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Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

9

Depression

DEFINITION

The term “depression” can apply to a transient mood, a sustained change in mood, a symptom, or a disorder. In this chapter, the term is used to refer to unipolar/major depression that is characterized by persistent low mood or sadness and accompanied by both physical and psychological symptoms of at least 2 weeks duration and with associated impact on social functioning. Both genetic and environmental factors are implicated in the etiology of depression.[1,2 and 3]

Depression can present as acute episodes with depressive psychosis that are severely disabling yet often treatable, and when recurrent are controllable with maintenance pharmacotherapy. 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. Cases may be identified by means of self-rating on a questionnaire or observer assessment. In the latter case, the patient is interviewed by a health professional with training in assessment and diagnosis (the level of training being consistent with the local resources available for mental health services). The use of operational criteria strengthens the reliability of a conventional clinical interview. Operational diagnosis of psychiatric disorders, which seeks to identify patterns of symptoms that characterize a given illness most reliably, has been one of the major advances in psychiatry within the last 40 years. This diagnostic method allows clinicians to classify illnesses even when etiology is unknown, and hence to communicate about and conduct research on patients with similar characteristics.[4,5 and 6]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

While criteria for diagnosis have been standardized by the American Psychiatric Association [7] and the International Classification of Disease, 10th revision,[8] their criteria are often of limited applicability in non-psychiatric 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]

There have been continuing studies on the reliability and validity of various methods of assessing depression, and in parallel there has been continuing work on evolving the classification systems and criteria used for these disorders. Current standardized classification systems used for depression appear in Table 9-1 and Table 9-2.

TABLE 9-1 DSM-IV Criteria for Major Depressive Episode

  1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

    1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others;

    2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day;

    3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day;

    4. Insomnia or hypersomnia nearly every day;

    5. Psychomotor agitation or retardation nearly every day;

    6. Fatigue or loss of energy nearly every day;

    7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day;

    8. Diminished ability to think or concentrate, or indecisiveness, nearly every day;

    9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

  2. The symptoms do not meet criteria for a Mixed Episode (see Table F).

  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  4. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

  5. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Source: [7]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

TABLE 9-2 ICD–10 Criteria for depressive episode

General

Episode must have lasted at least two weeks with symptoms nearly every day

Change from normal functioning

Key symptoms (n = 3)

Depressed mood

Anhedonia

Fatigue/loss of energy

Ancillary symptoms

Weight and appetite change

Sleep disturbance

Subjective or objective agitation/retardation

Low self esteem/confidence

Self reproach/guilt

Impaired thinking/concentration

Suicidal thoughts

Criteria

Mild episode: 2 key, 4 symptoms in total

Moderate episode: 2 key, 6 symptoms in total

Severe episode: 3 key, 8 symptoms in total

Exclusions

No history ever of manic symptoms

Not substance related

Not organic

Source: [8]

The vast majority of research on the clinical features of depression has been conducted in the United States and Europe. Although far fewer in number, comparable studies from the developing world deserve careful attention, for they reveal significant differences in the presentation of depression among cultures, as well as core features common to all societies. Where possible in this chapter, we examine and compare findings from research in both developed and developing countries. For the purposes of comprehensive reporting, developed-country data are noted and used alone when findings from developing countries are not available.

Although symptoms of depression are found everywhere, the Western bio-medical 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. In non-European cultures, for example, use of the term “depression” often leads to the mistaken belief that sadness is an essential presenting feature of the disorder. While the experience of dysphoric mood may be universal, the concept of depressive disorder that focuses on mood must be recognized as having evolved within Western cultures, and therefore may not be universally applicable.[12]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Several authors also imply that Cartesian mind–body dichotomies are absent from certain cultural worldviews. Nichter (1982), for example, noted that South Havik Brahmin women express distressed emotions and other social problems in terms of dietary preference for certain foods, religious metaphors, or humoral imbalance in the body.[13] Chinese popular explanations of mental illness ascribe problems to an imbalance in the psychosocial, physiological, or supernatural environment.[14,15] In African societies, health is viewed as more social than biological, and a unitary concept of psychosomatic interrelationship exists, with an apparent reciprocity between mind and matter.[16] Because these conceptualizations strongly influence how people express the experience of psychological distress and dysphoric mood, standardized instruments may not be applied accurately without regard to cultural differences among populations. Nevertheless, studies show that depression is found in countries around the world with significantly different cultural traditions and levels of economic development.[17,18 and 19]

The majority of people with depression eventually consult primary care doctors or nurses. While the overall symptoms of depression are ubiquitous in population surveys, research has shown somatic symptoms to be the most common presenting features of depression in developed as well as developing societies.[20,21 and 22] Most commonly, patients present with physical symptoms such as lack of energy or vitality, fatigue, and aches and pains.[20,23,24 and 25] Several studies in developing countries indicate that when people with depression present with somatic symptoms, they will upon questioning also report that they have experienced classic psychological symptoms of depression.[20,26,27]

SCOPE OF THE PROBLEM

Depressive disorders are common around the world and are associated with significant disability.[18,28,29,30 and 31] Depression is a long-term illness that produces significant psychological, physical, and functional disability.[28,32,33 and 34]. In a study conducted in Malaysia, over half the patients with chronic depression had dysfunctional behavior and experienced significant disabilities.[35] Indeed, depression is estimated to be the leading cause of disability worldwide, accounting for more than 1 in 10 years of life lived with disability. Those suffering from depressive disorders also have high premature mortality, both from suicide and from physical illness.[ 17,18,35,36] 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. Though treatments are often not entirely curative, they offer significant relief from many of the debilitating symptoms of depression and can significantly improve the level of social functioning. Yet depressive disorders still remain largely underdiag-

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

nosed and untreated around the world. Even in developed nations, depressed patients consistently receive either no medication or dosages that are ineffective in treating their symptoms.[19,37,38]

Mortality
Suicide

Suicide is estimated to be the 10th leading cause of death worldwide.[31] These estimates are based on nationally collected official data on suicide, which are thought to be significantly underestimated because of the stigma often associated with suicide. Reported rates of suicide vary widely throughout the world, with some of the highest rates being found in developing countries. For example, Sri Lanka [39] has the highest suicide rate in the world, followed closely by China.[40] Factors affecting the suicide rate among a given population include the rate of depression; the prevalence of alcohol abuse; the presence of high-risk occupational and demographic groups, including people with severe mental illness; the availability of easy means of suicide; the degree of social integration; and cultural attitudes toward suicide.

Psychological autopsy studies (which gather detailed information about the deceased from multiple key informants) indicate that more than 90 percent of people who commit suicide suffer from depression, substance abuse, psychosis, or some other form of mental illness.[ 41,42 and 43] In a major review of all studies of suicide reported in the English literature, Harris and Barraclough (1998) found that people with affective disorders combined (major depression, bipolar disorder, and affective disorder not otherwise specified) were 20 times more likely to kill themselves than the general population.[44] In non-Western countries, however, completed suicides may be less likely to have received a psychiatric diagnosis because of the paucity of mental health services.

Suicides often appear to be precipitated by a “last-straw phenomenon”: a recent social stress or life event in the context of multiple preexisting social stresses and an underlying mental illness. Official statistics tend to highlight the existence of social stresses rather than any underlying depression or other mental disorder. In settings where police officers, coroners, or physicians without mental health training are recording data about the principal causes of suicide, they are likely to focus on social and situational problems, rather than on preexisting depression. However, community surveys reveal that social problems are correlated with high rates of depression and anxiety.[45,46 and 47]

Individuals with limited or dysfunctional social networks have been shown to be predisposed to depression, suicidal thoughts, and suicide.[ 48] Similarly, at the broader societal level, social disruption in contemporary industrialized society is believed to contribute to anomie, depression, and suicide.[49] The suicide rate in Sri Lanka rose from 6.5 per 100,000 in 1950 to 47 per 100,000 in 1991 following

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

a period of profound social upheaval and violence.[39] War and social disruption have been associated with dramatically different suicide rates in various settings.

