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Depression in developing countries: Lessons from Zimbabwe


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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.
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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
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,
Vikram Patel
Beit research fellow
Melanie Abas
Jeremy Broadhead
Department of
University of
Zimbabwe Medical
Charles Todd
senior lecturer
Department of
University of
Zimbabwe Medical
Anthony Reeler
Correspondence to:
V Patel, Sangath
Centre, 841/1Alto
Porvorim, Goa
403521, India
BMJ 2001;322:482–4
482 BMJ VOLUME 322 24 FEBRUARY 2001
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
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
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
Education and debate
483BMJ VOLUME 322 24 FEBRUARY 2001
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)
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
... In all regions of the world, women are disproportionately affected, more vulnerable, and report a higher prevalence of depression compared to men [3]. Most research conducted in Zimbabwe has been done in primary health care settings, and about 25% have reported depressive symptoms [4,5]. Studies have shown high vulnerability to depression among women, especially during the postpartum period [5][6][7] and among people living with HIV [8,9]. ...
... Since the 2000s' , Zimbabwe's formal economy slumped, giving way to marked negative socio-economic impacts on its population, which include worsening unemployment rates, higher rates of poverty, food insecurity, and reliance on the informal economy for livelihoods [58]. The mental health impacts of the poor socio-economic conditions on women were documented in studies that have been conducted among localised and facility-based samples of pregnant women and those living with HIV [4,6]. Some studies have shown an increased prevalence of women's experiences of IPV in the past decade and attributed this to women's lower levels of economic autonomy and household decision-making [6,[59][60][61]. ...
... This study also extends the body of evidence of these associations within the general population. Similar impacts were reported in Zimbabwean studies that involved women attending antenatal clinics, people living with HIV, and adolescents in primary health care settings [4,6,7,79,80]. ...
Full-text available
Background Population-based research on the cumulative effects of socio-economic conditions and trauma exposures, particularly women’s experiences of intimate partner violence (IPV) on their mental health in Zimbabwe, has been limited. Aim Our study aimed to determine the associations between depressive symptoms and socio-economic factors, IPV, and traumatic exposures among a nationally representative sample of women from Zimbabwe. Methods Data was collected from 2905 women who volunteered to participate in a survey that had a multi-stage random sampling design. Depression was measured using the Centre for Epidemiologic Studies Depression Scale (CESD). Traumatic exposures included childhood trauma, life events, and experiences of IPV in the past year. We compared mean depression scores for different categories of variables, conducted linear regression modelling to investigate the bivariate and multivariate associations between variables and depressive symptoms’ outcomes, and applied Structural Equation Modelling (SEM) to investigate the inter-relationships between variables and depressive symptoms’ outcomes. Results Fifteen percent of women self-reported depressive symptoms (CESD score ≥ 21). Higher depressive symptomatology was associated with lower socio-economic status, experiencing IPV, history of childhood and other traumatic events, experiencing non-partner rape, and HIV positive status. Women who could find money in an emergency and sought informal or professional emotional support were less at risk of severe depressive symptoms. Conversely, seeking informal and formal social support was positively associated with more severe depressive symptoms. Conclusion This study contributes evidence showing that economic hardship, exposure to traumas including IPV, living with HIV, and low social support have a cumulative negative toll on mental health among Zimbabwean women from the general population. Programmes and services that respond to the mental ill-health effects reported by Zimbabwean women and prevention interventions that tackle the multiple risk factors for depression that we have identified must be prioritised.
... Limitations of wholesale application of western diagnostic and therapeutic models in non-western cultures have been identified in the literature. These include the context dependence of manifestations of psychological disorders (Littlewood, 1990;Patel et al., 2001;Patel & Winston, 1994;Tseng & Streltzer, 2001); the application of pathogenicity/pathoplasticity models in the diagnosis and treatment of culture bound syndromes (Kleinman & Good, 1985;Kleinman,1988); higher rates in non-western societies of somatic symptoms associated with psychological disorders (Escober, 1996;Myers, 2008;Okulate et al., 2004). However, extreme universalism and radical relativism have been abandoned in favor of a more integrationist approach in cross-cultural application of western theoretical and therapeutic models (Berry & Kim, 1993;Devereux, 1978;Kleinman, 1995;Lonmer & Malpass, 1994). ...
