Innovation summary

In 2014 the OECD found that mild-to-moderate mental health comorbidity affected around 20% of the working age population and cost over 4% of GDP.1 The percentage of those affected by mental health co-morbidity and the value to which ensuing impairment affects countries outside the OECD is not known and has long been ignored.

This program utilizes “total health screening” through a collaborative care model to determine the prevalence of mental disorders and other NCD co-morbidity in low- and middle- income countries. The presenters demonstrate how self-administered screening can be leveraged in a primary care setting to accurately determine clinical information for health teams and policy makers.

Impact summary

  • 1 in 4 to 1 in 7 people in China, India, Iran and Romania suffer from moderate to severe depression across genders
  • Cardiovascular disease and diabetes are most commonly reported co-morbidities presenting with depression

“This work will go a long way in diminishing shame, stigma, and discrimination because it is part of total healthcare; not segregated in specialty clinics.”

– Eliot Sorel, MD,  Professor at The George Washington University’s Department of Global Health

Innovation details

As the world undergoes varying degrees of disease transitions, non-communicable diseases (NCDs) lead in the global burden of diseases (GBD) and in disability. A high degree of co morbidity prevails among many of the NCDs including cardiovascular disorders, diabetes, depression, cancer, and others. Cardiovascular disorders and mental disorders lead among them. Mental disorders alone represent 14% of the GBD and 30-45% of the global burden of disability affecting hundreds of millions of people worldwide as well as the economies of low-, middle- and high-income countries.2

The global cost of mental disorders was estimated to be approximately US$2.5 trillion in 2010. It is projected to increase by 240% by 2030, to US$6.0 trillion. In 2010, 54% of that burden was attributable to low- and middle-income countries (LMICs). This LMIC burden is projected to increase to 58% by 2030. Due to insufficient investment and challenges in accessing treatment, mental disorders have serious economic consequences as well. The lost economic output to depression alone was estimated to have cost at least $800 billion in 2010, a sum expected to double to 2030. High-income countries are estimated to spend 2.4 % to 4% of GDP on mental disease burden. It is essential to generate evidence on costs attributable to mental health in LMICs, to fully understand its impact on GDP. 1-3

Total Health Screening

Most non-communicable diseases are first seen in primary care, depression included. Depression, one of leading conditions in the global burden of disease and of disability is frequently misdiagnosed, underdiagnosed and undertreated, especially in low- and middle-income countries. Depression often presents as a co-morbid condition with other non-communicable disease, especially cardiovascular disease and diabetes. Therefore, it is important to screen for mental health, including co-morbidities, in patients,at the first point of contact with the healthcare system, i.e. primary health care centers. This study of depression and co morbidity in primary care in China, India, Iran and Romania screens patients for depression at the primary care centers; using the PHQ-9 instrument, a reliable, internationally validated questionnaire, that takes 3-5 minutes to complete, and can be administered by non-clinical personnel. 

Key drivers

  • Good professional relationship and communication with the primary care clinic staff
  • Expertise and ease with transcultural diversity and specificity
  • Brevity and ease of use of free and validated self-administered screening tools such as the Periodic Health Questionnaire 9 (PHQ-9)
  • Central repository for information and analysis of data gathered  to make meaningful and informed recommendations    


  • Developing initial relationships with local primary care clinics
  • Need for brief standardized training sessions to teach primary care clinic staff on the use of the screening instrument
  • Periodic maintenance training throughout the year
  • Ongoing outcome evaluations and appropriate corrections for continuous improvement


The team hopes to expand to additional countries in Asia, Africa, South America, and the Caribbean so as to develop a more complete picture of the global burden of mental health co morbidity.

The team is currently in process of developing a training course in integrated care for Africa and an Africa Global Mental Health Institute. This training course will implement and integrate data obtained from the total health approach demonstrated by this project.



These studies were funded by voluntary contributions by the research team members in China, India, Iran, Romania, and the United States. Contributions made by the Romanian Ministry of Health, the participating academic institutions and clinical facilities in the four countries, and the physicians and members of the health teams.

Evaluation methods

The Total Health Screening for Integrated Care, project consists of a cross-sectional study implementing mental health screening tools in the primary setting. The first four studies, which are the subjects of this project, utilized the Patient Health Questionnaire (PHQ-9) to determine the rates of depression in the populations studied.

The PHQ-9 a self-report and analysis questionnaire, is a widely used screening tool to diagnose Major Depressive Disorder in the primary care setting. There are nine items which rate the frequency and severity of the major diagnostic symptoms of depression in the preceding two-week period prior to filling it.  The PHQ-9 can be filled out in three to five minutes and can be administered by non –clinical personnel, which can subsequently be rapidly assessed and correctly scored by a supporting clinician. The severity of depression is determined by the total score range: 1-4= Minimal, 5-9=Mild, 10-14=Moderate, 15-19=Moderately Severe and 20-27= Severe Depression. Chart diagnoses provided non-psychiatric diagnoses to determine co-morbidity.

