PRB

(June 2006) Although mental health is a sensitive topic the world over, the prevalence of mental illness and its consequences can no longer be overlooked. While mental disorders include a range of illnesses (such as anxiety, schizophrenia, and autism), depression is the most common and is pervasive worldwide.

Depression is now the fourth-leading cause of the global disease burden and the leading cause of disability worldwide.¹ While it is not a significant cause of mortality, depression seriously reduces the quality of life for individuals and their families, is a risk factor for suicide, and often worsens the outcome of other physical health problems.

Unfortunately, depression is particularly problematic in developing countries, where data on the prevalence and scope of the disease as well as the resources to address it are sorely lacking. Cost-effective interventions are available, but do not often reach those who need them because of a number of overwhelming challenges in low-resource settings—lack of facilities and trained mental health personnel, questions about effective population-based screening, and the general stigma surrounding mental disorders. (See table for the disparity of mental health workers between low-income and high-income countries).

Mental Health Workers, Low-Income and High-Income Countries

Median per 100,000 population

Source: WHO, Mental Health Atlas 2005 (2005).

But bringing attention to the pervasiveness of depression can help combat the stigma surrounding the disease and help overcome the obstacles to screening and treatment, so that these cost-effective interventions will be more acceptable (and therefore more utilized) in developing countries.

A Global Problem That Is Underreported and Feminized

Up to 20 percent of those attending primary health care in developing countries suffer from the often-linked disorders of anxiety and depression, but the symptoms of these conditions are often not recognized.² Indeed, underreporting of depression is a major problem worldwide. Dr. Vikram Patel, an expert in international mental health with the London School of Hygiene and Tropical Medicine, says that there are three major factors underlying this phenomenon.

“First, most patients do not complain of ‘depression’ but of physical symptoms,” says Patel. “Second, there is a lack of awareness that depression can be treated with cheap and simple interventions. And third, there is the stigma of mental illness, which pervades all mental health matters.”

The consequences of underreporting depression and lack of treatment for it are enormous. For instance, depression is the most important risk factor for suicide, which claims around 800,000 to 850,000 lives annually, and is among the top three causes of death in young people ages 15 to 35.³ Suicide is one of the leading causes of death in young women in India and China.⁴

And depression is a feminized issue: It afflicts twice as many women as men across different countries and settings.⁵ While there is considerable variation in the rates of depression in different countries, an average of 6 percent to 10 percent of women in developing countries are suffering from the condition, although higher rates have been reported from some settings such as rural Pakistan.⁶ And much higher rates of depression have been found in women attending primary health care centers in developing countries. In India, for instance, between 25 percent to 33 percent of women attending these centers may be suffering from depressive disorders.⁷

Many analysts argue that women’s multiple roles—as both caregivers and family breadwinners in one-third of households worldwide—are also to blame for women’s ill mental health.⁸ Stressful life events, such as death of a husband or a lack of male children, have also been linked with depression in women.⁹ Moreover, case studies from India, Brazil, and Chile show that low education, low income, and difficult relationships are critical determinants of mental ill health for women.¹⁰

In addition, depression is also an important consequence of domestic violence, which affects between one-quarter and over one-half of women at some point in their lives.¹¹ Studies have established a positive relationship between the frequency and severity of abuse and mental health problems.¹² In one study in urban Pakistan, women who were anxious and depressed were almost 12 times more likely to report physical abuse once a month as were women who were not anxious or depressed.¹³

Finally, depression is also a family issue: In mothers, it can lead to low birth-weight babies and child undernutrition. In a study in Goa, India, babies who were still underweight at six months were more than twice as likely to have a mother with depression.¹⁴ Thus, treating depression may not only lead to benefits for the individual, but may have an important impact on others in the family and community.

Formidable Obstacles to Mental Health Care

Challenges to addressing depression at a clinical and community level in less developed countries are numerous and vast—ranging from inadequate funding and personnel for diagnosis and treatment to stigma and the simple lack of understanding that mental illness is, in fact, a distinct medical condition.

Stigma

The stigma of mental illness is perhaps the biggest challenge to confronting depression in developing countries. Stigma facilitates a lack of awareness of the condition as an illness category and causes many people to delay seeking care.¹⁵ It is a strong contributor to underreporting of the disease and a barrier to using the available cost-effective interventions.

Lack of Treatment Access and Recognition of the Disease

Treatment for depression is often lacking, especially in developing countries: The World Health Organization reports that fewer than one in every four people affected by depression worldwide have access to effective treatments.¹⁶ Adding to the problem is that people with depression who seek help most often complain of nonspecific physical symptoms; such individuals receive a correct diagnosis in less than one-quarter of cases and typically are treated with medicines of doubtful efficacy.¹⁷

Lack of Trained Mental Health Personnel

Lack of trained mental health personnel and the paucity of basic primary care services needed to screen for depression and deliver effective treatments are major challenges.¹⁸ In general, depression receives little programmatic and research attention in developing countries because of the persistent belief that it is uncommon, unimportant because it does not contribute to mortality, and that effective and affordable treatment is not available.¹⁹

Furthermore, the brain drain of doctors and nurses from resource-poor countries to developed countries undermines the development of health care services in these regions, particularly in underserved areas such as mental health treatment.²⁰ The gap is wide between rich and poor countries regarding numbers of trained mental health providers. WHO reports that low-income populations have far fewer psychiatrists, psychologists, and social workers per every 100,000 people than do high-income countries (see table above).

