Recognition of depression by primary care clinicians in rural Ethiopia

Abstract

BackgroundDepression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression.MethodsCross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above.ResultsA total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms.ConclusionAlthough not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low income countries. Addressing this threat should be an urgent priority, and requires a better understanding of the nature of depression and its presentation in rural low-income primary care settings.

Quality of perinatal depression care in primary care setting in Nigeria

“…Similarly primary care physicians in Chile were able to detect 48% of cases of common mental disorders presenting in primary care [ 34 ]. However, the detection rate found in the current study compares well with detection rates of mental disorders or depression in primary care reported in other LMICs, which range from 0 to 1.3% [ 35 – 37 ]. The low detection rates of depression among PHCWs in LMICs have been attributed to low level of mental health knowledge and skill among PHCWs, and the prioritization of physical conditions over mental disorders when depressed patients present with multiple somatic symptoms [ 35 ].…”

“…However, the detection rate found in the current study compares well with detection rates of mental disorders or depression in primary care reported in other LMICs, which range from 0 to 1.3% [ 35 – 37 ]. The low detection rates of depression among PHCWs in LMICs have been attributed to low level of mental health knowledge and skill among PHCWs, and the prioritization of physical conditions over mental disorders when depressed patients present with multiple somatic symptoms [ 35 ]. The low capacity of the sampled facilities to provide quality chronic care for depression and the low detection rates for depression by the PHCWs demonstrate important gaps in both the organisational structures and manpower capacity of the frontline facilities to respond to common perinatal mental health conditions in a fully functional integrated chronic care model.…”

Under detection of depression in primary care settings in low and middle-income countries: A systematic review and meta-analysis

“…Only one of the included studies reported on predictors of detection, which noted severity of symptoms and suicidality as significant predictors 28 . Overall, these are consistent findings with what is known about the detection of depression 37 .…”

Engaging and staying engaged: a phenomenological study of barriers to equitable access to mental healthcare for people with severe mental disorders in a rural African setting

“…In a study conducted in the neighbouring district, the lifetime prevalence of schizophrenia is reported to be 0.5% [ 2 , 14 ]. The prevalence for bipolar disorder is 0.6% for males and 0.3% for females while major depression has 11% prevalence at the healthcare facility level [ 15 , 16 ].…”