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

Fekadu, Abebaw; Demissie, Mekdes; Birhane, Rahel; Medhin, Girmay; Bitew, Tesera; Hailemariam, Maji; Minaye, Abebaw; Habtamu, Kassahun; Milkias, Barkot; Petersen, Inge; Patel, Vikram; Cleare, Anthony J.; Mayston, Rosie; Thornicroft, Graham; Alem, Atalay; Hanlon, Charlotte; Prince, Martin

doi:10.1101/2020.03.20.20039628

Cited by 12 publications

(12 citation statements)

References 34 publications

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“…All three groups of respondents emphasised social attribution and somatic manifestation of depression, also seen across a range of other cultural settings [34,44] and consistent with findings from several other LMICs [24,41,45]. Presentation of depressive symptoms with somatic complaints might explain higher rates of emergency healthcare visits [38], non-indicated medical investigations, increased likelihood of misdiagnosis and lower detection rates of depression in such settings [46][47][48]. HCWs highlighted that under-detection of antenatal depression may also arise from: (1) the clinical difficulty for non-specialist workers in distinguishing a normal response to social adversity from a depressive episode, and (2) overlap between symptoms of depression and normal symptoms of pregnancy, such as sleep problems and fatigue.…”

Section: Discussionsupporting

confidence: 67%

Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study

Bitew

Keynejad

Honikman

et al. 2020

BMC Pregnancy Childbirth

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Background: Psychological interventions for antenatal depression are an integral part of evidence-based care but need to be contextualised for respective sociocultural settings. In this study, we aimed to understand women and healthcare workers' (HCWs) perspectives of antenatal depression, their treatment preferences and potential acceptability and feasibility of psychological interventions in the rural Ethiopian context. Methods: In-depth interviews were conducted with women who had previously scored above the locally validated cutoff (five or more) on the Patient Health Questionnaire during pregnancy (n = 8), primary healthcare workers (HCWs; nurses, midwives and health officers) (n = 8) and community-based health extension workers (n = 7). Translated interview transcripts were analysed using thematic analysis. Results: Women expressed their distress largely through somatic complaints, such as a headache and feeling weak. Facility and community-based HCWs suspected antenatal depression when women reported reduced appetite, sleep problems, difficulty bonding with the baby, or if they refused to breast-feed or were poorly engaged with antenatal care. Both women and HCWs perceived depression as a reaction ("thinking too much") to social adversities such as poverty, marital conflict, perinatal complications and losses. Depressive symptoms and social adversities were often attributed to spiritual causes. Women awaited God's will in isolation at home or talked to neighbours as coping mechanisms. HCWs' motivation to provide help, the availability of integrated primary mental health care and a culture among women of seeking advice were potential facilitators for acceptability of a psychological intervention. Fears of being seen publicly during pregnancy, domestic and farm workload and staff shortages in primary healthcare were potential barriers to acceptability of the intervention. Antenatal care providers such as midwives were considered best placed to deliver interventions, given their close interaction with women during pregnancy.

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Section: Discussionsupporting

confidence: 67%

Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study

Bitew

Keynejad

Honikman

et al. 2020

BMC Pregnancy Childbirth

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“…The low sensitivity of the PHC workers in detection of depression in our study sample is consistent with other studies carried out in Ethiopia and other parts of the world (18,(37)(38)(39). In this current study, less than half (45.5%) of the people with epilepsy and comorbid mental disorders were detected by PHC.…”

Section: Discussionsupporting

confidence: 89%

Performance of Primary Health Care Workers in Detection of Mental Disorders Comorbid with Epilepsy in Rural Ethiopia