Cost of implementation

The screening tool used in the studies is freely available online and has no associated licensing fees. It is also based on self-report which minimizes the amount of training required of primary care clinic staff. The main cost is that associated with reproduction of the one-page tool, liaison between the study team and clinic staff. As the instrument can be performed in less than five minutes and participants are recruited from the primary care clinic’s established population, no additional inducements are needed.

Impact details

The results from the four studies found similar results indicate that a large proportion of primary care patients may be either at risk, or suffering from major depression. The studies also confirm high levels of co morbidity with other non-communicable diseases, especially CVD and diabetes. These findings hold important implications for populations’ mental health, health systems performance, the delivery of care, health promotion, protection, and illness prevention – as well as the countries’ economies.

Over 4,090 individuals were screened through the four countries – China, India, Iran, and Romania. This has helped provide useful and actionable information on the prevalence of mental health co morbidities in countries home to 2.7 Billion people and combined GDP of $11.674 trillion USD. Using the 4% of GDP estimate of the OECD, the total cost of comorbidity could approximate $467 billion USD per year.

Country specific details


A multi-center, cross sectional study of patients visiting primary health clinics of three different regions of India was implemented. According to PHQ-9 scores 20.9% had moderate depressive symptoms, 19.1% had moderately severe depressive symptoms and participants 6.3% had severe depressive symptoms. Most patients with depression had medical co-morbidities – Diabetes Mellitus (46%) and with Cardiovascular Diseases (42.6%) were most commonly reported.


In this study, the PHQ-9 questionnaire was administered, using a cross-sectional study design, to 1710 patients, that referred to primary care offices in Romania. 8.4% had moderate depressive symptoms, 4.4% had moderately severe depressive symptoms and 1.5% had severe depressive symptoms. Cardiovascular diseases were the most frequent co morbidity (56.8%). Cardiovascular co morbidities were found to be possible risk factor for a PHQ-9 score≥10 [unadjusted odds ratio 2.29 (1.69-3.09)] and correlated positively with total PHQ-9 scores (r=0.25, p<0.001). However cardiovascular co morbidities were not independent predictive factors for PHQ-9≥10 when adjusted to other co morbidities, lifestyle and financial status.  


This research was conducted in two geographically distant and socio-culturally different regions of China to study the prevalence of depression in the primary care setting. A secondary objective was to investigate the relationship between depression and chronic medical conditions e.g. Diabetes Mellitus (DM), Cardiovascular Disease etc. 

A total of 823 people (51.0% women, 49.0% men) were screened with PHQ-9. 16.4% had moderate depression, 5.7% had moderately severe depression, and 2.4% had severe depression. Patients with DM were proved to have the highest PHQ-9 scores (7.7±5.8), followed by Cardiovascular Disease (7.4±5.5) and Gastro-intestinal Disease (7.2±3.4).


This was a multi-centric cross sectional study assessing patients attending 4 PHC centres of a mixed urban-rural area near Tehran. Participants were screened for depression using Patient Health Questionnaire-9 (PHQ-9. 8.5% of the patients had moderate depressive symptoms, 4.9% had moderately severe depressive symptoms and 2.1% had severe depressive symptoms. This study did not investigate co-morbidities. ​


  1. Unutzer J, Harbin H, Schoenbaum M, Druss B. (2014) The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes. Center for Medicare and Medicaid Services Brief 
  2. Hewlett E, Moran V. (2014) Making Mental Health Count. OECD Health Policy Studies
  3. Sorel E. (2015) Total Health for All in the 21st Century.

Other references

  • Sorel E. 21st Century Global Mental Health (2013) Jones & Bartlett Learning. Burlington, MA.
  • Zhang L, Zou T, Hao Y, Sorel E. (2016) A study of depression in primary care setting of China. International Medical Journal – In Press
  • Balanescu P, Botezat-Antonescu I, Dima C, Oana SC, Sorel E (2016). Depression screening in primary care and correlations with comorbidities in Romania. International Medical Journal – In Press
  • Tripathi A, Kallivayalil R, Bhagabati D, Sorel E (2016). An Exploratory Multi-centric Depression Screening Study in Primary Care Setting from India. International Medical Journal – In Press
  • Mohit A, Jalili A, Nohesara S, Bolhari J. A Study of Depression Screening in Primary Care Setting of Iran. International Medical Journal – In Press
  • Sorel E. (2016) Depression and Comorbidity in Primary Care in China, India, Iran, Romania. International Medical Journal – In Press
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China, India, Iran (Islamic Republic of), Romania


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