Access to means of suicide has a major influence on the suicide rate.[ 50] Where rapid and effective means of self-destruction are readily available, people making impulsive gestures may commit suicide inadvertently. This may explain at least in part the extremely high rates of self-poisoning with insecticides among young women in China, Sri Lanka, and Western Samoa.[39,40,51,52] Medicines that can be obtained without prescription and are lethal in overdose may also be used for self-poisoning. Barbiturates are frequently used in this way in Nigeria, as are chloroquine in East Africa [53] and paracetamol in Europe.[54] In addition, potentially lethal features of urban or rural landscapes appeal to those at risk by virtue of their symbolic association as an effective means of suicide. For example, tall buildings in Singapore and Hong Kong are popular sites for suicidal jumpers.[55]

Physical Illness

A growing body of evidence links untreated depression to severe and life-threatening physical illness.[56] Depression is associated with high premature mortality from physical causes, irrespective of premature mortality from suicide and trauma.[ 57,58 and 59]

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. The increased risk was present even for myocardial infarctions occurring 10 years after the first depressive episode.[59] Examining data from the Baltimore, Maryland, site of the Epidemiological Catchment Area Study, Pratt and co-workers (1996) found a fivefold increase in the risk of myocardial infarction following major depression and a twofold increase in those who suffered from less severe (subsyndromal) depression. The increased risk of cardiovascular disease with depression appears to apply equally to men and women.[60,61 and 62]

Conversely, high rates of depression have been found in older patients suffering from cerebrovascular disease.[63,64] The significant disability often associated with recovering stroke patients may account for episodes of depression.[63,65] A recent study has suggested that cerebrovascular disease may have an etiopathological role in late-life depression. The increased damage to frontal and subcortical brain circuitry following stroke, transient ischemia, and hypertension may explain the high prevalence of depression in older individuals with vascular risk factors.[66]

Hormonal changes may go a long way toward explaining how depression results in physiological harm. For example, major depression leads to increased activation of the hypothalamic-pituitary-adrenal axis, which has in turn been associated with decreases in bone mineral density and increases in intra-

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

abdominal fat, a known risk factor for coronary artery disease.[ 67,68 and 69] Researchers have examined the link between depression and osteoporosis.[ 70,71] One such study reported that depression-associated loss of bone density could be expected to increase hip fractures by more than 40 percent in 10 years.[68]

Social and Economic Costs

The most comprehensive analysis to date of the worldwide impact of depression was performed in 1990 as part of the Global Burden of Disease (GBD) study. A major finding of this study, released in 1996, was that conditions such as mental disorders that disable, may cause less mortality than a number of physical conditions, but exact a high cost in disability throughout the world. 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]

The disability-adjusted life years (DALYs) methodology employed in the GBD (see Appendix B) provides a way of linking information on disease occurrence to information on short- and long-term outcomes, including disabilities and restrictions on participation in usual life situations. The disability component is weighted according to the severity of the disability. For example, in the original GBD study, disability caused by major depression was weighted as being equivalent to blindness or paraplegia. Thus calculated, the GBD study ranked depressive disorders (considered as a single diagnostic category) as the leading cause of disability worldwide.

The GBD study also resulted in the prediction that in 2020, as the result of a combination of several demographic and epidemiological trends, unipolar major depression will rank second only to ischemic heart disease as the leading cause of disease and injury worldwide. These trends include the breakdown of extended family networks; increasing urbanization, migration, and mobility; and alcohol and drug abuse. In addition, the expected growth of the world's population, overall increases in life expectancy, and relative decreases in other communicable disorders are likely to result in depressive disorders becoming the leading cause of disability and overall disease burden worldwide.

Continuing debate and further scientific studies will be required to confirm and refine the findings of the GBD study. However, it is important to note several limitations of the study:

  • The figures used to calculate the burden due to depressive disorders are very low compared with the recent findings from large-scale epidemiological studies, such as the (U.S.) National Comorbidity Survey [72] and the British national psychiatric morbidity survey.[73]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×
  • The GBD study considered unipolar depression to be an episodic illness, while current concepts of the disorder describe it as a chronic relapsing medical illness.

  • Likewise, the study considered depression only as an adult disease, yet overwhelming evidence suggests that depression also occurs with considerable frequency in childhood and adolescence.[74]

  • Only two disability weights were used to calculate the global burden of depressive disorders—one for treated cases, the other for untreated cases.[31]

  • The impact of comorbidity of depression with other mental and substance abuse disorders was not addressed.[75]

  • The burden on families, which is particularly significant for depression, was also not addressed.

Given all of the above limitations, it is clear that the GBD estimates of the global burden of disability caused by depression are conservative at best, and more likely significantly underreport the worldwide burden exacted by depressive illness. Thus there is a pressing need for more precise information on the prevalence of and disability associated with these disorders in low-income countries.

As noted above, the burden on family members of patients was not included in the GBD. However, the findings of several studies in both developed and developing countries reveal the significant toll exacted by depressive illness on family members and family stability.[ 76,77 and 78] Family members of depressed individuals may have increased rates of physical illness and frequent symptoms of fatigue.[79,80].

As described in Chapter 2, the stigma associated with mental illness is often great in both developed and developing countries. The burden of stigma is experienced not only by those who suffer from the illness, but also by their family members. This burden can lead to lost social and employment opportunities, social isolation, and unwillingness to assist the ill family member in seeking treatment.[81]

A few studies in developed countries have begun to examine the cost to the workforce caused by depression. Findings indicate that depressive illness has resulted in more days of disability and lost work time than chronic physical conditions such as heart disease, hypertension, and lower back pain.[82,83] The governments and employers of developing countries would be likely to see similar results. Studies to determine this economic burden may reinforce the argument for robust, proactive efforts on the part of governments and communities to prevent and treat depression.

Recommendation 9-1. Depressive disorders exhibit high incidence and prevalence in the developing world, lead to disability and mortality, and exact high social costs. Therefore, they should be given high national priority as a public health problem of relevance to all government ministries, and be accorded high local priority by district planning committees.

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

PREVALENCE AND INCIDENCE

Over the last four decades, community surveys of mental disorders have provided diagnostic information, based on standardized methods of assessment, that permits comparison of research from different locations. Here we summarize selected epidemiological studies on depression conducted at the community level (Table 9-3) and on common mental disorders (which include depression) conducted at both the community (Table 9-4) and primary care (Table 9-5) levels.

The accumulated evidence from these studies reveals the widespread prevalence of depression within both the developing and developed worlds, ranging from 8–43 percent. The variation in rates reported by these studies also appears to be due in part to cultural and environmental differences among the populations studied. Overall rates are higher in surveys of primary care attenders than in surveys of community populations. Precise case rates vary among locations and populations, and depend partly on the methodology used.[17,83] Differing rates of depression among population groups are discussed in greater detail in the subsequent discussion of risk factors.

The most common psychiatric syndrome seen in community studies is a combination of depression and anxiety. For example, about one-half of those with a primary diagnosis of DSM-IV major depression also have an anxiety disorder.[84,85] This condition is sometimes referred to as comorbidity, but such a definition appears to be an artifact of classification systems designed primarily for hospital patients, rather than for the general population. When examined at the more universal level of primary care, anxiety and depression appear to coexist in the majority of depressed patients in both developing and developed countries.[86,87,88 and 89] 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).[ 90,91,92 and 93] This chapter at times includes research that has examined CMD because it not only provides data that would eitherwise be absent, but also offers an accurate reflection of the high frequency with which these coexisting mental disorders occur.

