Where did all the depression go?
This entry is a repost from the Programme for improving mental health care (PRIME) blog. The original entry by Charlotte Hanlon can be found here: "Where did all the depression go?". To learn more about the PRIME project, check out their innovation page: PRIME
This month has been all about detection... or lack of it. Early experiences from implementation of the PRIME district mental health care plans have identified a problem. Even though we expect depression to be common in primary care settings, our newly trained primary healthcare workers just don’t seem to be detecting it at anything like the level we would expect.
Truthfully, we are not completely surprised because this is a well-known issue that also affects general healthcare settings in high-income countries. Other experiences of implementing the World Health Organisation’s mhGAP have run into the same problem – see the report from Ethiopia of the mhGAP pilot in 19 health centres which showed that only 89 people were treated for depression over a period of six months[a] Even if we took a conservative estimate that 5% of people attending primary care have depression that is likely to need treatment, this would amount to detecting less than one in ten cases. And there are many more examples.
This is such a niggling problem that it even led the PRIME researchers to over-ride their conviction that more than one hour of teleconference is bad for your health and extend our monthly meeting to share our experiences and ideas. When we looked at patterns of depression detection across the PRIME countries, we found that the levels of detection vary considerably, with the highest levels approaching those found in high-income countries and the lowest levels being... well, really quite low. Being able to look at variation across sites is one of the bonuses of the PRIME project. The hope is that, by doing so, we can identify the factors facilitating better detection in some settings and use this learning across the other sites. So, what were some of the issues thought to be contributing to low detection? Our collective brainstorming led to a long list of potential factors, many of which were nothing to do with ‘detection’ problems at all.
First of all, perhaps the construct of depression is all wrong for the socio-cultural contexts within which we are working? We don’t think this is the core problem for various reasons. Previous research by members of PRIME has shown that an entity which can be characterised as depression is present in African settings. In Ethiopia this ‘depression entity’ is associated with increased disability and risk of premature death. The experience of the PRIME mental health professionals in their day-to-day clinical work also attests to the existence of depression and the suffering it causes. The non-existence of depression doesn’t seem to be the main reason for our low detection problem. What else? Well, in some of the PRIME countries, formative work indicated that depression was not considered by the community to be an illness. Instead, the symptoms of depression tended to be normalised against the back-drop of life suffering. Depression symptoms do not mark people out as ‘abnormal’ in the same way as psychosis and so are perhaps more easily tolerated by society. The high threshold for help-seeking for any kind of illness in high poverty - high illness populations might contribute to this state of affairs. Other more pressing symptoms with more obvious effects on functioning would be prioritised for help-seeking, which requires using up scarce resources. The non-availability of treatment for depression in healthcare settings could also be playing a role – time will tell whether or not the reliable presence of effective PHC-based depression services kick-starts demand.
What about detection issues? In keeping with many studies on the topic, the facility detection survey in one PRIME country suggested that people with undetected depression in PHC were more likely to present their problem in terms of physical health symptoms, even though other clinical signs of depression were present. The formative work from PRIME also showed that health care providers tend to only think about depression when the patient volunteers emotional symptoms, something which happens rather rarely at the present time. In India, the mhGAP training has been adapted to emphasise these physical presentations of depression. Detection of a condition like depression also needs the right approach in terms of communication skills, as well as the right environment: private and not rushed. The confidence of the primary care worker in their skills to detect and manage depression may also be a contributory factor. The PRIME team suspects that some of these critical issues may be undermining the possibility for depression detection.
More complex contextual and system level issues may also be weighing into this apparent ‘detection’ problem. As a PRIME country PI has shown previously, the socio-cultural context has a bearing on detection. Primary care workers may be only too aware of emotional problems in their patients but be reluctant to take on the emotional and societal burden of explicitly recognising the problem. Where patients and primary care health workers hale from the same community, stories of distress relating to social hardship may obligate the primary care worker to act to solve the problem, even when such actions go well beyond what should be expected of a health worker. Health system level issues relating to the availability of appropriate interventions for people with depression (not just medication but an acceptable and feasible psychosocial intervention), the lack of realistic referral pathways for severe cases as well as the adequacy of training, supervision and incentives to take on this new role are clearly part of the equation.
Having taken you on a tour of the many possible explanations for the low detection and treatment of depression in some of the PRIME sites, you might reasonably ask what we think is actually driving the different detection rates between countries. At this stage we don’t know, but the professional level of mhGAP trainees may be important e.g. better depression detection was seen with doctors compared to other cadres of primary care professional. Repeat training and high quality supervision are strong candidates for improving detection. The next step is to go back to the PHC workers, explain the problem and ask them for their views on what would help. We can also try to identify PHC facilities that are managing to detect depression and understand what is allowing that to happen. If we are lucky, we might find a PHC worker who has particular aptitude and enthusiasm for mental health work and can help as a ‘broker’ to convince their peers of the value of the work. Each country will take away the experiences of the other countries and we will see if we can indeed improve detection by enhancing what seem to be the facilitating factors.
[a] Amanuel Hospital and the World Health Organization. mhGAP in Ethiopia: a proof of concept 2013.
To learn more about the PRIME project, check out their innovation page: PRIME