Tsigebrhan

Fekadu

Medhin

et al. 2021

Preprint

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Background: Timely detection and management of comorbid mental disorders in people with epilepsy is essential to improve outcomes. The objective of this study was to measure the performance of primary health care (PHC) workers in identifying comorbid mental disorders in people with epilepsy against a standardised reference diagnosis and a screening instrument in rural Ethiopia.Methods: People with active convulsive epilepsy were identified from the community, with confirmatory diagnosis by trained PHC workers. Documented diagnosis of comorbid mental disorders by PHC workers was extracted from clinical records. The standardized reference measure for diagnosing mental disorders was the Operational Criteria for Research (OPCRIT plus) administered by psychiatric nurses. The mental disorder screening scale (Self-Reporting Questionnaire; SRQ-20), was administered by lay data collectors. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PHC worker diagnosis against the reference standard diagnosis was calculated. Logistic regression was used to examine the factors associated with misdiagnosis of comorbid mental disorder by PHC workers. Results: A total of 237 people with epilepsy were evaluated. The prevalence of mental disorders with standardised reference diagnosis was 13.9% (95% confidence interval (CI) 9.6%, 18.2%) and by PHC workers was 6.3% (95%CI 3.2%, 9.4%). The prevalence of common mental disorder using SRQ-20 at optimum cut-off point (9 or above) was 41.5% (95% CI 35.2%, 47.8%). The sensitivity and specificity of PHC workers diagnosis was 21.1% and 96.1%, respectively, compared to the standardised reference diagnosis. In those diagnosed with comorbid mental disorders by PHC workers, only 6 (40%) had SRQ-20 score of 9 or above. When a combination of both diagnostic methods (SRQ-20 score ≥9 and PHC diagnosis of depression) was compared with the standardised reference diagnosis of depression, sensitivity increased to 78.9% (95% (CI) 73.4, 84.4%) with specificity of 59.7% (95% CI 53.2, 66.2%). Only older age was significantly associated with misdiagnosis of comorbid mental disorders by PHC (adjusted odds ratio, 95% CI= 1.06, 1.02 to 1.11).Conclusion: Routine detection of co-morbid mental disorder in people with epilepsy was very low. Combining clinical judgement with use of a screening scale holds promise but needs further evaluation.

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“…Despite the use of a locally developed and validated measure, it is also possible that depression was under-detected in our patient population on the whole. Recent literature across a number of LMIC settings has documented challenges in depression detection among task-shared providers (Rathod et al ., 2018 ; Fekadu et al ., 2020 ). We also included only patients treated primarily at facilities, an approach that excluded patients with mild symptoms treated in in the community.…”

Section: Discussionmentioning

confidence: 99%

Evaluating clinical outcomes of routinely delivered task-shared care for depression in rural Haiti

et al. 2021

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Background There is a growing literature in support of the effectiveness of task-shared mental health interventions in resource-limited settings globally. However, despite evidence that effect sizes are greater in research studies than actual care, the literature is sparse on the impact of such interventions as delivered in routine care. In this paper, we examine the clinical outcomes of routine depression care in a task-shared mental health system established in rural Haiti by the international health care organization Partners In Health, in collaboration with the Haitian Ministry of Health, following the 2010 earthquake. Methods For patients seeking depression care betw|een January 2016 and December 2019, we conducted mixed-effects longitudinal regression to quantify the effect of depression visit dose on symptoms, incorporating interaction effects to examine the relationship between baseline severity and dose. Results 306 patients attended 2052 visits. Each visit was associated with an average reduction of 1.11 in depression score (range 0–39), controlling for sex, age, and days in treatment (95% CI −1.478 to −0.91; p < 0.001). Patients with more severe symptoms experienced greater improvement as a function of visits (p = 0.04). Psychotherapy was provided less frequently and medication more often than expected for patients with moderate symptoms. Conclusions Our findings support the potential positive impact of scaling up routine mental health services in low- and middle-income countries, despite greater than expected variability in service provision, as well as the importance of understanding potential barriers and facilitators to care as they occur in resource-limited settings.

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

Cited by 12 publications

References 34 publications

Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study

Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: a qualitative study

Performance of Primary Health Care Workers in Detection of Mental Disorders Comorbid with Epilepsy in Rural Ethiopia

Evaluating clinical outcomes of routinely delivered task-shared care for depression in rural Haiti

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