In Kazakhstan, 21-Year-Old Receives Care For Tuberculosis, Depression

Samal wasn’t showing up for therapy. But she had missed appointments before.

After filling out a depression questionnaire, the 21-year-old had missed her next two therapy sessions at the clinic where PIH works in Almaty, Kazakhstan. Social workers had tried calling her, but she hadn’t picked up. So it wasn’t a total surprise she was a no-show, again.

But for the next month, social workers heard nothing. The worry began to set in. They knew about the tuberculosis. The family estrangement. The sexual abuse.

And she had scored highly on the depression questionnaire. But there was little they could do but wait.

Samal is one of 160 of patients who have received mental health support from PIH in Kazakhstan, a landlocked nation of 18 million in Central Asia where PIH has worked since 2010 in partnership with the Ministry of Health. PIH provides these mental health services at the inter-district outpatient clinic in Almaty.

Kazakhstan has one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB) in the world—a disease that takes a devastating toll on patients’ physical and mental health. PIH’s work in the country has focused on tuberculosis care and, recently, has expanded to include mental health support for patients living with the disease—most commonly, for depression.

That mental health support is provided as part of PIH’s Many Voices Collaborative, a cross-site initiative begun in 2018 to support the development of mental health services across the countries where PIH works—support that has become even more crucial amid COVID-19, as the virus puts patients like Samal at disproportionate risk and creates heightened fear and anxiety each day.

A Turning Point

After a month of no news, social workers finally learned Samal’s whereabouts: She had been re-admitted to the National Institute of Physiopulmonology, after test results had showed her tuberculosis worsening.

Fortunately, after months of constant care, her bacterial excretion stopped, her vital signs improved, and she was discharged from the hospital and able to continue treatment at the clinic in Almaty. That meant her mental health care could resume, too.

As the therapy sessions restarted, social workers learned more about her past, including how she had been raised by her mother’s relative, as is common for large families in the rural grasslands of the Kazakh Steppe, and how her parents hadn’t taken action to end the sexual abuse.

These sessions led to a diagnosis of complex trauma and depression—conditions linked to her past but compounded by her present, including her struggle with tuberculosis and its long, painful treatment regimen.

From diagnosis to treatment, PIH’s mental health team was there to support her, using common elements treatment approach (CETA)—a cognitive behavioral approach developed for non-mental health providers in low- and middle-income countries—to help her understand and manage her complex thoughts and feelings.

She is one of dozens of patients who received such care from PIH.

Over the past year, the PIH mental health team in Kazakhstan conducted 555 consultations by phone, visited 160 patients in person, and trained 238 health workers in psychological first aid. In May, PIH trained seven psychologists on staff and six from partner nonprofits in the CETA approach.

PIH also provided social support, including 2,100 food vouchers, removing systemic barriers such as food, housing, and transportation, which can prevent the poorest patients from accessing health care.

“The problem of mental health is very important for our country, because there are a lot of people in the country in need of psychological help,” says Serik Kozhabekov, mental health coordinator with PIH Kazakhstan. “As we can see from our experience, cognitive therapy is a very effective tool in the fight against depression.”

Through PIH’s support, Samal was able to reduce the intensity of her traumatic memories and clear her mind of stuck, unproductive thoughts. She completed her therapy in May 2021, after showing clinical improvement. More good news followed: she gave birth to a child and finished her tuberculosis treatment, making a full recovery.

Then, another tragedy struck: her mother died of COVID-19.

Samal was spotted by a social worker, through a bus window, wandering aimlessly down a city street in Almaty with her child in her arms. Worried, the social worker got off the bus at the nearest stop and led Samal, by the hands, to the clinic, where she was offered additional mental health care.

Now, Samal is in therapy to treat her depression. She is already showing signs of improvement, learning how to detect and manage negative thoughts related to her mother’s passing and her postpartum depression.

“I am still very young,” she says. “Even if I stumbled…I have time to take a break and start fighting for life with renewed vigor.”