Depression in developing countries: Lessons from Zimbabwe

Abstract

Depression is one of the most important causes of morbidity and disability in developing countries. 1 Zim-babwe, in common with other developing nations, has absolute poverty, economic reform programmes, limited public health services, widespread private and traditional healthcare services, civil unrest, cultural diversity, and sex inequality. We have conducted research on depression in Zimbabwe over the past 15 years, covering ethnographic and epidemiological studies in a range of populations. We compared our findings with research from other developing countries and with evidence from industrialised countries. In the context of developing countries we examined the validity of World Health Organization classifications and medical concepts of depression, the public health implications of depression, and the implications for clinical practice and research.

Full text

Education and debate
Depression in developing countries: lessons from Zimbabwe
Vikram Patel, Melanie Abas, Jeremy Broadhead, Charles Todd, Anthony Reeler
Depression is one of the most important causes of
morbidity and disability in developing countries.1Zim-
babwe, in common with other developing nations, has
absolute poverty, economic reform programmes,
limited public health services, widespread private and
traditional healthcare services, civil unrest, cultural
diversity, and sex inequality. We have conducted
research on depression in Zimbabwe over the past 15
years, covering ethnographic and epidemiological
studies in a range of populations. We compared our
findings with research from other developing countries
and with evidence from industrialised countries. In the
context of developing countries we examined the
validity of World Health Organization classifications
and medical concepts of depression, the public health
implications of depression, and the implications for
clinical practice and research.
The validity of Western biomedical
models of depression
In Zimbabwe, multiple somatic complaints such as
headaches and fatigue are the most common
presentations of depression.23 On inquiry, however,
most patients freely admit to cognitive and emotional
symptoms.4Many somatic symptoms, especially those
related to the heart and the head, are cultural
metaphors for fear or grief.Most depressed individuals
attribute their symptoms to “thinking too much”
(kufungisisa), to a supernatural cause, and to social
stressors. Our data confirm the view that although
depression in developing countries often presents with
somatic symptoms, most patients do not attribute their
symptoms to a somatic illness and cannot be said to
have “pure” somatisation.256This means that it is vital
to understand the culture specific terminology used by
patients and to assess mood in those with multiple
somatic complaints.
The labels of distress
—
As in many other languages,
there are no direct equivalents in the Zimbabwean
Shona language for the terms depression or anxiety.7
In the West, these terms are used in everyday language
to describe mood changes and by clinicians to denote
illnesses. In Zimbabwe, the word “depression” is used
almost exclusively to signify an illness, which rarely
presents with emotional symptoms. There is therefore
an incongruity between the term and its relevance for
patients and health workers. As a result, case records
that require health workers to state a diagnosis show
far lower numbers of depression than is expected from
epidemiological studies.8An alternative could be to
identify local concepts that may signify depression.
Shona models of illness, such as thinking too much
(kufungisisa) and a belief that supernatural factors had
caused the symptoms, have been shown to be closely
linked to depression.9–12 Similarly, labels such as
shenjing shuairuo (neurasthenia) in China, ghabrahat
(anxiety) in India, pelo y tata (heart too much) in
Botswana, and “nerves” in some Latin American and
South African societies are described as local illness
categories that overlap with depression.13–16
Diagnosis and classification
—
The WHO self report-
ing questionnaire was used in studies in Zimbabwe in
the 1980s.17 Subsequently,the 14 item Shona symptom
questionnaire (SSQ), written in the local language, was
developed.18 The two questionnaires classified more
than 80% of primary care attenders in the same way,
suggesting a high degree of agreement.19 The
symptoms represented in the items of the Shona ques-
tionnaire were remarkably similar to symptoms in
instruments used to measure depression in the West.
Analysis of main symptom scores showed that anxiety-
depression and panic-phobias were strongly related.2
ICD-10 (international classification of diseases, 10th
revision) currently categorises depression separately
from anxiety.Data from Zimbabwe,however,show that
anxiety and depression are strongly associated with
each other.2These findings are similar to those from
other cultural settings20 and from the recent multina-
tional studies of common mental disorders,21 suggest-
Summary points
Depression is common in developing countries,
especially in women, with a vicious cycle of
poverty, depression, and disability
Depression typically presents with multiple
physical symptoms of chronic duration, though
simple questions can often elicit psychological
symptoms
Anxiety often coexists with depression, and
multiple diagnostic categories for common
mental disorders have limited validity
Low recognition and treatment of symptoms
rather than cause are the hallmarks of current
practice in general health care
University of
Zimbabwe Medical
School, Harare,
Zimbabwe
Vikram Patel
Beit research fellow
Melanie Abas
lecturer
Jeremy Broadhead
lecturer
Department of
Community
Medicine,
University of
Zimbabwe Medical
School
Charles Todd
senior lecturer
Department of
Psychiatry,
University of
Zimbabwe Medical
School
Anthony Reeler
lecturer
Correspondence to:
V Patel, Sangath
Centre, 841/1Alto
Porvorim, Goa
403521, India
vikpat@
goatelecom.com
BMJ 2001;322:482–4
482 BMJ VOLUME 322 24 FEBRUARY 2001 bmj.com