... Early research on the prevalence of depression in Africa between the 1930's and 60's indicated very low incidences of depression and suicide in West Africa (Asuni, 1962;Aubin, 1939;Carothers, 1947;Laubscher, 1938). But more recent literature have raised questions about this assumption and report prevalence rates of depression ranging from 3% to as high as 12% in Africa (Patel et al., 2001;Marsella, 1980;Marsella et al., 1985;Kleinman, 1978;1982). Depression also contributes significantly to morbidity and disability in Africa (Patel et al., 1997). ...
The unique re-entry challenges of African psychologists trained in western universities is evolving strategies for applying general clinical theories and therapeutic techniques in ways that are clinically effective and culturally sensitive. This case study presents the cross-cultural application of Cognitive Behavioral Theory (CBT) for the treatment of Major Depressive Disorder (MDD) with a 12-year-old Nigerian adolescent. Cultural relevance is enhanced by the integration of culture-based trickster folktales in the cross-cultural application of CBT. The strategies for identifying major themes, contents, contexts, the characteristics of the villains and victims, nature of interpersonal relationships, emotions, behavior and consequences in trickster folktales are described. The case study further demonstrates how these components of trickster folktales are used for the implementation of core therapeutic techniques of Cognitive Behavioral Therapy (CBT). The outcomes are discussed in terms of the benefits of the therapeutic application of CBT, efficacy of modified CBT in nonwestern countries, and client’s characteristics important in the treatment of Major Depressive Disorder with culturally modified CBT in adolescents.
... Related to the former, kufungisisa revealed that the idiom communicated how people express distress in relation to a supernatural cause or social stressor (Patel et al. 1995a, b). Related to the latter, studies suggested that ''thinking too much'' in Zimbabwe demonstrated significant overlap with depression and anxiety, thereby signaling that it could inform biomedical diagnoses (Patel et al. 2001). Anthropologists criticized this approach and argued that psychiatric utilization of cultural concepts often reify culture as a static measure (Summerfield 2008). ...
... One study was represented from people originally from Eritrea, Ethiopia, the Democratic Republic of the Congo, Liberia, Malawi, Sierra Leone, Somalia, Tanzania, The Gambia, and Zambia. Most people Persons living with chronic non-communicable diseases, such as diabetes, depression, or cancer 8 14 Abas and Broadhead (1997), Kim et al. (2019), Mendenhall et al. (2019a, b), Patel et al. ( , 1995aPatel et al. ( , 2001 and Peltzer (1989) Patients with perinatal or postnatal depression Scorza et al. (2015) and Tol et al. (2018) Healthcare workers and caregivers 7 13 Abas et al. (1994Abas et al. ( , 2003, Muhwezi et al. (2008), Murray et al. (2017), and Patel et al. (1995b, c) Traditional health practitioners 3 5 Fox (2003), Mbwayao et al. (2013) and Sorsdahl et al. (2010) Non-clinical samples General population with depression 4 7 Avotri andWalters (1999, 2001), Mushavi et al. (2020) and Pike and Williams (2006) General population without depression Ventevogel et al. (2013) and Zraly and Nyirazinyoye (2010) Refugees relocated in Europe 2 4 Markova and Sandal (2016) and Toffle (2015) Almedom et al. (2003) Ethiopia None specified Thinking too much Teferra and Shibre (2012) Ghana Taamebubasugbor Thinking too much Avotri andWalters (1999, 2001) and Avotri (1997) Ghana None specified Thinking too much Scorza et al. (2015) Kenya (Luo) ...
