Case report

Innovative actions for mental health in Greece during economic crisis

The Citizens against Depression project

Angeliki Menediatou, Stelios Stylianidis, Panagiotis Chondros, Tim Greacen, Emmanuelle Jouet, Michail Lavdas, Ian Dawson

Publication Date: 14.02.2018
Swiss Arch Neurol Psychiatr Psychother. 2018;169(02):48-50


Greece has been experiencing a long-lasting socioeconomic crisis with substantial consequences for the mental health of the population. The main purpose of the Citizens against Depression project (2014–2016) was to train mental health service users in organising self-help groups for ­depression. The overall aim of the project was to set the basis for reducing depression through mutual support and empowerment of service users. This article describes the multiple aspects of the programme and the evaluation of the training actions.

Key words: self-help groups; depression; user training; low-cost intervention


Since 2008, Greece has been facing rises in unemployment and poverty rates, substantial income loss and social instability. Τhe percentage of people who claim that their medical needs are not being met has reached 11% among those with lower incomes [1]. In 2015, the rate of unemployment reached 25.7%; the rates among people aged between 15 and 24 years old was 52%. The mental health system in Greece, according to the latest ex-post evaluation for the Ministry of Health, can be described as fragmented, inefficient and un­coordinated [2]. As for the use of services, only 32% among those who presented a common mental dis­order during the preceding year turned to a spe­cialist [3].

The crisis has had a major impact on the prevalence of affective disorders: one-month prevalence of major depression rose from 3.3% in 2008 to 12.3% in 2013 [4]. EPAPSY, the Hellenic Association for Mood Disorders – “Mazi” and the Salten Psychiatric Center (Norway) ­implemented a project in the context of the EEA Grants NGO Programme “We are all Citizens”. The ­project aimed to create a low-cost, community intervention based on psychoeducation groups and on ­self-help groups for coping with depression. The specific psy­cho­education group protocol was selected on the basis of its documented low-cost efficacy in mild and moderate ­depression [5,6]. The emphasis on self-help on the other hand was based on the increasing ­evidence for the efficacy of self-help groups on mental health [7, 8, 9].


The project was implemented in five selected areas in Attica, as well as in six Cycladic islands. It involved a ­series of different steps and actions:

1. Mental health experts created two original training manuals for self-help group facilitators (profes­sionals and mental healthcare users). The manuals cover the following issues: the concepts of empowerment and recovery; definitions, basic characteristics, and effectiveness of self-help groups; the role, skills and attributes of a self-help group facilitator; ­depression; suicide and suicidality; coping with stigma [10, 11].

2. Mental health professionals as well as mental health service users trained mental health professionals in how to teach others to run self-help groups for depression. The mental health professionals ­selected to be trained were all psychologists, and already colla­borators to EPAPSY structures in Athens and the ­Cyclades. Therefore they were already familiar with the needs and specific characteristics of the ­local population, increasing the possible impact of the project.

3. Cognitive Behaviour Therapy (CBT) specialists trained mental health professionals on implementing psychoeducation groups for depression, using Lewinsohn’s “Coping with depression course – CWDC”, translated and adapted to the Greek context. [12, 13].

4. The trained mental health professionals trained people with personal experience of depression to be self-help group facilitators (18 hours training). ­Specifically, people who had been diagnosed with or experienced (without a formal diagnosis) ­de­pression and related problems, and who responded to an open invitation through the organised public ­informative events, were selected through a telephone ­conversation, on the basis of their motivation and availability to organise ­self-help groups.

5. The professionals also ran psychoeducation groups (12 sessions). The evaluation of the groups was part of the structured protocol of the intervention.

6. Training material and general mental health information was also provided online, with free access to the public.

7. Evaluation of the training actions 2 and 4. The ­evaluation strategies were developed by experts from Maison Blanche Hospital (Paris, France).