In addition to anxiety, several other conditions frequently coexist with depression; these include panic and dissociative disorders, neurasthenia, and sleep problems.[94] Recent studies rank CMD among the most important causes of morbidity in primary care settings.[95] For example, a review of the recent literature on CMD from South Asia [11] indicated that these disorders can be detected in more than a third of people who seek primary health care.

A World Health Organization (WHO) collaborative study provided important information on the form, frequency, and outcome of psychological disorders seen in general health care settings. This study was carried out in 14 countries in different parts of the world: Brazil, Chile, the Federal Republic of Germany, France, Greece, India, Italy, Japan, the Netherlands, Nigeria, the People's Republic of China, Turkey, the United Kingdom, and the United States.[96] In the

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

study, 25,916 people aged 18 to 65 who consulted health care services were screened. Well-defined psychological problems were found in 24 percent of these subjects; most common were depressive disorders, anxiety disorders, alcohol use disorders, somatoform disorders, and neurasthenia.

The results of the WHO study indicate a strong association between CMD and disability, defined as impairment of physical and social functioning. Disability levels were found to be greater on average among primary care patients with a psychological disorder than among those with common chronic diseases such as hypertension, diabetes, arthritis, and back pain. This finding of enhanced disability for psychological disorders was consistent across centers, across time, and across individual diagnoses.[33,34,97,98] The conditions categorized as CMD were also found frequently to be chronic. Approximately half of those with CMD when they first sought primary care continued to be afflicted a year later.[19]

People with CMD frequently seek primary care for physical symptoms. 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]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

TABLE 9-3 Selected Prevalence Studies of Depression

Country

Population

Method

Prevalence per 1,000

Population at Risk

Lesotho [99]

Rural village (n = 356); age 19–93

Sample survey Modules of DIS

88.5

South Africa [100]

Rural village (n = 481); age > 18

Two-stage sample survey SRQ and PSE

180

Uganda [101]

Two rural villages (n = 206); age > 18

Homestead survey PSE/SPI

143 males

226 females

Taiwan [102]

Rural

 

6

Taiwan [102]

Urban, small town

 

11

Taiwan [102]

Taipei (urban)

 

8

Taiwan [18]

Urban and rural (n = 11,004); age 18–65

DIS

8

South Korea [18]

National sample (n = 5,100); adults 18–65

DIS

23

India [103]

Rural (n = 4,481)

Interviews by trained field worker

430

India [104]

Urban (n = 4,481)

Interviews by field worker

10

China [105]

(n = 388,136)

 

Neurotic depression, 0.37

affective psychosis, 13 neurasthenia

Brazil [106]

3 urban localities

Household survey

13–67 across different localities

Dubai [107]

Females (n = 300)

 

137

Australia [108]

Canberra (n = 756)

Household survey PSE

26 male

67 female

48 total

United Kingdom [109]

Camberwell (n = 800)

Household survey PSE

48 male

90 female

70 total

Holland [110]

Nijmegen (n = 3,232)

Household survey PSE

55

Finland [111]

(n = 742)

Household survey PSE

46

United Kingdom [112]

Camberwell Cypriot community in inner London (n = 307)

Household survey PSE

42 male

71 female

56 total

Italy [113]

Sardinia (n = 374)

Household survey PSE

52 male

110 female

83 total

United States of America [114]

48 contiguous states (n = 8098); age 15–54

Household survey

77 male

129 female annual prevalence

United Kingdom [73]

Sample of total population excluding Northern Ireland and the highlands and islands of Scotland (n = 10,1108); age 18–64

Household survey CIS-R and SCAN

18 male

27 female one week prevalence

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

RISK FACTORS

A variety of social, psychological, and biological factors may predispose an individual to depressive illness. Studies of risk factors for depression in developed and developing countries have yielded similar findings with regard to social and economic variables, such as life events, chronic social adversity, poverty, and gender. The vast majority of research concerning biological risk factors for depression, such as neuroendocrinological and genetic factors, derives from the developed world. This section briefly reviews the evidence for a variety of risk factors for depression and points, where possible, to data from developing countries.

TABLE 9-4 Prevalence of Common Mental Disorders in Community Studies

Country

Population

Method

Prevalence

Ethiopia [115]

Rural (n = 337); all ages

Lujik's method

190

South Africa [116]

Urban

Structured questio nnaire

118–230

Lesotho [99]

Rural (n = 356); age 19–93

DIS

228

Ethiopia [117]

Urban (n = 40); age > 18

SRQ

120

Uganda [101]

Rural (n = 206); age > 18

PSE

204

Sudan [118]

Urban (n = 204); age 22–35

SRQ

166

South Africa [100]

Rural (n = 481); age > 18

SRQ/PSE

270

Ethiopia [119]

Rural (n = 2000); age 15–55

SRQ

172

South Africa [120]

Urban and rural (n = 139); age > 65

PSE/MMSE

237

South Africa [121]

Urban and rural (n = 400); age > 65

SRQ

390

South Africa [122]

Urban (n = 365); age > 60

Short Care

252

West Bengal, India [123]

Urban and rural (n = 1424)

Trained field investigators

23–40

Pakistan [45]

Rural Punjab (n = 664)

 

660 female

250 male

Pakistan [124]

Rural Chitral

 

460 female

150 male

India [125]

Rural (n = 2,183 in 1972 and 3,488 in 1992); ages-all

Bengali case detection schedule

117 in 1972

105 in 1992

Brazil [126]

Urban

SRQ-20

350

Brazil [127]

Urban

CIS-R

 

United Kingdom [128]

Urban and rural (n = 1,277)

Household survey

160

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

TABLE 9-5 Prevalence of Common Mental Disorders in Studies of Primary Care Attenders

Country

Population

Method

Prevalence

Nigeria [129]

Urban (n = 277); Pregnant women

GHQ 28/PAS

157

Guinea-Bissau [130]

Rural (n = 251); age > 16

SRQ/PSE

120–180

Kenya [131]

Urban (n = 200); age 18–55

SRQ/SPI

258

Kenya [132]

Rural/semi-urban (n = 388); age > 16

SRQ

290

Senegal [133]

Rural (n = 933); adults

SRQ

162

South Africa [134]

Urban/rural (n = 363); age > 16

SRQ/PSE

83

Ethiopia [115]

Rural (n = 337); all ages

Lujik's

190

Zimbabwe [135]

Urban (n = 448); age > 16

SRQ

105

4 developing countries [136]

Rural (n = 360); age > 18

SRQ/PSE

106

Ethiopia [117]

Urban (n = 30); age > 18

SRQ

270

South Africa [137]

Rural (n = 159); age > 15

GHQ 28

45

South Africa [138]

Urban (n = 301); age 16–60

SRQ/PSE

103–143

Sri Lanka [139]

Urban (n = 3,000); age

Clinical Interview

210

India

     

Karnataka [140]

Urban (n = 300); age

GHQ/IPSS

360

Maharashtra [141]

Urban (n = 500); age

GHQ/Clinical Interview

570

Karnataka [142]

Urban (n = 882); age

GHQ/IPSS

360

West Bengal [88]

Urban (n = 202); age

SRQ/CIS

250

Bangalore [143]

Urban (n = 1366); age

GHQ/CIDI

240

Haryan [144]

Rural (n = 218); age

SRQ/Clinical Interview

420

Goa [26]

Rural (n = 303); age

GHQ/CIS-R

465

Gujarat [145]

(n = 200); age

BDI/Clinical Interview

210

Environmental

Life events that lead to the threat of loss or to actual loss, such as the death of a family member, marital separation, maternal deprivation, or loss of employment, have been shown to cluster before the onset of depressive episodes and to influence the course of depression in both developed and developing countries.[1,2,146,147 and 148] 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) negative interpretation of experience, and (3) negative view of the future.[149] Personality traits found to be associated with depression include avoidance, dependence, reactivity, and impulsiveness.[150] People with such personality traits may cope less effectively with stress and may also tend to encounter continuing adversity. These traits that often contribute or predispose individuals to experience depressive episodes are both genetically and socially influenced.[ 151,152] Most people

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

with depression do not have personality disorders. It is important to remember that efforts to assess personality during times of acute illness are misleading, and personality assessments frequently change when patients recover.