Full-text available
Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom “thinking too much” is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people’s well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom “thinking too much” within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing “thinking too much” across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on “thinking too much” focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. “Thinking too much” reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with “too many thoughts.” This research demonstrates that “thinking too much” is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.
... The aggregate prevalence of depression in elderly population among developing countries; 40.78% [38, 42, 69-73, 75, 76, 78, 81-83, 86, 88, 90, 92-98, 101, 102, 105] was higher than the prevalence in developed countries; 17.05% [50,57,74,77,79,80,84,85,87,89,91,99,100,103,104]. The huge variation might be due to absolute poverty, economic reform programs, limited public health services, civil unrest, and sex inequality are very common in developing countries [117]. ...
Full-text available
Background Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It is also one of the most common geriatric psychiatric disorders and a major risk factor for disability and mortality in elderly patients. Even though depression is a common mental health problem in the elderly population, it is undiagnosed in half of the cases. Several studies showed different and inconsistent prevalence rates in the world. Hence, this study aimed to fill the above gap by producing an average prevalence of depression and associated factors in old age. Objective This study aims to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression and its determinants among old age. Method A comprehensive search of PubMed, Scopus, Web of sciences, Google Scholar, and Psych-info from database inception to January 2020. Moreover, the reference list of selected articles was looked at manually to have further eligible articles. The random-effects model was employed during the analysis. Stata-11 was used to determine the average prevalence of depression among old age. A sub-group analysis and sensitivity analysis were also run. A graphical inspection of the funnel plots and Egger’s publication bias plot test were checked for the occurrence of publication bias. Result A search of the electronic and manual system resulted in 1263 articles. Nevertheless, after the huge screening, 42 relevant studies were identified, including, for this meta-analysis, n = 57,486 elderly populations. The average expected prevalence of depression among old age was 31.74% (95% CI 27.90, 35.59). In the sub-group analysis, the pooled prevalence was higher among developing countries; 40.78% than developed countries; 17.05%), studies utilized Geriatrics Depression Scale-30(GDS-30); 40.60% than studies that used GMS; 18.85%, study instrument, and studies having a lower sample size (40.12%) than studies with the higher sample; 20.19%. Conclusion A high prevalence rate of depression among the old population in the world was unraveled. This study can be considered as an early warning and advised health professionals, health policymakers, and other pertinent stakeholders to take effective control measures and periodic care for the elderly population.
... A similar trend was observed in South Africa: in a survey where respondents were given vignettes with obvious presentations of depression and substance use disorder, they were more likely to attribute those symptoms to stress [17]. Further, in Zimbabwe, depression is commonly characterized as "thinking too much" [43]. These descriptions highlight the variation in language used around depressive symptoms amongst patients in Malawi, which is similar to other southern African countries. ...
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PurposeThere are no validated tools in Malawi to measure mental health stigma. Accordingly, this study evaluates the validity and reliability of a short quantitative instrument to measure depression-related stigma in patients exhibiting depressive symptoms in Malawi.Methods The SHARP study began depression screening in 10 NCD clinics across Malawi in April 2019; recruitment is ongoing. Eligible participants were 18–65 years, had a patient health questionnaire (PHQ-9) score ≥ 5, and were new or current diabetes or hypertension patients. Participants completed a baseline questionnaire that measured depression-related stigma, depressive symptoms, and sociodemographic information. The stigma instrument included a vignette of a depressed woman named Thandi, and participants rated their level of agreement with statements about Thandi’s situation in nine prompts on a 5-point Likert scale. Inter-item reliability was assessed with Cronbach’s alpha. Exploratory factor analysis (EFA) was used to assess structural validity, and OLS regression models were used to assess convergent and divergent validity between measured levels of depression-related stigma and covariates.ResultsThe analysis of patient responses (n = 688) to the stigma tool demonstrated acceptable inter-item reliability across all scales and subsequent subscales of the instrument, with alpha values ranging from 0.70 to 0.87. The EFA demonstrated clustering around three domains: negative affect, treatment carryover, and disclosure carryover. Regression models demonstrated convergence with several covariates and demonstrated divergence as expected.Conclusion This study supports the reliability and validity of a short stigma questionnaire in this population. Future studies should continue to assess the validity of this stigma instrument in this population.