Thirty-eight mental health professionals were trained as psy­choeducation group facilitators and as self-help group ­facilitator trainers. Overall, 140 mental health users were trained as self-help group facili­tators. Ten psycho­education groups took place with 120 parti­cipants in total. Five new self-help groups had already started meetings before the end of the ­programme. Apart from these results, it is important to notice that there was an impressive networking of 35 local stakeholders. Furthermore, 13 public infor­mative events concerning depression and self-help groups took place (estimated overall attendance: 1450 persons).


Concerning action 2, the 38 professionals each completed an evaluation form at the end of their training session [14]. In addition, participants were assessed as to whether they felt prepared to go out and train self-help group facilitators. Working in small groups, they were asked to design a facilitator-training ­program addressing key questions. Satis­faction levels with the overall experience and the training material, measured on a five-point Likert Scale, were high: ­general impression 4.9/5; training material 4.6/5; duration and schedule 3.8/5. Knowledge acquisition was also rated highly: only 8 participants scored under 45/55 on the questionnaire and only 2 groups (out of 15) scored under 35/50 on the group ­exercise. Qualitative feedback concerning the training and the evaluation was generally positive. The parti­cipation of users as trainers was much appreciated and the participants understood the final aim of the project: i.e., not just ­acquisition of mental health knowledge and skills but, more importantly, a reduction in depression.

Feedback from open questions throughout the eva­luation process underlined the following issues for ­improving ­future training sessions. Some participants answered certain questions too much from their ­professional point of view. Responding to questions that required pedagogical or group management skills, they tended to remain in their role of mental health clinicians. Too few participants mentioned community empowerment in their answers: i.e., self-help groups as a means for empowering communities and positive networking. Based on the evaluation ­feedback, changes were made to the training material and process, before the implementation of action 4.

In the implementation of action 4, a total of 105 future facilitators participated in the training evaluation ­sessions. Respondents’ age ranged from 31 to 69 years, with a median age of 50; 77% were women. Almost one in two (47%) were currently employed, 39% were un­employed and 14% retired. The results indicated high levels of overall satisfaction with the training ­sessions and the materials used. As with the mental health professionals in action 2, the duration and schedule of the training sessions were difficult to adapt to all parti­cipants’ needs, particularly of those currently employed: overall impression 4.7/5; training material 4.6/5; duration and schedule 4.1/5. Qualitative feedback on the training process revealed that it was generally con­sidered to have been a positive experience, mainly through the opportunity it provided for meeting other people with similar problems, ­acquiring new and ­immediately useful skills, being part of a group and making new friends. In terms of ­areas for improvement, many participants insisted that the whole training process needs more time, more practical exercises and greater participation of people with personal ­experience of depression and ­experience as self-help group facilitators and trainers. Participants underlined how much the training had ­actually influenced their personal lives. The objective of promoting the ­notion of recovery from depression was highly appreciated and many participants expressed their enthu­siasm for going out to set up self-help groups [14].


The Citizens against Depression project put into practice several actions that were truly innovative for Greece. Experienced experts were part of the programme at every stage (planning, training sessions, evaluation, dissemination, public conferences) on a paid basis. Self-help groups for mental health problems such as depression are rare in Greece. And finally, structured group interventions are not yet incor­porated into first-line mental health care, although they have proved to be both effective and low-cost. These three innovations were welcomed by the users. The role of social capital, the availability of social ­resources and the concept of personal recovery are key elements in supporting people with mental health problems and understanding the effectiveness of self-help groups and self-help interventions in ­general [15,16]. The next step will be to organise a ­strategic plan integrated into Greek national mental healthcare policy for supporting the setting-up of ­self-help groups across the country in a persisting ­period of socio­economic crisis.

 1 OECD. Health at a Glance: Europe 2014. OECD Publishing [Internet]. 2014. Available from­eur-2014-en

 2 Loukidou E, Mastroyannakis A, Power T, Thornicroft G, Craig T & Bouras N. Evaluation of Greek psychiatric reforms: methodo­logical issues. International Journal of Mental Health Systems ­[Internet]. 2013 [cited 2013 March 28]; 7(1), 11. Available from doi: 10.1186/1752-4458-7-11.