Rates of depression are increased in a variety of vulnerable groups, including refugees, neglected ethnic minority groups, and those exposed to war trauma. As discussed in Chapter 2, a large body of evidence demonstrates the association between poverty and CMD. For example, five cross-sectional surveys of people who sought treatment in primary care and community samples from Brazil, Zimbabwe, India, and Chile were collated to examine the economic risk factors for CMD.[153] In all five studies, a consistent and significant relationship was found between low income and risk of CMD. Similarly, a population-based study from Indonesia revealed that people with less education and material possessions were more likely to suffer from depression.[ 154] It appears that both absolute and relative poverty are important in the genesis of depression.

Further investigation to disentangle the complex relationship among stressful life events, social behavior, the interpretation of life events, and genetic influence (see below) would contribute to more effective methods for identifying individuals at high risk and appropriate methods of intervention.

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 have provided evidence of the genetic contribution to the etiology of depressive disorders and clearly shown the transmission of increased risk through heredity.[3,155,156,157 and 158] Twin studies, in particular, also point to a strong role of the nonshared (i.e., individually experienced) environment in the causation of depression.[2] However, understanding of the genetics of behavioral variation and of mental illness has proven enormously complex and has been constrained by small sample populations with sometimes unclear or limited ranges of environmental variation.[159] Future genetic studies would benefit from the collection and analysis of one or more of the following types of data sets [160]:

  • Large numbers of pedigrees from outbred populations containing multiple individuals affected with a given mental disorder;

  • Pedigrees from genetically isolated populations; and

  • Large numbers of affected individuals and control samples.

Examination of gene-environment interactions is essential to future research and could benefit from a much wider range of variation in the psychosocial environments studied, making it possible to better delineate the etiological contribution of each, including such environmental factors as socioeconomic adversity, pervasive stress, and the breakdown of social support networks. The

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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populations and environments of many developing countries provide such conditions for research and may prove particularly useful in elucidating the complex nature of depressive disorders.

It is currently understood that multiple genes act in conjunction with other, nongenetic factors to produce a risk for mental disorder. Future discoveries in genetics and neuroscience can be expected to lead to better models for understanding the complexity of the interactions between the brain and behavior and the development of both. These discoveries are likely to have significant impacts on clinical practice in both developed and developing countries.[161,162]

Gender and Reproductive Health

Both community-based and primary care studies indicate that women are often affected disproportionately by depression in both developing and developed countries (see also Chapter 2).[153,163,164] Women often develop the disorder in response to life events, social adversity, and other environmental factors.[164,165 and 166] The multiple roles assumed by women—including the bearing and rearing of children; responsibility for the home; caring for both healthy and ill relatives; and, increasingly, earning income—can lead to considerable stress. Women in both developed and developing countries also encounter difficulties related to their social position, aspirations, social support networks, and domestic problems, which may include physical or sexual abuse.[153,167,168 and 169] 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] Periods after childbirth and during menopause for women involve significant hormonal changes whose examination may provide further evidence regarding the higher rates of depression in women.[174,175,176 and 177]

Postpartum depression has been identified in both developed and developing countries.[178,179,180,181,182 and 183] The greatest risk for postpartum depression is within the first 30 days of childbirth and the condition can persist for up to 2 years.[ 184] Certain practices in developing countries such as isolation of recent mothers from family and the new infant, are disruptive to the initial mother–infant relationship and eliminate the benefits of positive social supports. These practices have been identified as possible contributing factors to the onset of postpartum depression.[ 179,180 and 181,183] In a recent study conducted in Zimbabwe, a brief screening questionnaire proved effective in identifying women (in the eighth month of pregnancy) as being at higher risk of postpartum depression. Such a tool may be useful in devising

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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preventive measures aimed at identifing high-risk individuals and implementing appropriate interventions shortly after childbirth.[ 178]

Neuroendocrine

Defective neurotransmission [185,186] and defective neuroendocrine receptor responses [187,188 and 189] are associated with depression. Three monoamines have been implicated: 5-hydroxytryptamine (serotonin), noradrenaline, and dopamine. Conclusive evidence on the impact of these defects on the course of depressive disorders remains to be found. It is still unclear whether associations with neurological function represent cause or effect in the pathogenesis of depression.

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] In one study of patients attending primary care, of nearly 21 percent of patients with clinically significant depressive symptoms, only 1.2 percent cited depression as the reason for their visit to the physician.[190]

Comorbidity of physical and mental illness has been found to increase with age, as described earlier with regard to stroke and ischemic heart disease.[24,191,192] Substance abuse is a frequent comorbid condition with depressive illness. Studies in both developed and developing countries point to substance abuse as both a cause and effect of depression linked to both genetic and environmental factors.[193,194 and 195] Depression has been shown to be a major factor in contributing to relapse in women abusing alcohol and drugs.[196,197] Identifying substance abuse in patients presenting with depressive illness is an important component of determining an effective course of treatment. Depression is also a common concomitant of HIV/AIDS.[ 198]

Associations with Age

Several studies conducted in developing countries have indicated a greater risk for depression among the aged.[199,200 and 201] Other large studies have found the highest rates of the disorder among those aged 25 to 34.[114,202,203] Additionally, the rates of suicide are increasing rapidly among adolescents and young adults in developed countries and more recently in developing countries.[204,205] This inconsistency in findings arises from age bias (instruments do not have equivalent validity across the age span) and covarying risk factors, including sociodemographic factors and rates of physical illness.[206] A cross-national study of both developed and developing countries using the standardized DSM-III diagnostic criteria found the mean age of onset to be 24.8–34.8

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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years[18] Studies that use standardized measurements are still needed in developing countries to determine more conclusively the role of age as a risk factor for depression.

Factors Affecting Course and Outcome

The course of depression is influenced by the type of depression, its causes, its severity, its prior duration, and the underlying presence of chronic minor depression. Patients who are genetically predisposed to develop depression have a less favorable long-term prognosis than those who become depressed following a specific life event.[207] The prognosis for depression also appears to worsen for cases that are either severe or long-standing at the outset of treatment.[208,209] Early-onset depression (in both children and adolescents) 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. Similarly, a WHO cross-national study of more than 5,000 outpatients in developing as well as developed countries has shown that psychiatric disorder produces significant functional disability over and above any associated physical health problems.[ 96]

Recovery rates for depression depend on how recovery is measured: by complete remission of symptoms or by remission to below case-threshold levels. Data from the U.S. National Institute of Mental Health's collaborative study on the psychobiology of depression indicate that the rate of recovery from a first depressive episode declines over time. Although 70 percent of patients in this study were found to recover during the first year, only an additional 18 percent had recovered by the fifth year.[212] A review of 51 follow-up studies of depressed adults treated by inpatient or outpatient psychiatric services in developed countries assessed outcome in terms of recovery, recurrence, and persistent depression. The authors estimated that 50 to 60 percent of patients with major depression recovered at least briefly over 1 year, while up to 90 percent experienced short-term recovery or better over 5 years.[213] However, only 43 percent of these patients reported that they experienced sustained recovery after 1 year, a figure that declined to 24 percent after 10 years. Significant numbers of people with depression suffer from chronic versions of the disease. A variety of studies indicate that between 10 and 25 percent of patients with depression suffer non-remitting episodes lasting 2 years or more.[212,213,214,215,216 and 217]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Recommendation 9-2. Trained health care providers (health care workers, nurses, and general physicians), particularly those in primary care settings, should be prepared to identify patients at risk for depression, who include those with a family history of the disorder, postpartum women and those of childbearing age, and those who experienced early-onset depressive episodes in childhood or adolescence. These providers should be adequately trained and informed to recommend additional sources of information, and counseling in available support systems, and to provide treatment. Severe cases should be referred to specialist mental health personnel that maintain oversight of primary care facilities.