... In Zimbabwe for instance, in-depth interviews with people living with HIV found that they experienced emotional symptoms of stress, thinking too much, and poor concentration (Kidia et al. 2015). In the local language, Shona, the closest idiom for depression, is "kufungisisa" or "thinking too much" (Patel et al. 2001). People with "kufungisisa" describe that thinking too much and poor concentration get in the way of their ability to adhere to HIV treatment (Kidia et al. 2015). ...
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Antiretroviral therapy has transformed HIV into a manageable disease, preventing the progression of HIV to AIDS and improving quality of life for people living with HIV. Increasing the number of people who test for HIV, initiating people living with HIV on anti- retroviral therapy, and supporting them to adhere to their regimen have become central goals to the global strategy to end AIDS by 2030. Although we have seen extraordinary achievements, we are not on track to achieve these goals. People living with HIV face considerable emotional and social challenges which are known to adversely impact on their capacity to engage fully with HIV care and to maintain adherence to HIV medication. Among formally diagnosed mental disorders in people living with HIV, depression has received the most attention. However, in many settings where HIV is endemic, there is no single word for depression and emotional responses may be seen as “weakness” and something to be hidden (Aggarwal et al., Int J Soc Psychiatr 62 (2):198–200, 2016). Sub-Saharan Africa carries the highest burden of HIV and has limited numbers of trained mental health care professionals. This chapter describes the global challenges to reducing new infections and HIV related deaths and illustrates innovative ways in which depression can be treated alongside HIV to allow people living with HIV to benefit from antiretroviral therapy and maintain healthy survival. Examples of innovations from sub- Saharan Africa provide evidence to support the urgent need for integrating mental health care into primary HIV services.
... The Friendship Bench is a brief psychological intervention delivered by trained lay health workers through individual problem-solving therapy (Chibanda et al., 2016). In Zimbabwe, depression is encapsulated in the local concept of 'thinking too much' (kufungisia in Shona) (Patel et al., 2001), and problem-solving therapy has been shown to be effective at managing kufungisisa. In a cluster-randomised trial in urban Zimbabwe, participants receiving the intervention had a significant reduction in common mental disorders at 6 months and lower risk of depression symptoms compared to enhanced usual care [13.7% v. 49.9%; adjusted risk ratio 0.28; 95% confidence interval (CI) 0.22-0.34] ...
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Background There is a large treatment gap for common mental disorders in rural areas of low-income countries. We tested the Friendship Bench as a brief psychological intervention delivered by village health workers (VHWs) in rural Zimbabwe. Methods Rural women identified with depression in a previous trial received weekly home-based problem-solving therapy from VHWs for 6 weeks, and joined a peer-support group. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and Shona Symptom Questionnaire (SSQ). Acceptability was explored through in-depth interviews and focus group discussions. The proportion of women with depression pre- and post-intervention was compared using McNemar's test. Results Ten VHWs delivered problem-solving therapy to 27 women of mean age 33 years; 25 completed six sessions. Women valued an established and trustful relationship with their VHW, which ensured confidentiality and prevented gossip, and reported finding individual problem-solving therapy beneficial. Peer-support meetings provided space to share problems, solutions and skills. The proportion of women with depression or suicidal ideation on the EPDS declined from 68% to 12% [difference 56% (95% confidence interval (CI) 27.0–85.0); p = 0.001], and the proportion scoring high (>7) on the SSQ declined from 52% to 4% [difference 48% (95% CI 24.4–71.6); p < 0.001] after the 6-week intervention. Conclusion VHW-delivered problem-solving therapy and peer-support was acceptable and showed promising results in this pilot evaluation, leading to quantitative and qualitative improvements in mental health among rural Zimbabwean women. Scale-up of the Friendship Bench in rural areas would help close the treatment gap for common mental disorders.