And mental health services in low-income countries are far less prevalent than those in higher-income countries. In 2001, WHO launched Project Atlas to map the available mental health resources in developing countries. The project’s recent Mental Health Atlas 2005 profiles the epidemiology of mental illnesses and the resources available to address mental health issues from all 192 WHO member states.²¹ According to WHO, mental health facilities at the primary level are present in only 76 percent of low-income countries, compared with 97 percent of high-income countries (see figure).

Culturally Appropriate Screening

Integration of Mental Health Care in Primary Health Care, by Income Group

Low: < $755 annual per capita income
Lower-middle: $756-$2,995 annual per capita income
Higher-middle: $2,996-$9,265 annual per capita income
High: > $9,266 annual per capita income

Source: World Bank (2004).

Other challenges include the cost, scope, and cultural context of population-based screening for mental disorders. While some international screening tools—such as the General Health Questionnaire or the Self Reporting Questionnaire— are available and have been used across countries and cultures, others have been developed locally to better tailor measurement of depression to the local context.

Measurement of depression can be undertaken with similar tools in different cultural settings, but care must be taken to ensure adequate translation and an appropriate cut-off score for a depression diagnosis.²² Examples of locally developed screening tools include the Primary Care Psychiatric Questionnaire in India, the Shona Symptom Questionnaire in Zimbabwe, and the Chinese Health Questionnaire.²³

But culture remains important. For example, the concept of a depressive disorder that focuses on mood change as the primary or core feature of the disorder has evolved from a Western culture and may not be universally applicable.²⁴

Cost-Effective Interventions Work in Low-Resource Settings—But There Are Complications

According to the Disease Control Priorities Project (DCPP), a research group that produces evidence-based analysis and resource materials to inform health policymaking in developing countries, the single most cost-effective treatment for depression in developing countries is older antidepressants (tricyclic antidepressants).

DCPP argues that tricyclic antidepressants are lower in cost but similar in efficacy to new antidepressants (serotonin reuptake inhibitors or SSRIs) that have fewer side effects. Its analysts also report that treating depression with new antidepressants and group psychotherapy (which should be included with either drug to achieve results) would only cost between US$2,000 and US$3,000 per DALY (disability-adjusted life year) averted.²⁵ But lack of access and recognition of the disease as well as the paucity of trained mental health personnel are significant barriers to using these interventions.

The frequent recurrence of depression also complicates treatment. Around 30 percent of individuals diagnosed with depression experience a relapse within three months—and in the absence of continued treatment, 50 percent of those with depression will experience another episode within two years.²⁶ Thus, proactive management of depression must include both long-term drug treatment and group psychotherapy. But a study from India showed that individual “talk” therapy—which is widely practiced in developed countries—had little efficacy, probably because it was culturally unacceptable.²⁷

Vikram Patel argues that psychiatric terms for these illnesses might be counterproductive in some less developed countries. “I think we need to move away from the focus on the psychiatric labels we tend to use—particularly labels like ‘depression’ and ‘anxiety,’ because these have no meaning or value in non-Western settings,” says Patel. “Using locally valid terms and idioms would enhance the recognition of these disorders, and potentially be less stigmatizing, too.”

Heidi Worley is a senior policy analyst at the Population Reference Bureau.

References

1. Steve Hyman et al., “Mental Disorders,” in Disease Control Priorities in Developing Countries, 2d ed., ed. Dean T. Jamison et al. (New York: Oxford University Press, 2006).
2. World Health Organization (WHO), Gender and Women’s Mental Health (1997), accessed online at www.who.int, on June 9, 2006.
3. WHO, Depression (2003), accessed online at www.who.int, on June 8, 2006; and WHO, Preventing Suicide: A Resource for Primary Health Care Workers (2000), accessed online at www.who.int, on June 12, 2006.
4. Rita Aaron et al., “Suicides in Young People in Rural Southern India,” Lancet 363, no. 9415 (2004): 1117-8; and Michael R. Phillips, Xianyun Li, and Yanping Zhang, “Suicide Rates in China, 1995-99,” Lancet 359, no. 9309 (2002): 835-40.
5. T.B. Ustun et al., “Global Burden of Depressive Disorders: Methods and Data Sources,” British Journal of Psychiatry 184 (2004): 386-92; and Robert Desjarlais et al., World Mental Health: Problems and Priorities in Low Income Countries (New York: Oxford University Press, 1995).
6. D.B. Mumford et al., “Stress and Psychiatric Disorder in Rural Punjab: A Community Survey,” British Journal of Psychiatry 170 (1997): 473-78.
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8. WHO, Women and Mental Health (2000), accessed online at www.who.int, on June 12, 2006.
9. Vikram Patel et al., “Gender Disadvantage and Reproductive Health Risk Factors for Common Mental Disorders in Women: A Community Survey in India,” Archives of General Psychiatry 63, no. 4 (2006): 404-13.
10. Ilona Blue et al., “The Mental Health of Low-Income Urban Women: Case Studies from Bombay, India; Olinda, Brazil; and Santiago, Chile,” in Urbanization and Mental Health in Developing Countries, ed. Trudy Harpham and Ilona Blue (Aldershot, UK: Avebury, 1995).
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25. Dean T. Jamison et al., Priorities in Health (New York: Oxford University Press, 2006).
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27. Patel, Araya, and Bolton, “Editorial: Treating Depression in the Developing World.”