INTERVENTIONS

Because depression typically results from a combination of causes, effective prevention and treatment of the disorder and its consequences demands a multi-faceted approach. In developing countries, this may translate into a combination of health care, public health awareness, community care, and socioeconomic development, as has been the case, for example, in India and Iran (see Box 9-1 and Box 9-2). Many prevention and treatment interventions have not been proven conclusively to be cost-effective in developing countries. However, where developing-country data exist for the following interventions, this is noted. In other instances, comparable evaluations have been included from developed countries, and implementation of their findings in developing countries is addressed.

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.

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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BOX 9-1 Primary Mental Health Care in India

Like other developing countries, India has limited resources for mental health care. In 1999, 3,000 psychiatrists served its 1 billion people. To cope with this disparity, India has taken a community approach to promoting mental health through a variety of initiatives. Most important, mental health care has become an integral part of the country's program of primary care, which provides mechanisms for mental health planning at both the state and national levels.

Several studies have shown not only that mental disorders are common in India, but also that few physicians diagnose and treat them appropriately. In response to this situation, simple, rapid training programs on mental health have been developed for primary health care personnel. Manuals of mental health for different categories of health personnel, recording systems, training videos, assessment forms, and public education materials have also been developed. A demonstration project on primary mental health care, conducted between 1985 and 1990, showed that it is possible to provide basic mental health care with limited reliance on mental health specialists.

Psychiatry in India is showing strong signs of growth as culturally sensitive interventions are developed. At this time, research efforts are limited, and longitudinal studies remain to be done. However, existing findings on mental disorders, their antecedents, and patterns of care are sufficient to prompt a reexamination of long-held concepts regarding mental health care. Increasing efforts toward this goal promise to benefit the practice of mental health care throughout the world.

Source: [218,219,220,221,222,223,224,225,226 and 227]

BOX 9-2 Primary Mental Health Care in Iran

Prior to 1985, mental health care in Iran was based on institutional care by medical specialists and was based primarily in cities. With the debut of a national program of universal coverage, mental health care became integrated into Iran's existing primary health care system. The village-based primary care system in Iran was implemented in the1970s and has spread to over 60 regions. Highlighting the importance of comprehensive, well-supported primary care, the program has continued to link village-based care centers to surrounding hospitals and medical schools. Iran's national health program supports training in mental health for all personnel, development of a district-level mental health support system, and an annual mental health week.

One male and one female village health worker serve every 2,000 people in the rural regions of Iran. Workers are trained in assessment, diagnosis, and management of priority conditions, which include depression, anxiety, psychosis, epilepsy, infectious diseases, childbirth, and, as of 1999, substance abuse. They use good-practice guidelines for as-

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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sessment, diagnosis, and management, and they are able to prescribe a limited list of essential medicines, including antidepressants and lithium for depression and bipolar disorder. Village health workers practice prevention and mental health promotion, regularly visiting each person in their area to screen for illness. They also see patients in the clinic, and are expected to collect routine data on diagnosis, consultations, and health outcomes, which are collated annually.

Quality control is achieved by health psychologists who make monthly visits to each village health center to provide support to the village health workers and ensure quality of treatment Village health workers refer complex or severely ill patients to a primary care doctor who is responsible for 10,000 people. He or she is also trained in the use of good-practice guidelines in the priority conditions. Because Iran's Ministry of Health and Medical Education is responsible for education as well as for the administration of care, the medical curriculum taught in universities is consistent with and supportive of the role of primary care for mental health. At present the program is active in almost half of the nation's rural areas, with 9,200 of the total 15,500 “houses of health” of the country being engaged in mental health programs. To date, 18,200 behvarzes (multipurpose health workers) and 5,500 general practitioners have received the appropriate training. Within the 14 years since the program was introduced, 12.7 million rural residents have been covered by the program. The total population covered by the program at this point is 16.4 million, which constitutes one-fourth of the country's total population.

Additional innovative programs in Iran include the following:

  • An urban mental health program, which was introduced into the primary health care system during the past 3 years and at present time covers 10 percent of the urban population (3.7 million). It is hoped that this percentage will increase to 20 percent by the end of 2000.

  • Primary prevention of mental disorders with emphasis on depression and suicide has been planned and initiated in four districts since 1999.

  • Integration of a prevention program on substance abuse into the primary health care system is planned for five districts as pilot studies during 2000.

  • Other new mental health programs and activities for the Ministry of Health and Medical Education include:

  • A second revision of the National Program of Mental Health, scheduled for late 2000.

  • Preparation of a comprehensive mental health act.

  • Development of a school mental health program.

  • Development of a child abuse prevention program.

  • A second independent evaluation of the National Mental Health Program during 2000.

Source: [228,229,230 and 231]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Social and Public Health Models

Public education campaigns to raise awareness about depression have been undertaken in a number of developed countries.[232,233 and 234] These campaigns have included messages that identify depression as a treatable and common condition to reduce the stigma surrounding the disease and to encourage afflicted individuals to seek treatment. These campaigns have also included strong anti-suicide messages.[ 235] Though limited in scope, recent evaluation has shown that some of these campaigns have resulted in improved attitudes toward seeking treatment.[236]

Educational programs aimed at promoting mental health should provide information on prevention and treatment; reduce the stigma associated with mental disorders; and offer ways to improve every person's capacity to cope with predictable life events, as well as with crises. In some cases, programs might be targeted at community leaders who are in key positions to affect the lives of others (e.g., clergy, teachers, employers, and doctors). Similarly, both national and local policy makers must be kept informed about mental health issues through the efforts of mental health professionals and advocates. Mental health programs in schools aim chiefly to improve life skills. Within communities, mental health initiatives that involve a variety of local organizations (e.g., schools, social services, and law enforcement agencies) may also serve to increase community awareness of health issues, such as children's welfare, rape, and domestic violence.[237,238] Such cooperative participation and intersectoral funding from national-and-local level government agencies and other organizations serves to reinforce and expand prevention efforts. 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 school programs on mental health. In Zanzibar, primary care teams include health education workers who link with schools on a local basis. In some countries, moreover, such as India and Pakistan, school children play a vital role by recognizing adults with epilepsy, schizophrenia, and other disorders and bringing them to medical attention.[239]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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BOX 9-3 School Mental Health Program of Pakistan

Pakistan has an estimated population of 136 million. The fertility rate is 5.8 per 100, and the literacy rate has been estimated between 27 percent and 30 percent. In rural areas, school-going children are often the only members of the community who are able to read and write. They are thus in a unique position to be the agents of change for their communities. In rural areas, school, along with the family, is the strongest social institution. Therefore, schools are a possible point of access to the community.

A school mental health program was initiated as part of the Community Mental Health Program in the Rawalpindi District by the Institute of Psychiatry in 1987, with the objective of raising awareness about health in general and mental health in particular among school children, teachers, and the community. The program was carried out in a phased manner, in the familiarization phase, education administrators were sensitized to the application of mental health principles in the field of education. In addition, baseline data regarding knowledge and attitudes about mental health among the schoolteachers and students were collected. This was followed by training. Male and female teachers were trained with the aim of providing knowledge and counseling skills. This training was reinforced by regular visits to the schools by the community support team, who assisted with the organization of parent–teacher associations; speech and essay contests on mental health; and the development of slogans carrying primary, secondary, and tertiary prevention health messages such as the following:

  • Smoking is the gateway to substance use;

  • Mental illnesses are treatable like physical illness and not due to jinns and possessions; and

  • The mentally ill may be different, and it is a sin to laugh at somebody 's disability.

