremely common, so there’s not a lot of research globally. It is hard to diagnosis especially in TB patients because there’s a lot of overlapping symptoms such as low energy, low appetite, fatigue… A lot of symptoms mimic depression and also it tends to affect people living in extreme poverty. Very often people say “oh, of course they’re depressed, they’re sick, they’re poor” and not really recognize it as a clinical disorder, that’s treatable. So, the goal is to treat depression while you’re treating TB. To improve quality of life, to improve outcomes, to reduce transmission in the community, to reduce drug resistance, all of those things, so this would apply to any other illness as well. So, the way that we’re gonna address that problem at a global level is to integrate services into primary care. And when mental health people go to primary care they often get like “oh, we’re too busy trying to keep people alive, what a luxury to treat mental health” and so it’s been difficult to logistically penetrate primary care systems in low income settings. However, TB providers are very receptive because they’re desperate for tools to help their patients and to help prevent the spread of this air borne infectious disease. What I’m hoping in the bigger picture is to start with TB, but treating depression is the same with TB as with HIV, as with Cancer, as with Diabetes. Depression is depression. Even without those things. So I’m trying to build capacity to treat depression, starting with TB, where they’re very receptive. A subversive goal of infiltrating primary care!


And how do you treat it? Do you treat it medically or through therapy?

Well, there’s different evidence-based practices. Medication is one option to depressants, those are always available in settings, but you also need to have physician supervising so this is tricky. The there´s common to behavioral therapy and interpersonal psychotherapy, which are two interventions recommended by the World Health Organization. There are also variations from these therapies, such as Cognate Behavioral Therapy and Behavioral Activation. These treatments are very structured so non-specialists can be trained to deliver with expert supervision. Some of these therapies are 3 to 5 sessions and seem like it could be effective. Recently there has been a trial conducted in São Paulo, using interpersonal counseling, with community health workers delivering it with supervision by psychiatrists versus enhanced treatment as usual. In the traditional treatment the person may or may not receive care. Instead, the enhanced treatment has a psychologist do the evaluation, the referral and the follow up. He or she calls the patience up to 3 times to make sure that they and get the treatment that they need. The results of the trial are that there was no difference between groups, with remission in both groups at around 20%. However, the fact that they did that with community workers, is amazing!


And they do the sessions when they go to get their medicine?

They do it in the homes.


But what about when you associate with other diseases?

Well, the SF System they’re supposed to do everything, they’re supposed to be holistic providers, so in this case it was like adding this to their toolkit.


From a more institutional point of view, what are you taking back to Columbia from your experience here?

Well, the research question that I’m exploring is beyond if treating depression is gonna improve TB outcomes. It’s looking at how do we scale up interventions within systems of care. The actual research question is I’m using social network analysis, which is basically like marketing; thinking how you spread product, how you get people to buy your product. Using those principles and figuring out how do we get best practices disseminated within a system of care. The focus of my study in Itaboraí, is looking at receptivity, so trying to find clinics and individuals who were receptive, who think depression is a problem, who think that if they were trained they would be competent to do it. I wanna find people in places that are receptive but at the same time using social network analysis principles, we also wanna find settings that are very connected to others in the system of care, so they have a lot of influence. If we have two settings that are both receptive and one of them has people that are talking to others about it, because the questions are who do you discuss cases with, who do you give advice to, and who do you get advice from.


Does raising community awareness fit into that?

In this case, my research is looking at the provider level. All of the interviews and everything is at the provider level. That’s certainly a challenge to the TB Program and in terms of awareness about depression. There´s International Nursing Day and other events that happen throughout the year in Itaboraí, with health workers, and I wanna help take advantage of those forums to create awareness about treatments


How are you going to instruct people to recognize depression as a clinical disease and not “just a mood”?

People just assume they’re sick: they’re poor of course they’re depressed! There’s another line of research that I’m exploring here in Rio with UFRJ, which is the biological underpinnings behind depression such as inflammation. TB, for example is an inflammatory response. So, we also know now that depression is associated with inflammation. Also, when the inflammation happens, there’s a drop in defenses and immune functions, so hypothetically, in people with depression, their defenses are low, they might be more likely to have a latent infection. Or the TB inflammation could cause a depression but we believe it’s probably in both directions, so we’re doing a study looking at active TB, latent TB, and no TB.


That’s a lot of work! How long do you think it’ll take?

That project has been going on for two years, that’s through FAPERJ. And we’ve been doing that for the last two years and we just applied for grant in Peru, where we’re working with a Brazilian team to replicate the same type of study and a pillared basis so we can apply for larger grant in the future with both countries.


Tell me something about yourself beyond this amazing work.

Well, on a professional side I’d say that I’m a very multidisciplinary oriented person. I studied Psychology, then Social Work, then my public health program at Mailman was at the Department of Sociomedical Sciences, which is a very unique program. It’s the only one that I know of that has a focus on multidisciplinary quality, so it’s Anthropology, Sociology, History, Political Science, Psychology and Public Health. They focus on how do we learn from the Social Sciences to understand public health problems, it’s a very unique multidisciplinary program. I couldn’t pick between the disciplines, and so I found one program that was everything and was perfect for me, and so after that I did my Postdoc in Sustainable Development. I’ve worked as a social worker for years but now I’m 100% research because I feel like I can have way more impact at a policy level. I guess I should mention that I’m also at the International Union Against TB and Lung Diseases. On a personal level, I just got married a couple years ago. My husband is a photographer, so being married to an artist is amazing because I have artistic hobbies too. I make jewelry, I make lots of things. And we play street hockey. There’s an asphalt rink in New York City that we play on. I got my husband playing and he loves it now. It’s a mostly male league, so I’m one of the only girls in my team. So, you know, I got the sports, I got the art, I got the research, and I got love. And I love it.