... Our study showed prevalence of PPD of 15.78% and it was supported by studies conducted by Patel et al and Hegde S et al who also concluded that in their studies that incidence of PPD was 11-16%. 9,20 This study showed that there is increased incidence of postpartum depression in primigravida (77.33% more compared to multigravidas (22.66%). This was supported by study conducted by Blackmore et al and Kruthika K et al, who concluded in their study primiparity to be associated to be associated with PPD. ...
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Background: The overall pooled estimate of the prevalence of Postpartum depression in Indian mothers is 22%. In India, women who deliver at a health facility often stays less than 48hrs after delivery and this leaves little opportunity for health personnel to counsel the mother and family members on the signs and symptoms of Postpartum depression (PPD) and when to seek care. So, it is important to screen the postpartum woman for depression. Edinburgh Postnatal Depression Scale is used as an effective tool to assess the level of postnatal depression. The objective of the study was to assess the prevalence and risk factors associated with postpartum depression in the postnatal mothers using EDPS scale.Methods: This study was conducted at A. J. Institute of Medical Sciences and Research Center from January 2019 to May 2020. A total of 950 postnatal mothers were interviewed using Edinburgh Postnatal Depression Scale.Results: A total of 950 cases were studied. Prevalence of Postpartum depression was 15.78%. Increased incidence was seen in the primigravida (12.2%) compared to multigravidas (3.57%). This study showed 1.89% mothers belonging to upper middle class, 5.05% belonging to lower middle class had PPD and 7.26% belonging to upper lower class and 1.57 % patients belonging to lower class had PPD. In our study, 9.26% patients who underwent normal vaginal delivery had PPD and 6.52% of patients who underwent lower segment caesarean section had PPD. In the present study, it was found that 1.05% mothers having IUD babies and 5.2% (96/950) mothers who required NICU admission developed PPD.Conclusions: In this study, the prevalence of postpartum depression was 15.78%. Risk of PPD is more with primigravida, belonging to lower middle class status, mothers who had NVD and mothers of IUD babies. Postpartum depression screening should be an integral part of postnatal care using EPDS scale. A multidisciplinary approach including obstetrician and psychiatrists and counsellor can jointly take care of the depressed mothers. Early screening of the women may reduce the adverse outcomes among both mother and child. Proper counselling should be done to all the pregnant women and the family members for the birth preparedness.
... Depression is a highly prevalent mental health condition [1], it is the second-largest disability contributor affecting millions of people worldwide [1][2][3][4]. In recent years, with the advent of more and more antidepressants, people with depression have more treatment options, but about 30%-50% of patients fail to respond to those treatments [5], suggesting the complexity of the pathological mechanism of depression. ...