Evaluation of the program is currently in progress.

The impact of the school mental health program on raising awareness about and reducing the stigma attached to mental illness among school children, their parents, friends not attending school, and neighbors was assessed. Significant improvement in awareness and attitudes was seen among school children and those at increasing social distance (i.e., parents, friends not attending school, and neighbors.)

It would be safe to conclude that the establishment of school mental health programs is a cost-effective means of raising mental health awareness and reducing the stigma attached to mental illness.

Source: [240]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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To date, evidence for the effectiveness of these school-level interventions has included a reduced requirement for special education classes and fewer occurrences of bullying behavior.[241] Such programs aimed at empowerment and enhanced coping capacity may be expected to have long-term effects on conditions such as depression that often result from an inability to cope with life stresses. Longitudinal research is needed to provide evidence for these effects.

Recommendation 9-3. 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;

  • Workplace mental health programs; and

  • Mental health care in prisons.

Preventing Suicide

As with efforts to prevent depression, interventions to reduce suicide should take place on multiple levels. General approaches must be complemented by specific strategies directed toward high-risk groups (based on such factors as demography, occupation, and health status). A 1996 survey of suicide prevention programs in nine countries [ 242] revealed several common themes for intervention, including:

  • Improving the detection and treatment of depression through better basic training and continuing education of health professionals [ 243] and through access to crisis intervention.

  • Promoting responsible media reporting so that suicide is not glamorized, and the method of suicide is not reported.[244]

Additional key interventions should include:

  • Training health care personnel to assess and counsel individuals who have attempted suicide.[245]

  • Identifying alcohol abuse as a pathway to suicide.[39,246]

  • Reducing access to the means of suicide. For example, restricting packet sizes, retail outlets, and advertising to prevent overdoses of over-the-counter medicines, such as paracetamol; restricting access to guns; and, restricting access to and labeling of pesticides.[ 54]

  • Recognizing that self-destructive and risk-taking behaviors, particularly in young people, often precede formal suicide attempts. The peak incidence of these behaviors occurs between ages 15 and 24, a group for which, in males,

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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suicide rates have been rising for three decades in developed countries; indeed, there is considerable concern that a similar rise may be under way in developing countries. Suicide rates in young women are already known to be extremely high in Southeast Asia.[39]

  • Conducting routine clinical audits of suicides as a way of better understanding their causes and establishing and assimilating the implications for prevention.[247,248]

In addition to the above interventions, effective strategies to prevent suicide must be supported by comprehensive national policy. The United Nations (1996) has identified several key traits of successful national suicide prevention plans. These include government backing, specific aims and goals, measurable objectives, plans for implementation, and mechanisms for monitoring and evaluation.[249]

Recommendation 9-4. The consequences of depression have an impact on all levels of society and the economy. Therefore, increased intersectoral funding should be allocated by all relevant ministries (e.g., education, employment, environment, housing, tourism, youth, information, home affairs, criminal justice, and finance, as well as health) for programs aimed at the prevention of depression and suicide, with consideration of the strategies discussed above.

Treatment

Effective treatment strategies exist for depression in the form of both pharmacotherapies [250] 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.[250,251,252 and 253] Despite the availability of these interventions, however, many individuals in developed countries and an even greater number in developing countries remain underdiagnosed and untreated.[254,255,256,257,258 and 259] Particular gaps in treatment remain for children experiencing depression and in the appropriate sequencing of treatment for adults.[260,261]

Medical interventions

Antidepressants. Because of their efficacy and cost-effectiveness, antidepressant medications represent the mainstay of treatment for depression in developed countries. Research indicates that 70 percent of patients prescribed an antidepressant will show a worthwhile clinical improvement in their symptoms.[262,263] Antidepressants have also been found to be effective in prophylaxis; treatment has been shown to reduce the relapse rate for recurrent depression from 80 percent (when untreated) over 3 years to 22 percent.[ 264] The use of antidepressants in developing countries has not been as widespread,

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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but the limited available evidence shows similar rates of efficacy, through there have been variations in treatment dosage and sequencing.[ 265,266] Additional research in developing countries will be necessary to determine appropriate treatment guidelines for the use of these medications in different populations.

Two of the three main types of antidepressants—tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) [267,268]—have been in use for four decades, while selective serotonin re-uptake inhibitors (SSRIs) are more recent. TCAs are broad-spectrum drugs that treat most types of depression effectively.[269,270] Traditional TCAs and the newer SSRIs have similar efficacy for moderate depression.[271] Meta-analysis has shown that traditional TCAs produce clinical improvements more quickly than SSRIs, but the two have similar efficacy at 6 weeks.[272]

Studies to date indicate that SSRIs and TCAs have similar effectiveness. However, the reduced side effects of SSRIs are likely to enhance patient compliance and therefore improve overall treatment outcomes.[ 266,273,274] Tricyclic anti-depressants are currently the first line of treatment in many developing countries because the higher costs of SSRIs remains prohibitive.[275,276] However, as SSRIs become affordable, they should also be considered first-line treatments in developing countries.

MAOIs are an important option for patients who are refractory to TCA treatment, who have responded to them before, or who have marked anxiety/panic features. They work best in patients with specific symptom combinations, such as anxiety or phobias. Despite the efficacy of MAOIs, their clinical use is limited because of a frequently occurring side effect that induces a rapid rise in blood pressure (associated with certain food intake such as cheese or pickles) and can contribute to long-term hypertensive conditions or acute cardioand cerbrovascular episodes.[277] The difficulty for many developing countries in monitoring blood pressure [278] would prohibit use of these drugs.

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).

Evaluations of cost-effectiveness will depend on the actual costs of specific drugs, which vary among countries and will decrease as newer drugs come off-patent. Requisite long-term follow-up studies (which would include attention not only to recovery from symptoms and disability, but also to reduction of family, social, and economic burden over 5 years) have not been conducted. Such studies are needed before cost-effectiveness can be definitively established.

Future research developments associated with tolerability, drug-to-drug interactions, and levels of efficacy in preventing relapse will continue to increase the desirability of many antidepressants as a first-line treatment for depression.[279,280] Research into these new drug developments may benefit from examining clinical environments in developing countries. Collaborations on such

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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research that will benefit developing country populations should be encouraged by the establishment of national research and training centers in these countries (as recommended in Chapter 4).

Recommendation 9-5. An adequate supply of essential medicines (TCAs and low-cost SSRIs), based on epidemiological estimates of need, should be made available to all primary and secondary care facilities. Training of staff will be required to ensure appropriate monitoring for possible side effects of these drugs and to determine when changes in treatment regimens are required.

Electroconvulsive Therapy. Numerous studies have shown electroconvulsive therapy (ECT) to be an effective treatment for severe depressive illness.[281,282] However, its nature and fears regarding long-term cognitive side effects have significantly curtailed its use, although follow-up studies have failed to show such effects or structural damage to the brain.[281,282 and 283]

Patients with severe depression, delusions, agitation, or retardation are particularly likely to improve if treated with ECT. Such symptoms are often found among the elderly, who represent a substantial fraction of the treatment population in developed countries.[284] Modern practice of ECT also poses less risk to pregnant women than the risk associated with some psychotropic drugs used in the treatment of depression. In contrast, ECT is considered a treatment of last resort among children and adolescents.[281,284] The risk of death from ECT is similar to that for general anesthesia for minor surgical procedures—about 2 deaths per 100,000 treatments.[ 285]

It is important to note that when used appropriately, ECT is an effective treatment for severe and refractory depression. Because ECT works more rapidly than antidepressants (which typically take more than 2 weeks before improvement starts and 6 weeks to achieve full effect), it can be life-saving for those who are suicidal and not responding quickly enough to antidepressants, or those who are mute and refusing to eat and drink.[286] However, caution must be exercised to ensure that the treatment is not misused or overused because of its inexpensive cost relative to antidepressant medication.[287]

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) in caring for people with depression.

