Depression in Southern Africa: Lessons from Zimbabwe

1
Depression in Southern AfricaLessons from
Zimbabwe

• Vikram Patel
• Senior Lecturer, London School of Hygiene
  Tropical Medicine
• Sangath Society,Goa, India

2
The focus

• Depression the commonest mental disorder
• Term used synonymous to Common Mental Disorders,
  i.e. Includes the broad spectrum of depressive
  and anxiety disorders
• Single most important cause of disability amongst
  mental disorders
• (Global Burden of Disease Report 1996)

3
The nature of the evidence

• Series of research studies conducted since the
  1980s with the shared features
• multidisciplinary
• intersectoral (academic, health services, NGOs)
• locally evolved agenda of priorities
• most studies based in Harare city

4
The authors of the evidence

• Melanie Abas, Jeremy Broadhead colleagues
• Tony Reeler colleagues
• Vikram Patel, Charles Todd colleagues
• Sekai Nhiwatiwa

5
The type of evidence

• Ethnographic Studies
• explanatory models of primary and traditional
  care attenders
• explanatory models of nurses and traditional
  healers
• Shona models of depression

6
The type of evidence (2)

• Pathways to Care
• Pathways to primary care
• Pathways to traditional healers
• Pathways to tertiary care

7
The type of evidence (3)

• Clinical Diagnostic Studies
• Phenomenology of depression
• Development of Shona measures of depression
• Comparison of emic and etic models of depression

8
The type of evidence (4)

• Epidemiological Studies
• Prevalence and risk factors in community, primary
  care and traditional healer populations
• Incidence and outcome in primary care,
  traditional healer and GP attenders
• Life events and depression in women

9
The type of evidence (5)

• Special Populations
• Motherhood and Post-natal depression
• Refugees from Mozambique survivors of torture

10
The type of evidence (6)

• Interventions
• Training Program for City of Harare Health
  Department Nurses
• Psychotherapy for survivors of torture

11
The Lessons Learned

• The symptoms of depression are largely universal,
  but the construct is not
• Depression is commonest amongst marginalized
  populations
• Depression has a profound adverse impact on the
  lives of the sufferers

12
Lesson1Many symptoms are Universal...

• Somatic presentations typical, e.g. Tiredness,
  heart-ache and sleep problems
• On inquiry, emotional and cognitive symptoms can
  be elicited
• Local idioms common, e.g. Kufungisisa
• Some typical symptoms e.g. Loss of appetite not
  specific due to physical causes
• Some symptoms culturally explained, e.g. Visual
  hallucinations at night

13
..but the construct is not

• No Shona term conceptually equivalent for
  depression
• Local models, esp. Kufungisisa, show high
  concordance with depression
• Causal attributions include relationship problems
  and supernatural causes not a mental disorder

14
So What?

• Case finding measures developed in Western
  cultures can be used with emphasis on conceptual
  translation
• Include local idioms in research and training
  programs
• The clinical and cultural validity of categorical
  and psychiatric models of depression and
  anxiety not sustained

15
Lesson2The marginalized are vulnerable

• Women
• Refugees and torture survivors
• The poor

16
Women

• Risk in primary care populations twice that for
  men
• _at_16 of mothers and women living in the community
  suffer from depression
• Severe life events, e.g. Marital crises,
  violence, bereavement, infertility and unwanted
  pregnancy common
• Support from close family member protective

17
Survivors of Torture Trauma

• Experience of violence common both as a result of
  war, civil conflict and crime
• Rates of depression high amongst those who had
  been victims as well as witnesses

18
The poor

• Hunger (due to lack of money) and low income risk
  factors for depression
• Incidence in those who had experienced hunger due
  to lack of money 30 vs 12
• Persistence in those whose economic problems had
  resolved compared to those who had new problems
  31 vs 56

19
So What?

• Active efforts to remove the myths that
  depression are a luxury for the marginalized
• Integrate mental health into existing health and
  development activities targeted to the
  marginalized
• Potential strategies for prevention in high-risk
  groups e.g. the bereaved, women with infertility,
  for poor (micro-credit)

20
Lesson3The profound impact

• Under-recognition inappropriate treatment
• Chronicity Disability
• Costs of Illness

21
Recognition and Treatment

• More than 75 of morbidity not diagnosed by
  health providers, but often recognized
• Symptomatic treatments predominate (e.g. Vitamins
  for tiredness hypnotics for sleep)
• Minimal efforts to link symptoms with
  psychosocial stressors
• Recognition linked to improved outcome in
  traditional and biomedical health attenders

22
Chronicity Disability

• In primary and traditional healer attenders, 40
  show morbidity at 12 months
• In community populations, 30 remain ill at 12
  months
• Twice the number of days spent out of work or in
  bed both in cross-sectional and longitudinal
  studies

23
Costs of Illness

• Multiple consultations with range of health care
  providers
• Traditional healers and private GPs expensive
• Disability impairs economic productivity A cycle
  of poverty, disability and depression

24
A Vicious cycle of poverty and mental illness
Economic Deprivation Malnutrition, Low
Education, Domestic Violence, Indebtedness etc
Ill-Health e.g. Depression Anxiety, physical
ill-health, Alcohol abuse
Economic Impact Reduced productivity
Disability Increased health costs
25
So What?

• Aggressive program to raise diagnostic and
  management skills in health providers
• Greater availability of antidepressants and
  non-medical counselors in health facilities
• Consolidate collaborative linkages between
  different health sectors (e.g. NGOs, traditional
  healers, GPs)

26
Secondary Prevention Educating Health Social
Welfare Professionals

• Depression is a health priority because it is
  common, chronic, costly and disabling
• Patients are already flooding health services
  providing care will not increase workload
• There are effective treatments for Depression
• Depression is a general health problem, not a
  psychiatric (or specialist) illness

27
Key Message to health workers

• Just as we treat other diseases associated with
  poverty, so too we must treat mental disorders
  for they are not the natural outcome of
  impoverishment
• most poor people are mentally healthy

28
Implications for Policy

• To realize agenda of integrating mental health in
  primary health, there is limited scope for stand
  alone or add-on programs
• Linkages must be built with other health and
  social sectors, e.g. Womens health, Violence
  prevention, Child Education
• Policies aimed at increasing gender equality and
  poverty alleviation will have a profound effect
  in improving mental health

29
Implications for Research

• Priorities must be intervention research and
  linkage research (to date, no trials for
  depression in primary care from Africa)
• Regional research priorities with participatory
  evolution of agendas
• Collaborations with other developing countries
  which share similar health systems to avoid
  reinventing the wheel

30
Shared Health System Characteristics of DCs

• History of Psychiatry
• Concepts of Mental Illness
• Communicable diseases burden
• Income and gender inequality
• Globalization and economic reform
• Medical Pluralism and few specialists
• Violence and Political Instability

31
Outstanding Research Questions

• What are the protective factors in those who
  remain in good mental health, despite stressful
  circumstances?
• What interventions speed recovery from
  depression?

32

• Full reference list can be obtained from the
  paper based on this lecture
• Patel, V et al (2001) Depression in Developing
  Countries Lessons from Zimbabwe. British Medical
  Journal
• or from the author on vikpat_at_goatelecom.com