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Depression in Southern Africa: Lessons from Zimbabwe

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Title: 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
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