ing lack of a clear distinction between depression and
generalised anxiety in primary care. Therefore, there is
a need to review the validity of categorical diagnoses
used in current guidelines (such as ICD-10) and to
train health workers to diagnose and treat depression
comorbid with anxiety.
The public health relevance of depression
In one study among adults a quarter of people attend-
ing primary care and a third attending traditional
healer attenders had depression.12 Up to 40% were still
ill at 12 months,22 and the incidence of new episodes
was 16%.23 The one month prevalence of depressive
and anxiety disorders was 15.7% in a random sample
of women from the community,4and the proportion
with postnatal depression was 16%.24 Such high rates of
depression, particularly in women, have been reported
in several recent studies from other developing
countries,25 with some community surveys reporting
prevalence rates exceeding 50%.26
Risk factors for depression
—
In a clinic based
case-control study, depression was significantly associ-
ated with female sex. After adjustment for age, sex, and
clinic site, depression was significantly associated with
chronicity of illness ( > 1 month), number of present-
ing complaints (>3), lack of cash savings, job loss, and
infertility in the previous year.11 Persistence of
depression at 12 months was associated with
bereavement, higher morbidity scores, psychological
illness, and greater disability.22 Among the community
sample of women, severe life events were significantly
associated with the onset of depression, usually within
one month.27 Significant events were marital or other
relationship crises, deaths, and events directly related
to infertility or to an unwanted pregnancy. Women
who had a severe event were less likely to develop
depression if they had social support after the event
and more likely to become depressed if they had been
separated from their mother in childhood for more
than a year. Evidence from Western countries is
remarkably similar,28 suggesting common mechanisms
across cultures for the development of depression.
Events involving loss of primary sources of self esteem
seem to predict depression in societies in which this
has been studied.29 Women in Zimbabwe have a high
rate of such events, which may partly explain their high
incidence of depression. Evidence from the West
suggests that vulnerability to events accumulates
—
for
example, from childhood to adulthood.28
Cycle of poverty,disability, and depression
—
The relation
between depression and change in economic status has
been examined in cohorts derived from a clinic based
case-control study.22 23 Economic stressors, such as hav-
ing experienced hunger in the past month, were asso-
ciated with both the onset of new episodes of
depression and the persistence of existing episodes.
Disability scores (including social, functional, and
psychological) were twice as high in subjects with
depression throughout the follow up period, inde-
pendent of economic status.11 22 23 Depressed people
visit health services frequently and also consult private
doctors and traditional medical practitioners. This is
associated with high financial costs of health care.11 30
Similar findings in other developing countries suggest
a vicious cycle of poverty, depression, illness, disability,
increased health costs, inadequate health care, and
further impoverishment.25 26 31
Implications for clinical management
—
In Zimbabwe
most patients consult both the medical and traditional
healthcare systems.12 32 Few consult a mental health
professional. Primary care providers are usually
consulted first, but patients move on to providers of
traditional care as the illness becomes chronic. Patients’
perceptions of their illnesses and costs are the key fac-
tors in the choice between providers. Primary
healthcare workers and private general practitioners
commonly prescribe non-specific treatments such as
analgesics, vitamins, and hypnotics.30 32 Recognition of
psychiatric morbidity by either traditional healers or
medical staff was found to be related to a better
outcome.22 In Zimbabwe, this benefit is unlikely to be
the result of antidepressant medications as they are
rarely prescribed. In industrialised countries, ran-
domised trials of antidepressant and brief psychologi-
cal treatments in primary care have shown robust
improvements in outcome.33 There are no comparable
data from developing countries. There are, however,
descriptions of initiatives to train primary care
workers34 and pilots showing the effectiveness of brief
counselling for survivors of torture35 and of cognitive
behaviour therapy for multiple somatic symptoms.36
Conclusions
Depression in Zimbabwe is common, especially in
women, and causes considerable disability. Most
patients do not receive effective treatment. The
symptoms are fairly universal and methods to identify
patients with depression that have been developed in
Life events and economic stressors are associated with episodes of
depression
DURELL McKENNA/PANOS PICTURES
Education and debate
483BMJ VOLUME 322 24 FEBRUARY 2001 bmj.com

