Neurological, Psychiatric, and Developmental Disorders Meeting the Challenge in the Developing World (2001) / Chapter Skim
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9 Depression
9 Depression
Pages 283-338
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From page 283... ...
More often depression presents as an overlapping syndrome of depression, anxiety, and somatization forms such as bodily aches and pain, persistent backache, or genitourinary complaints. The diagnosis of a depressive illness is based on symptomatology, the severity and duration of the symptoms, and their impact on social functioning.
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From page 284... ...
their criteria are often of limited applicability in non-psychia~ic settings, especially by primary care physicians, who often see patients with significant physical comorbidity. The accurate and timely diagnosis of depression is also complicated by the reluctance of patients to seek help because of the stigma associated with mental illness and by the nature of the complaints, which may often be thought to have a physical origin.~9]
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From page 285... ...
Although symptoms of depression are found everywhere, the Western biomedical definition of depressive illness does not fit local concepts of illness in many developing communities.~10,11] Diagnoses of some mental disorders, including depression, have no conceptual equivalent in many languages.
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From page 286... ...
Prevalence rates for depression vary among and between countries, but age of onset, social and environmental risk factors, and the preponderance of depressive disorders within families are similar across many cultures. Once recognized, depression can often be treated effectively.
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From page 287... ...
998) found that people with affective disorders combined (major depression, bipolar disorder, and affective disorder not otherwise specified)
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From page 288... ...
In a 40-year study, Ford and colleagues (1998) found that increased risk of coronary heart disease among people with major depression persisted for years after their first depressive episode.
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From page 289... ...
Previous public health assessments, derived only from mortality data, did not rank mental disorders among the most burdensome diseases. Once disability was entered into the equation, mental disorders joined the ranks of cardiovascular and respiratory diseases, revealing a burden that surpassed both AIDS and all combined malignancies.~31]
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From page 290... ...
As described in Chapter 2, the stigma associated win mental illness is open great in bow developed and developing counties. The burden of stigma is exper~enced not only by Dose who super Dom Be illness, but also by their family members.
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From page 291... ...
indeed, many mental health professionals now support the grouping of depression, anxiety, and other conditions often found to coexist in a single category referred to as common mental disorders (CMD)
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From page 292... ...
The latter may either serve as a risk factor for mental illness or result from somatization of psychological symptoms. As a result, CMD contributes significantly to the workload in both primary health care clinics and specialty medical clinics (Table 9-5~.~94,97,98]
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From page 293... ...
; age 1~54 Sample of total pop ulation excluding Northern Ireland and the highlands and islands of Scotland (n = 10,1108) ; age 18-64 Household survey Household survey CIS-R and SCAN 88.5 180 143 males 226 females 6 11 8 8 23 430 10 Neurotic depression, 0.37 affective psychosis, 13 neurasthenia 13-67 across different localities 137 26 male 67 female 48 total 48 male 90 female 70 total 55 46 42 male 71 female 56 total 52 male lIOfemale 83 total 77 male 129 female annual prevalence 18 male 27 female one week prevalence
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From page 294... ...
TABLE 9-4 Prevalence of Common Mental Disorders in Community Studies Country Population Method Prevalence Ethiopia []
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Beck has described a cognitive triad that may contribute to the onset or reocurrence of depressive episodes by increasing the risk for exposure to stressful life events: (1) negative self-view, (2)
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From page 296... ...
Genetic Understanding of the biological basis for depression has been one of the more recent and important findings regarding the etiology and risk factors for this disorder. Family, twin, and adoption studies leave provided evidence of the genetic contribution to the etiology of depressive disorders and clearly shown the transmission of increased risk through heredity.~3,155-158]
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From page 297... ...
Additionally, because mental illness in women may engender a greater amount of shame and dishonor and have a greater impact on family life because of the woman's role in running the household, the condition is often hidden and treatment not pursued (see also Chapter 2~.~9,170,171] Initial scientific evidence has suggested that hormonal changes in and imbalances of such hormones as oxytocin, estrogen, and vasopressin may contribute to the onset of depressive disorders.~172,173]
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From page 298... ...
Comorbidity Comorbidity (the coexistence of two or more current disorders) has been found to be common among patients suffering from depression, and typically to involve a combination of physical and mental disorders.~36,59,63,89]
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From page 299... ...
is often chronic and continues into adulthood with higher rates of overall impairment and significant rates of attempted suicide.~74,210,211 ~ On the basis of data from 11,242 outpatients in New Zealand, Wells and colleagues concluded that depressive symptoms produce impairment comparable to that associated with chronic medical conditions such as diabetes, lung disease, hypertension, and heart disease.~202] Approximately 40 percent of patients with major depression remained functionally impaired 2 years after treatment, while 54 percent of those previously treated for dysthymia had a major depressive episode during this period.
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From page 300... ...
Prevention Evidence on the effectiveness of depression prevention strategies remains inconclusive, and it is likely that no single strategy could ameliorate the occurrence of the disorder, but only serve to reduce its cumulative effects. The multiple issues to be considered In preventing depression include precipitating life events, efforts to enhance the use of coping strategies, the provision of social and community support, and the need for general educational support for mental health.
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One such program instituted in Pakistan is described in Box 9-3. An important role for primary health care personnel is to recognize and address mental disorders in children, as well as to provide support for schoo]
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Intersectoral funding should be provided for population-based strategies aimed at preventing depression and their evaluation. This support should be directed at interventions as the following: · School mental health programs; · Public education programs designed to reduce the stigma associated with mental disorders; .