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Background: As a prevalent mental health condition, depression is believed to be mediated by stress-induced neuroinflammation. Transcutaneous auricular vagus nerve stimulation (taVNS) has been used in the treatment of depression as the latest neuromodulation therapy. However, the antidepressant mechanism of the treatment at the molecular level is still unclear. Our previous study evaluated the effectiveness of the taVNS in antidepressant-like behavior. The objective of this study is to explore the role of P2X7R mediated hippocampal neuroinflammation in taVNS’s antidepressant effect. Methods: Rat depression model was established by using a chronic unpredicted mild stress (CUMS) method for five weeks. Starting from the 3rd week, taVNS intervention was applied through an electroacupuncture apparatus (HANS-100A, 2/15 Hz, 2mA) for 30 minutes every day for three weeks. Body weight test (BWT) and behavioral assessments such as open field test (OFT) and sucrose preference test (SPT) were conducted on days 0, 7, 14, 21, 28 and 35. The protein levels of P2X7R, NLRP3, caspase-1, IL-1β and IL-18 in the hippocampus were examined using western blot. Moreover, P2X7R expressing cells were detected using immunohistochemistry. Results: The results showed that CUMS induced body weight loss and depression-like behavior in rats. Hippocampal neuroinflammation was upregulated, which was manifested in the higher expression of P2X7R, NLRP3, caspase-1, IL-1β and IL-18. Interestingly, 3 weeks of the taVNS significantly reduced the depression-like behaviors and strengthen the growth of the body, and the CUMS-induced expression of P2X7R, NLRP3, caspase-1, IL-1β and IL-18 was attenuated. We also found that P2X7R was expressed in microglia of the hippocampus. Conclusion: In summary, the taVNS has antidepressant effect. It alleviates hippocampal neuroinflammation, which may be related to the regulation of the initial signal of P2X7R.
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Adequate measurement is an essential component of the assessment of mental health disorders and symptoms such as depression and anxiety. The present study investigated sex-specific differences in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). This comprehensive cross-sectional design study pursued four objectives: measurement invariance of PHQ-9 and GAD-7 between male and female; depression and anxiety prevalence differences; cross-sex differences in the relationship between depression and anxiety; and a comparison of symptom heterogeneity. A sample of 1966 (male = 592; female = 1374; mean age = 21 years) students from South Africa completed the PHQ-9 and the GAD-7. Data analyses for measurement invariance, latent class analysis, inter-variable correlations and group comparisons were conducted in Mplus. The two-dimensional PHQ-9 achieved scalar invariance, while the GAD-7 yielded metric invariance. The somatic and non-somatic latent dimensions of depression were compared and showed no significant difference between male and female groups. The positive relationship between depression and anxiety was also not significantly different between the two groups. While the PHQ-9 symptoms formed three classes in the male group, and four classes in the female group, the GAD-7 had the same number of classes (three) and a similar pattern between the two groups. These findings hold implications for the measurement, assessment and understanding of symptom manifestation and distribution, as well as the treatment of depression and anxiety in South Africa.
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The prevalence of mental morbidity including comorbidity with physical illnesses in a rural primary health centre is very high. Most common entitites in the diagnostic group according to DSM-IU-R were mood disorders (28%), somatoform disorders (27%), and anxiety disorders (17.6%). Majority of them presented with somatic symptoms. There were significant differences in rates for mental disorders when age (particularly 35-44 years), marital status, types of family, and females operated for tubectomy were analysed. The study emphasises the need for effective mental health care to the rural community through primary health centres.
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A study was carried out on the pathways to psychiatric care in Harare, Zimbabwe. Encounter forms were completed on 48 patients admitted to psychiatric beds. Analysis indicated that there was a by-pass of primary care facilities, with a significant number presenting directly to tertiary care facilities, here were lengthy delays before seeking care, but delays while receiving care were moderate. The sample as a whole was composed of major disorders, displaying severe symptoms, and there was a suggestion that some patients become more disturbed along the pathway. As a whole, the sample is very different to samples screened from primary care settings, and the consequences of this are discussed.
The Self-Report Questionnaire (SRQ) is the most widely used psychiatric instrument for screening for mental illness in Africa, but it has rarely been rigorously validated. A total of 302 attenders at two primary care clinics and 10 traditional medical practitioners in two high-density suburbs of Harare were classified as cases (n = 100) or non-cases based on the agreement between a standardized psychiatric interview and the clinical assessment of the health-care provider. The SRQ items were subjected to a discriminant analysis which identified eight items as predictors of caseness. The validity of the 20-item and 8-item SRQ were then compared on this sample, as well as on another sample of 273 rural PHC attenders, using standard validity coefficients and ROC analysis. Some items of the SRQ were found to lack conceptual validity. The optimal cut-off score for the SRQ is 9/10 which is higher than the one used in most studies (6/7). The 8-item version of the instrument compared favourably with the 20-item version in both samples. The 8-item SRQ is shorter and is as valid a detector of psychiatric morbidity as the full version of the SRQ; we recommend this measure be used in future epidemiological research and as a clinical screening instrument with Shona speakers in Zimbabwe.