one culture can be used in others, as long as careful
attention is given to conceptual translation. Somatic
symptoms are the commonest presentations but are
not specific for diagnosis.Chronic, multiple symptoms,
however, should signal the possibility of depression
and should lead to specific inquiry about cognitive and
psychological symptoms. Most patients with a mental
disorder have a mixture of depressive and anxiety dis-
order. Dimensional constructs (such as common men-
tal disorders) are more useful in primary care settings
than categorical classifications. Culture specific con-
cepts of mental illness, which are similar to the medical
model of depression, can be identified and incorpo-
rated into the training of health workers. Training
guidelines should be based on the clinical problem
solving approach rather than the categorical diagnos-
tic approach, therefore the WHO guidelines37 should
be modified with these points in mind.
The implications of our study are that, firstly,
depression should be included in the general medical
training for all levels of health workers and, secondly,
health policy in developing countries needs to
recognise the considerable public health burden of
depression, particularly in marginalised sections of the
community.Key health service issues include strength-
ening of supervision and training for general health
staff, putting antidepressants on to the essential drugs
lists, limiting the use of medicines that just treat symp-
toms, and forming referral networks between tra-
ditional healers and voluntary organisations. Preven-
tive strategies for depression should include social
policies aimed at increasing sex equality, eliminating
poverty, and strengthening social support networks for
populations at risk. Future research must focus on cost
effectiveness studies of treatments for depression and
the identification of protective factors that enable
people living in deprived circumstances to remain in
good mental health.38
We acknowledge the active collaboration of many members of
the Department of Psychiatry, University of Zimbabwe, staff of
the City of Harare Health Department, traditional healers in the
study areas, and staff of ZIMNAMH in the research.
Funding: Beit Medical Trust, IDRC (Canada), the Zimbabwe
Ministry of Health, GTZ (Zimbabwe), the University of
Zimbabwe, MacArthur Foundation, NORAD (Zimbabwe),
Maudsley Mapother Trust, and Royal College of Psychiatrists Eli
Lilly Award (UK).
Competing interests: None declared.
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(Accepted 11 October 2000)
Endpiece
Where truth lies
All writers know that the truth is in the fiction. That’s
where the spiritual thermometer gives its reading.
Martin Amis, All from experience,
London: Jonathan Cape, 2000
Education and debate
484 BMJ VOLUME 322 24 FEBRUARY 2001 bmj.com