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From page 306... ...
and psychosocial treatments.~251] Though no treatment interventions have proven entirely curative for all forms of depression, a large number of efficacious and low-cost treatments are available.~250-253]
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Many low-income countries have insufficient psychotropic medicines available in secondary care, and hardly any such medicines in primary care. It is possible, using basic epidemiological data, to calculate the requirements for essential medicines provided by a primary health care unit (e.g., for a population of 10,000~.
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Psychosocial interventions Four main factors support the psychosocial treatment of depression: recognition that the effects of pharmacological treatments can be enhanced when administered with adjunctive psychotherapy; evidence of the effectiveness of psychosocial treatments; increased understanding of the psychosocial causes of depression (e.g., life events and lack of social support) ; and the increasing role of nonmedical professionals (e.g., psychologists and social workers)
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From page 309... ...
Results of an open trial of cognitive belabor therapy with 25 depressed patients from Bangalore indicate the feasibility and effectiveness of the treatment.~302] Similarly, a recent randomized controlled trial of cognitive behavior therapy for medically unexplained symptoms in patients attending general medical clinics in Sri Lanka revealed significant improvements in psychiatric morbidity and number of medical consultations.~303]
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From page 310... ...
In developing countries, consultation of traditional healers is common even among the well educated, and a high proportion of people consult both traditional and modern systems.~305-307] Traditional and religious healers frequently play a major role in treating mental disorders.~304,308-3]
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From page 311... ...
CAPACITY Because depression is common throughout populations, the existing capacity and location of psychiatric specialists in both developed and developing countries cannot meet the needs of those suffering from mental disorders.tl9,34,37] As a result, the integration of mental health with primary care services has become a significant policy objective in both wealthy and lowincome areas of the world (see Chapter 3~.~340-345]
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In Asia, there have been evaluative studies of methods of training multipurpose health care workers in the delivery of basic mental health care.~351] In Zanzibar, education coordinators organize and deliver continuing education for primary health care staff.
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Recognizing and addressing similar limitations in developing country primary care settings will be important for both treatment and Paining models. Maintaining standards is crucial to providing cost-effective primary health care.
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From page 314... ...
disorders. For example, committee members have noted that the primary care diagnostic fond in use in several East African counties includes 34 categories for separate physical illnesses, but only a single category for"mental disorder." Diagnostic recording forms that are appropriately modified to identify separately each of the main mental disorders, including depression, would greatly improve local capacity to determine and evaluate mental health needs.
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From page 315... ...
; · Evaluation of programs for chronic disease management (including depression) in primary care; · Evaluation of programs for continuing education for primary health care personnel; .
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From page 316... ...
Fernandes. Is labeling of common mental disorders as psychiatric illness useful in primary care?
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From page 317... ...
Psychiatric morbidity in primary health care in Santiago, Chile. Preliminary findings.
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From page 318... ...
Mental disorders and comorbidity in suicide. American Journal of Psychiatry 150:935-940, 1993.
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From page 319... ...
Increased intraabdominal fat deposition in patients with major depressive illness as measured by computed tomography. Biology and Psychiatry June I ;4 1 ~ 11 )
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From page 320... ...
Extent and determinants of burden among families of patients with affective disorders. Acta Psychiatrica Scandinavica Sep;86~3~:247-252, 1992.
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From page 321... ...
OIdeninkel. Common mental disorders and disability across cultures.
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Prevalence of mental disorders among adults in Finland: Basic results from Mini-Finland Health Survey. Acta Psychiatrica Scandinavica May 81~5~:418~25, 1990.
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Socioeconomic status, employment, migration and common mental disorders in Olinda, NE Brazil.
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LadrgoIgnacio, et al. Mental disorders in primary health care: A study of their frequency and diagnosis in four developing countries.
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Todd. Women, Poverty and Common Mental Disorders in four restructuring societies.
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Maternity blues in Brazilian women. Acta Psychiatrica Scandinavica Mar;95~3~:231-235, 1997.
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Alcoholism and depression in a Swedish female population: Co-morbidity and risk factors. Acta Psychiatrica Scandinavica Ju1;102(1 )
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Deliberate Self-Harm in Sri Lanka: An overlooked tragedy in the developing world. British Medical Journal 137:133-135, 1998.
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Mental health delivery in rural primary health care Development and evaluation of a pilot training programme. Indian Journal of Psychiatry 24:131-132, 1982.
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From page 330... ...
School mental health program in Pakistan. In: Preventing Mental Illness Mental Health Promotion in Primary Care.
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The ability of general practitioners to detect mental disorders in primary health care. Acta Psychiatrica Scandinavica 9 ]
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From page 332... ...
Electroconvulsive therapy of depressive disorders. Therapeutische Umschau Feb;57~2~:9~94, 2000.
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From page 333... ...
Witch doctors and mental illness in mainland China: A preliminary study. American Journal of Psychiatry Feb.
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Prevalence and treatment of mental disorders and epilepsy in Zanzibar. Acta Psychiatrica Scandinavica Apr;81~4~:327331, 1990.
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From page 335... ...
The treatment of common mental disorders by a community team based in primary care: A costeffectiveness study. Psychological Medicine May;26~3~:487-492, 1996.
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Knowledge and attitude concerning mental health of primary health care workers in Nigeria. International Journal of Social Psychiatry 37~2~:1 13-120, Summer 1991.
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