Depression: epidemic or pseudo-epidemic?

A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria

BACKGROUND

Depression is common in primary care and is often unrecognized and untreated. Studies are needed to demonstrate the feasibility of implementing evidence-based depression care provided by primary health care workers (PHCWs) in sub-Saharan Africa. We carried out a pilot two-parallel arm cluster randomized controlled trial of a package of care for depression in primary care.

METHODS

Six primary health care centers (PHCC) in two Local Government Areas of Oyo State, South West Nigeria were randomized into 3 intervention and 3 control clinics. Three PHCWs were selected for training from each of the participating clinics. The PHCWs from the intervention clinics were trained to deliver a manualized multicomponent stepped care intervention package for depression consisting of psychoeducation, activity scheduling, problem solving treatment and medication for severe depression. Providers from the control clinics delivered care as usual, enhanced by a refresher training on depression diagnosis and management. Outcome measures Patient's Health Questionnaire (PHQ-9), WHO quality of Life instrument (WHOQOL-Bref) and the WHO disability assessment schedule (WHODAS) were administered in the participants' home at baseline, 3 and 6 months.

RESULTS

About 98% of the consecutive attendees to the clinics agreed to have the screening interview. Of those screened, 284 (22.7%) were positive (PHQ-9 score ≥ 8) and 234 gave consent for inclusion in the study: 165 from intervention and 69 from control clinics. The rates of eligible and consenting participants were similar in the control and intervention arms. In all 85.9% (92.8% in intervention and 83% in control) of the participants were successfully administered outcome assessments at 6 months. The PHCWs had little difficulty in delivering the intervention package. At 6 months follow up, depression symptoms had improved in 73.0% from the intervention arm compared to 51.6% control. Compared to the mean scores at baseline, there was improvement in the mean scores on all outcome measures in both arms at six months.

CONCLUSION

The results provide support for the feasibility of conducting a fully-powered randomized study in this setting and suggest that the instruments used may have the potential to detect differences between the arms.

TRIAL REGISTRATION NUMBER

ISRCTN46754188 (ISRTCN registry at isrtcn.com); registered 23 September 2013, details of the pilot study added 12/02/2015.

The Meaning of Coping for Psychiatric Patients

Contemporary psychiatric theory holds that a precipitant of major mental illness is the inability of some vulnerable individuals to cope with the difficulties of everyday life. Such mentally ill people are characterized as having deficient, dysfunctional, or absent coping skills. Recently, researchers have exerted considerable effort to distinguish between productive and nonproductive coping. In this article, we argue that not only are such conceptualizations reliant on reductive, circular logic, but they also miss the essentially rational, local, and individual nature of coping in psychiatric patients' lives. We used semistructured interviews and thematic analyses of psychiatric patients' descriptions of their coping. Patients reported that professional intervention reduced their ability to cope, that they distrusted the mental health system and its professionals, that coping mechanisms were misinterpreted, that situational crises modulated coping, and that sometimes coping was just "not coping." We argue for a more respectful, nuanced understanding of coping among mental health professionals.

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force's findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.

Epidemiology and symptomatology of depression in Sri Lanka: a cross-sectional population-based survey in Colombo District

BACKGROUND

It is important to understand the nature of depression in non-Western and lower-income countries, but little such research exists. This study aimed to examine the characteristic features of depression in Sri Lanka, and to identify environmental risk factors.

METHODS

Depression diagnoses, symptoms and impairment were measured using the Composite International Diagnostic Interview, in a population-based sample of 6014 twins and non-twins in the Colombo region of Sri Lanka (the CoTASS sample). Socio-demographic factors and environments were assessed via questionnaires.

RESULTS

Lifetime-ever depression was reported in 6.6% of participants, rising to 11.2% if the functional impairment criterion was excluded. The symptom profile of depression and its socio-demographic associations were very comparable to those in Western and more economically developed countries, whether functional impairment was included in the definition or not. Standard of living was independently associated with depression, especially among men at the more deprived end of the distribution. Specific associations were found with both financial wellbeing and material characteristics of the home environment.

