Why is there a treatment gap for depression? A case study from rural India
Kavita* is 62 years old, she thinks. Like many of her generation in rural India, she is illiterate and has no record of her exact year of birth, so this is a guess. Having worked in the fields all her life doing unforgiving manual labour in the searing sun, she looks older.
My colleague and I meet her on a neighbouring farm, where she gets casual work as a daily labourer for 100 rupees (£1.10) a day. We’re sweating and scratched from the bumpy motorbike ride to get here. At the moment it’s 35°C, but it will reach close to 45°C at the peak of the summer.
Kavita pauses for half an hour from harvesting crops to speak to the two outsiders – one British woman and one Indian woman from the city – about her life. The reason we’ve come to talk to her is that Kavita is one of the 15% of people in this area who screened positive for depression in a recent survey. Screening positive means reporting symptoms such as lack of energy, sleeplessness, feeling hopeless, and loss of appetite. Many also report bodily aches and pains.
Like most of her peers, Kavita has no pension, so to feed and maintain the family she continues to work, despite her age. She explains that these symptoms arise from her work:
“It is like, when a person works day and night at home as well as at the workplace, they may get weakness and due to that weakness, one gets tired… I get anxiety due to over working and over burden.”
Here’s a statistic that will sound pretty familiar to anyone who’s been involved in global mental health over the past few years - in India, only around 1 out of 10 people who screens positive for depression seeks treatment. This mirrors the situation around the world, where only a small fraction of people who meet criteria for a mental illness seek formal help (the “treatment gap”).
The big question I wanted to answer in my research was why this is. What accounts for the huge gap between the number of people supposedly affected by common mental illness, according to population surveys, and the number who seek and receive formal help? Usually it’s assumed that the answer is lack of services (i.e. a supply problem). There aren’t many qualified mental health workers to go around, and it’s rare for psychiatric care to be available locally and affordable, particularly for people living in rural areas. However, this explanation doesn’t quite make sense in Kavita’s area, where a programme called PRIME has trained health workers in the local community health centres to provide depression treatment. Evidence-based services are now available, free of charge, in a nearby town, but still most people who these are intended to help don’t use them.
I was also surprised to discover, through this research, that that people who live within walking distance of one of these community health centres were also just as unlikely to have sought help for their depression symptoms as those who face a long journey to get to these services (see article). When people were surveyed as part of the PRIME evaluation, nearly 90% of people who screened positive for depression said that they had not sought help, regardless of where they lived. Reducing travel distance to services made no difference to the treatment gap.
If supply issues don’t explain the low rates of treatment, then perhaps we need to better understand the reasons for low demand. Why don’t people like Kavita seek treatment for depression symptoms even when it’s available and accessible?
Raj*, an outspoken man in a traditional lungi who we spoke to in the yard of his house, gave us a direct answer:
“No doctor can’t provide bread to your home. When your hunger is ended then your mind will become fine.”
A similar story emerged when we spoke to others, who talked of their feelings in terms of “tension” or stress. Sheetal*, a woman in her thirties with young children, told us: “The most important and huge tension for me is debt… If it [debt] will get solved then my tension will get ended.”
Like Kavita, these people attributed their suffering to their situation. They simply didn’t believe that health workers could help them to feel better without addressing the ongoing causes of their distress. Discussion of demand-side barriers to treatment in global mental health are often reduced to the notion of “stigma”, but this misses a simpler insight: The services being offered didn’t address what people saw as their core needs. People don’t want medical solutions to social problems (see article).
The backdrop to the lives of all those we interviewed were poverty and insecurity. Their problems went beyond poverty, but were all exacerbated by lack of resources. Women often described their problem as alcoholic, abusive, or economically inactive husbands. Men and women both described the stress of trying to make ends meet and provide education and marriage opportunities for their children. Many people talked of losing loved ones to preventable causes, due to illness, accidents or poor living conditions, often without access to quality health care. So when we asked what kind of help they needed to reduce their suffering and distress, they often spoke not of mental health services but of the need for financial support, change in their social situation, and routes out of poverty for their families. They didn’t want help to feel better about their circumstances, through medication or talking therapy; they wanted help to actually change their situation.
As Raj explained:
“There is no treatment for sadness, dissatisfaction and tension… If there is no production of wheat in my farm and I am in tension due to no production of wheat, can the government give me wheat and take away my tension?”
Reframing our perspective
So what does this mean for the global mental health community? I think we need a paradigm shift in how we think about people’s needs. This involves, first, acknowledging the “credibility gap” between how most people think of their wellbeing – as intrinsically linked with the wider context of their lives – and the context-free approach that we apply when we just ask people about their symptoms. Just because someone screens positive on a depression questionnaire doesn’t necessarily mean that their primary need is for depression treatment, without better understanding the context of their life.
Second, we need to start taking social determinants and eco-social models of health seriously, and understand that mental health doesn’t exist in a vacuum. People experiencing mental distress have many other needs that will make it hard for them to benefit from treatment if these are not met, so helping them may well require working outside the health system. Achieving better working conditions, accessing financial protections, or improving family relationships, may all be potentially effective antidepressants, and initiatives to promote these may make more sense to the people we’re trying to help since they address the sources of people’s despair.
Finally, we need the humility to recognise that scaling up mental health treatment is not a solution to all suffering. There is a human rights case for making services available to those who want them, but this is unlikely to be what transforms mental health at the population level; only addressing the causes of mental ill health can do that. For many people who meet criteria for common mental disorders, prevention is better than cure.