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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Psychosocial therapy can be an important means of reinforcing the social support networks involved in overall mental health for patients suffering from depression. The use of psychosocial interventions in combination with antidepressant medications targets both the biological and social causes of the disease and provides a comprehensive approach to treatment.[288,289 and 290] Patients involved in such therapy can benefit from both the more immediate effects of medication and the longer-term successes that are achieved in psychotherapeutic environments.[290] Furthermore, psychosocial treatments are frequently used with patients who have become depressed as a result of suffering a physical ill-ness, such as coronary artery disease, AIDS, or cancer.[291,292] Psychosocial treatments have been suggested as particularly useful in the case of postpartum depression.[293,294]

Though limited evidence of effectiveness is available on the many varieties of psychosocial interventions used in developed countries, cognitive behavior therapy,[295,296] problem-solving therapy,[297,298 and 299] and family-focused therapy [300] have met with proven success in the treatment of depression. A small number of published reports address the use of psychosocial interventions to treat depression in developing countries.

Problem-solving therapy has been suggested as an effective psychosocial treatment, particularly because it seeks to provide the patient with a technique for coping with future problems, thereby potentially preventing a recurrence of depressive symptoms or enabling the patient to dealt with them more effectively when they recur.[298,301] Problem-solving therapy has been conducted effectively by trained community nurses in primary care settings,[297] making the approach particularly attractive for resource-poor settings where psychiatrists and specially trained general physicians are often not regularly available. Additional research should be conducted in developing countries to determine the cost-effectiveness of this strategy in primary health care settings.

Results of an open trial of cognitive behavior 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] Yet cognitive behavior therapy requires levels of training most likely to appear in secondary levels of care in developing countries (such as district hospitals or more urban centers) and is therefore recommended for use in such settings.[304]

Family-focused therapy for psychoeducation and communication enhancement has proven effective in facilitating greater support for family members with depression. Therapeutic and nonjudgmental environments allow for open discussion about symptoms, treatment, and their side effects, which can create long-term stability, optimize compliance, and allow for early identification and intervention when relapsing episodes occur.[300] Definitive research on

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
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family burden exploring attitudes and beliefs about depressive illness would provide valuable guidance for the design of locally appropriate educational interventions designed to decrease the impact of family and other relationship stresses on the patient and to enhance the family's support for the patient.

Current models of psychosocial treatment focus on modifying the effects of social or familial risk factors and may help improve the course of the disorder. Indeed, the psychosocial treatments described above may prove especially advantageous in developing countries because most can be administered by trained, nonspecialist health care personnel and can help empower patients to attain and maintain recovery.

Traditional healers

Traditional healers are common in most low-income countries and, despite the presence of practitioners of modern Western medicine, are routinely consulted in the first instance. 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.[305,306 and 307]

Traditional and religious healers frequently play a major role in treating mental disorders.[304,308,309 and 310] Many healers are familiar with concepts of psychosis, depression, epilepsy, and alcohol abuse; some recognize the value of hospital tests and encourage their clients to use orthodox care.[311] As a result, some health care services in developing countries are attempting to forge collaborations with these kinds of traditional healers to foster more efficacious and culturally sensitive treatments for depression.[312,313]

Cost Analysis

Despite the acknowledged need for economic analysis of mental health care strategies, few such studies have been conducted in either the developed or developing world.[314,315,316,317,318,319 and 320] Where cost-effective models of care exist, it may not always be possible to transfer them directly from developed to developing countries, or from one developing country to another. Nevertheless, strategies for cost-effective mental health care have been adapted by several developing nations, including Brazil, India, Guinea-Bissau, China, Pakistan, and South Africa (See Box 3.1, Box 3.2 and Box 3.3 in Chapter 3).[104,130,321,322,323,324 and 325]

The refinement of mental health economics and policy analysis in industrialized countries have paved the way for the creation of appropriate frameworks for evaluating health care costs in developing countries.[ 326,327,328 and 329] In addition, a recently completed demonstration project conducted in India and Pakistan illustrates the feasibility of applying economic analysis to community mental health programs in low-income countries (see Chapter 3 for a description of this analysis).[330]

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Encouraging evidence has also emerged to support the cost-effectiveness of depression management through primary care in developed countries.[ 19,331,332 and 333] However, more extensive prospective studies are required to provide definitive evaluation of alternative interventions for depression.[ 334,335 and 336] Cost-effective treatments for depression appear likely to produce measurable benefits, such as reducing disability in the workplace [337] and averting indirect human, social, and family costs.[338,339]

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.[19,34,37] As a result, the integration of mental health with primary care services has become a significant policy objective in both wealthy and low-income areas of the world (see Chapter 3).[340,341,342,343,344 and 345] Countries differ in the extent to which they have achieved this objective. Some of the most proactive examples are to be found in low-income countries, where programs have often been assisted by WHO and have followed a public health model modified for the needs of mental health.[301,341,342,343,344 and 345]

Each country has its own unique health care delivery system, and what makes sense in one country may not in another country. In formulating health care policy, it is important to examine the existing primary and secondary care systems, staffing, basic training and continuing education for each of the professional groups involved, and the system for data collection. The composition of primary care teams will vary from country to country. In low-income countries, the team may contain no doctors and perhaps a few medical assistants, and be staffed largely by nurses and trained health workers. In some countries, health workers with months rather than years of training are on the front line, dealing with screening and case finding, assessment, and maintenance treatments (see Box 9-3).

In Zanzibar, the first tier is the primary health care unit, which usually contains several male and female nurses responsible for a population of 10,000. In Tanzania, the front line is the first-aid volunteer, who attends to the simple health needs of approximately 50 people; the second tier is the dispensary, which is responsible for a population of 2,000; and the third tier is the primary health care unit, which is run by nurses and medical assistants who care for a population of 10,000. In Pakistan, the first tier comprises health workers, usually married women with adult children, who receive brief training; the second tier is the primary care doctor, often responsible for a population of approximately 2,000.

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×
Training

Currently, the limited number of psychiatrists and other mental health professionals dictates in developing countries that their roles be defined as being focused primarily on providing training; designing methodological tools, such as problem detection and treatment guidelines; and confirming initial diagnosis and course of treatment through secondary and tertiary consultation.[96] For these purposes, the curriculum and training of both psychiatrists and general physicians should be adapted to consider not only the clinical presentation of these disorders in tertiary centers, but also the frequently somatized conditions that present in both primary and secondary settings. Diagnostic training should be problem-solving based and rooted in national and community health priorities.[346] Acquiring training skills that are effective in reaching multiple levels of health care personnel will be important for transferring the necessary knowledge base. Specialists and general physicians must be prepared for their critical responsibility in the establishment and continuing oversight of programs in both urban and rural areas and in promoting sound health policy for efforts to address depression and other mental illnesses.[347,348] Where there are few physicians in primary care, nurses can play an effective role in the management of those with mental disorders if given appropriate training.[128,349,350] It is also important to provide mental health education to midwives and traditional birth attendants in low-income countries so they can identify cases of postpartum depression and other psychoses.