LIMITATIONS

The observational associations identified are cross-sectional, so do not necessarily imply causal links.

CONCLUSIONS

Aside from a lower prevalence, depression is very similar in this predominantly urban Sri Lankan sample to higher-income, Western countries, and may be under-identified due to a relatively low cultural appropriateness of the assessment of impairment. Under Sri Lanka's cultural and environmental context, certain aspects of the material environment are associated with depression among certain segments of society, perhaps because of their particular link to social status and social networks.

Are psychiatrists an endangered species? Observations on internal and external challenges to the profession

Based on recently voiced concerns about a crisis in psychiatry, six challenges to our profession are identified and discussed. As we approach the revisions of ICD-10 and DSM-IV, the validity of psychiatry's diagnostic definitions and classification systems is increasingly questioned also from inside psychiatry. In addition, confidence in the results of therapeutic intervention studies is waning. A further challenge is the existence of de facto subgroups with opposing ideologies, a situation which is responsible for an unclear role profile of the psychiatrist. Challenges from outside include mounting patient and carer criticism, intrusion of other professions into psychiatry's traditional field of competence, and psychiatry's low status within medicine and in society in general. Studies suggest that the decline of the recruitment into psychiatry, as it is observed in many countries, might be related to problems arising from these challenges. It is unclear whether psychiatry will survive as a unitary medical discipline or whether those segments which are more rewarding, both financially and in status, will break away, leaving the unattractive tasks to carry out by what remains of psychiatry. The demise of the generalist and the rise of the specialist in modern society may contribute to this development. Attempts are underway by professional bodies to define the profile of a "general psychiatrist". Such discussions should be complemented by an analysis of the incentives which contribute to the centrifugal tendencies in psychiatry.

Genetic and environmental contributions to depression in Sri Lanka

BACKGROUND

Susceptibility to depression results from genetic and non-familially shared environmental influences in high-income, Western countries. Environments may play a different role for populations in different contexts.

AIMS

To examine heritability of depression in the first large, population-based twin study in a low-income country.

METHOD

Lifetime depression and a broader measure of depression susceptibility (D-probe) were assessed in 3908 adult twins in Sri Lanka (the CoTASS study).

RESULTS

There were gender differences for the broad definition (D-probe), with a higher genetic contribution in females (61%) than males (4%). Results were similar for depression, but the prevalence was too low to estimate heritability for males.

CONCLUSIONS

Genetic influences on depression in women appear to be at least as strong in this Sri Lankan sample as in higher-income countries. Conclusions are less clear for men but suggest a larger role for environments rather than genes. The nature as well as the magnitude of environmental influences may also differ across populations.

How scientifically valid is the knowledge base of global mental health?

Mental health is a construct that cannot be seen as independent of culture, society and situation. Derek Summerfield argues that Western definitions and solutions cannot be routinely applied to people in developing countries

Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981-2004

OBJECTIVE

To describe trends in prevalence and incidence of depressive disorder in a cohort from Eastern Baltimore.

METHOD

Twenty-three-year-old longitudinal cohort, the Baltimore Epidemiologic Catchment Area Follow-up. Participants were selected probabilistically from the household population in 1981, and interviewed in 1981, 1993, and 2004. Diagnoses were made via the Diagnostic Interview Schedule according to successive editions of the American Psychiatric Association Diagnostic and Statistical Manual.

RESULTS

Older age, lower education, non-White race, and cognitive impairment are independent predictors of attrition due to death and loss of contact, but depressive disorder is not related to attrition. Prevalence rates rise for females between 1981, 1993, and 2004. Incidence rates in the period 1993-2004 are lower than the period 1981-1993, suggesting the rise in prevalence is due to increasing chronicity.

CONCLUSION

There has been a rise in the prevalence of depression in the prior quarter century among middle-aged females.