 3 Skapinakis P, Bellos S, Koupidis S, Grammatikopoulos I, Theodo­rakis PN & Mavreas V. Prevalence and sociodemographic associations of common mental disorders in a nationally representative sample of the general population. BMC Psychiatry. 2013;13:163–76.

 4 Economou M, Peppou LE, Souliotis K, Stylianidis S. The impact of the economic crisis in Greece: Epidemiological perspective and community implications. In: Stylianidis S, editor. Social and Community Psychiatry. Cham (Switzerland): Springer Inter­national Publishing; 2016. p. 469–83.

 5 Cuijpers P. A psycho educational approach to the treatment of ­depression: A meta-analysis of Lewinsohn’s coping with depression course. Behavior Therapy. 1998;29:521–33.

 6 Swan J, Sorell E, Mac Vicar B, Durham R, Matthews K. “Coping with Depression”: an open study of efficacy of a group psycho­educational intervention in chronic, treatment-refractory depression. Journal of Affective Disorders. 2004;82:125–9.

 7 Menediatou A. [Self-help groups and mental health]. In ­Stylianidis S, editor. [Empowerment and advocacy]. Athens (GR): Topos; 2015. p. 179–89. Greek.

 8 Kyrouz EM, Humpherys K & Loomis C. A review of research on the effectiveness of self-help mutual aid groups. In White BJ ­& ­Madara EJ, editors. Self-help Group Sourcebook . 7th ed. NJ: ­American Self-help Clearinghouse; 2002. Chapter 5; p. 1–16.

 9 Repper J, Carter T. A review of the literature on peer support in mental health services. Journal of Mental Health [Internet]. 2011 [cited 2011 Jul 19]; 20(4): 392–411. Available from doi: 10.3109/09638237.2011.583947

10 Menediatou A, Chondros P, editors. [Facilitation of self-help group for depression: Trainer’s manual]. Athens (GR): Association for Regional Development and Mental Health; 2015. 204 p. Greek.

11 Menediatou A, Chondros P, editors. [Facilitation of self-help group for depression: Trainee’s manual]. Athens (GR): Association for Regional Development and Mental Health; 2015. 181 p. Greek.

12 Efthimiou K, Kaklamani G, Kapnoyanni S. [Defeat depression: The P.M. Lewinsohn structured CBT program]. Athens (GR): ­Behavioral Research and Therapy Institute; 2015. Greek.

13 Lewinsohn PM, Antonuccio DO, Steinmetz-Breckenridge J, Teri L (1984). The coping with depression course: A psychoeducational intervention for unipolar depression. Eugene, OR: Castalia Press.

14 Greacen T, Jouet E (2016). Evaluating the Citizens against ­Depression Training Programmes. Report submitted for the ­project Self-help, networking and therapeutic support in coping with depression in urban and isolated areas, 30/5/16.

15 Rossi A, Galderisi S, Rocca P, Bertolino A, Rucci P, Gibertoni D, Stratta P, et al. Personal resources and depression in schizo­phrenia: the role of self-esteem, resilience and internalized stigma. Psychiatry Research [Internet]. 2017 [cited 2017 June 26]; 256:359–64. Available from:

16 De Silva MJ, McKenzie K, Harpham T, Huttly SR. Social capital and mental illness: a systematic review. Journal of Epidemiology and Community Health. 2005;59:619–627.

Angeliki Menediatouª, Stelios Stylianidisb, Panagiotis Chondrosc, Tim Greacend, Emmanuelle Jouetd, ­Michail ­Lavdasc, Ian Dawsone

ª Hellenic Association for Mood Disorders, Athens, Greece
b Panteion University of Political and Social Sciences, Athens, Greece

c Association for Regional Development and Mental Health (EPAPSY), Athens, Greece

d Laboratoire de recherche, EPS Maison Blanche, Paris, France

e Salten distrisktspsykiatriske senter, Norway

No financial support and no other potential conflict of interest ­relevant to this article was reported.

Angeliki Memediatou, M.A.
Hellenic Association
for Mood Disorders
Iras 54, N. Irakleio
GR- 14122 Athens