When establishing mental health care programs, it is important to assess the basic training needs of each level of personnel for all levels of care in the health care system and the extent to which mental health training is already included. In Iran, health workers receive several months of training in a few priority topics that include depression, and medical students are given extensive training in psychiatric disorders, including depression. In Zanzibar, the College of Health Sciences runs a 4-year basic nurse training course, of which the fourth year for men is psychiatry and the fourth year for women is midwifery. A similar situation exists in Tanzania, so that these countries now have a substantial population of nurses in primary and specialist care who have received at least a year of basic training in psychiatry.

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. This continuing education takes place during several weekends per year, and the primary care workers receive transport allowances and incentive payments to attend. Unfortunately, continuing education programs in most countries focus largely on physical illness; mental health topics tend to be considered optional or extra, and thus are not an integral component of general training.

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Research in the United States has demonstrated the success of primary care programs that train general physicians to diagnose depression at night, more valid rates.[258,352,353] However, this research has also shown that even after proper diagnosis, appropriate drug treatment and referral to psychosocial therapy remain inadequate.[260] Recognizing and addressing similar limitations in developing country primary care settings will be important for both treatment and training models.

Maintaining standards is crucial to providing cost-effective primary health care. In Iran, for example, health psychologists monitor the performance of health workers, visiting every month to provide support and to supervise and check on the quality of the work.[228] In many countries, especially in rural areas with little or no public transport, outreach from primary care to the community and from secondary care to primary care and to the community cannot occur without access to transportation. Program planning must account for the provision of these services to ensure that efforts to provide care reach those in need.

Recommendation 9-6. A feasible and affordable community-based management program to diagnose and treat depressive illness should have five specific aims:

  • Reduce the frequency of depressive episodes.

  • Reduce the social withdrawal and isolation commonly associated with the disease that leads to high levels of disability and impairment of social functioning.

  • Reduce the risk of premature mortality due to suicide or physical disease.

  • Identify those at risk because of familial history or negative life events.

  • Reduce stigma and protect the patient's human rights.

Such a program should involve at least three operational components:

  • Pharmacological treatment, with specific guidelines for symptom control in acute episodes, maintenance for stabilization and prevention of relapse, and means of ensuring adherence to the treatment protocol.

  • Problem-solving psychosocial therapy programs to encourage recovery and assist patients in developing techniques for coping with future events to potentially prevent the severity or occurrence of relapse.

  • Mobilization of family and community support, including providing education about the nature of the disorder and its treatment, involving the family in simple problem-solving skills training,

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

and involving the local community in providing a supportive and nonstigmatizing environment.

Recommendation 9-7. Implementation of comprehensive primary care programs for depression should include the following elements:

  • Basic training (undergraduate and graduate) and continuing education of primary care personnel at all levels (from village-level health workers to primary care physicians);

  • Organized periodic support and supervision from mental health specialists;

  • Good-practice guidelines on the distribution of antidepressant medications and psychosocial treatments for depression;

  • Concise and meaningful materials for increasing awareness and self-management and for monitoring and evaluating outcomes; and

  • Public education efforts to enhance the impact of these programs.

Research

Adequate planning is not possible without good systems for routine data collection within the health care system. Prevalence and outcome data may be gathered, as is routinely done in Iran (see Box 9-2). However, existing standard forms for recording consultations in primary care pay inadequate attention to mental disorders. For example, committee members have noted that the primary care diagnostic form in use in several East African countries 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.

Research capacity for mental health services and training is essential to appropriate evaluation and implementation strategies. Local health researchers should be empowered to conduct and lead research programs, including the development of methods for screening and outcome measurement. The establishment of national centers for research and training and of standard protocols would facilitate these developments (see Chapter 4 for a description of these centers).

Recommendation 9-8. To better inform ongoing and future programs in developing countries aimed at reducing the burden of depression, research is needed on the following topics, with responsibility at the indicated levels:

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×

Local

  • Locally appropriate practice guidelines for prevention and treatment in primary care;

  • Aspects of disability and burden of depression in different population groups to determine priority strategies for local and national programs;

  • Development and evaluation of communication strategies for education at the national and local levels, including public awareness programs to reduce stigma; and

  • Cost-effectiveness evaluations of local prevention and treatment programs.

National

  • Aspects of disability and burden of depression in different population groups to determine priority strategies for local and national programs;

  • Impact of the social determinants for depression (e.g., poverty, illiteracy, violence at home, unemployment);

  • Evaluation of preventive interventions based on knowledge of risk factors (including the establishment of long-term cohorts);

  • Evaluation of programs for chronic disease management (including depression) in primary care;

  • Evaluation of programs for continuing education for primary health care personnel;

  • Development and evaluation of communication strategies for mental health education at the national and local levels, including public awareness programs to reduce stigma; and

  • Methods for disseminating model programs to create successful intervention policies at the national level.

Collaborative

  • Genetic etiology of depression, to include gene–environment interactions; and

  • Treatment outcome and dosage studies for TCAs and SSRIs to determine population-specific needs.

Recommendation 9-9. To assist in the widespread implementation of improved prevention and care for people with depression, a series of demonstration projects should be undertaken in low-income countries. These projects should incorporate the following:

  • Practice guidelines for prevention and treatment in primary care;

  • Scientific evaluation of outcomes and cost-effectiveness; and

Suggested Citation:"9 Depression." Institute of Medicine. 2001. Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: The National Academies Press. doi: 10.17226/10111.
×
  • Capacity to support dissemination and generalization within countries.

Support for these projects should be provided by a wide range of international and local organizations, including the World Health Organization Nations for Mental Health Initiative; the World Bank; the U.S. National Institute of Mental Health; government development agencies; national ministries of health, education, welfare, and finance; and international and local professional and patient advocacy organizations.

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Summary of Findings: Stroke in Developing Countries

  • Stroke ranked as the third leading cause of death in 1990 in developing countries and was responsible for about 2.4 percent of disability-adjusted life years (DALYs) worldwide. Projections for 2020 place stroke fifth among the causes of disease burden for developing countries.

  • Prevalence and incidence rates for stroke vary dramatically among populations and may be influenced by economic, behavioral, and genetic factors, among others. Comparative epidemiological studies of stroke based on common definitions, methods, and modes of data presentation are needed to increase understanding of this disease.

  • Because of the high risk for death, long-term disability, and recurrence after a first stroke, prevention is key to reducing the public health impacts of cerebrovascular disease. And prevention is feasible, given the remarkable reduction in stroke mortality achieved in several developed countries.

  • Low-cost community health education programs that promote exercise, healthy diets, and smoking cessation may significantly reduce risk of stroke in developing countries.

  • Several low-cost treatments for hypertension, diabetes, and other conditions are likely to reduce significantly the incidence and severity of stroke and stroke-related vascular disease in developing countries.

  • Primary health care workers, nurses, and physicians play an important role in detecting, diagnosing, and treating hypertension and other conditions that increase stroke risk, and in ensuring compliance with treatment. Key resources such as stroke units in major hospitals, rehabilitation facilities, and post-stroke community support programs may serve a minority of patients, but promote the development and introduction of appropriate, cost-effective methods and technology for stroke prevention, treatment, and rehabilitation.

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Brain disorders—neurological, psychiatric, and developmental—now affect at least 250 million people in the developing world, and this number is expected to rise as life expectancy increases. Yet public and private health systems in developing countries have paid relatively little attention to brain disorders. The negative attitudes, prejudice, and stigma that often surround many of these disorders have contributed to this neglect.

Lacking proper diagnosis and treatment, millions of individual lives are lost to disability and death. Such conditions exact both personal and economic costs on families, communities, and nations. The report describes the causes and risk factors associated with brain disorders. It focuses on six representative brain disorders that are prevalent in developing countries: developmental disabilities, epilepsy, schizophrenia, bipolar disorder, depression, and stroke.

The report makes detailed recommendations of ways to reduce the toll exacted by these six disorders. In broader strokes, the report also proposes six major strategies toward reducing the overall burden of brain disorders in the developing world.

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