The authors' goal was to examine the prevalence and experience of psychiatric morbidity among primary care patients with chronic fatigue in Hong Kong. One hundred adult patients with medically unexplained fatigue for 6 or more months were assessed with the Explanatory Model Interview Catalogue, psychopathological rating scales, and an enhanced version of the Structured Clinical Interview for DSM-III-R. The lifetime prevalence of DSM-III-R depressive and anxiety disorders was 54%. Current depressive and anxiety disorders were identified in 28 patients, who exhibited more psychopathology and functional impairment than other patients. Thirty-three patients had somatoform pain disorder, and 30 had undifferentiated somatoform disorder, but most of them could also be diagnosed as having shenjing shuairuo (weakness of nerves) and, to a lesser extent, ICD-10 neurasthenia. Chronic fatigue syndrome diagnosed according to the 1988 Centers for Disease Control criteria was rare (3%) and atypical. Generally, patients mentioned fatigue if asked, but pains (36%), insomnia (20%), and worries (13%) were the most troublesome symptoms. Most patients attributed illness onset to psychosocial sources. Psychiatric morbidity was common among primary care patients with chronic fatigue. Subthreshold psychiatric morbidity was very common and was more validly represented by the disease construct of shenjing shuairuo or neurasthenia than somatoform disorder.
Little is known about the outcome of common mental disorders (CMD) in primary care attenders in low income countries. Two and 12 month (T1 and T2) follow-up of a cohort of cases of CMD (n = 199) recruited from primary health, traditional medical practitioner, and general practitioner clinics in Harare, Zimbabwe. The Shona Symptom Questionnaire (SSQ) was the measure of caseness. The persistence of case level morbidity was recorded in 41% of subjects at 12 months. Of the 134 subjects interviewed at both follow-up points, 49% had recovered by T1 and remained well at T2 while 28% were persistent cases at both T1 and T2. Higher SSQ scores, a psychological illness model, bereavement and disability predicted a poor outcome at both times. Poorer outcome at T1 only was associated with a causal model of witch-craft and an unhappy childhood. Caseness at follow-up was associated with disability and economic deprivation. A quarter of cases of CMD were likely to be ill throughout the 12 month follow-up period. Targeting risk groups for poor outcome for interventions and policy interventions to reduce the impact of economic deprivation may provide a way of tackling CMD in primary care in low income countries.
This study suggests that 'nerves' as presented in a primary care clinic is a lay idiom for emotional distress and documents a relationship between the folk ailment 'nerves' and anxiety and depression. One hundred and forty-nine patients at a Virginia clinic were studied, 47 with 'nerves', and 102 controls. Testing with the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) showed 'nerves' patients to be more anxious and depressed than controls. 'Nerves' patients had a mean GHQ score of 13.0 compared to 5.8 for controls (P less than 0.0001) and a BDI score of 7.6 compared to 2.5 for controls (P less than 0.0001). Testing with the Holmes-Rahe Social Readjustment Rating Scale showed 'nerves' patients to suffer more recent life stresses than controls: 'nerves' patients had a mean score of 187.1 compared to 119.3 for controls (P less than 0.05). 'Nerves' patients had somatic symptoms including gastrointestinal disturbances, headaches and shaking. 'Nerves' is most common among women and housewives, and is often attributed to misfortune and tragedy. The ethnomedical illness 'nerves' encompasses a rich array of cultural meanings reflecting the lifestyle and worldview of its sufferers. Despite its chronic debilitating nature, it is rarely recognized by physicians; it is, however, treated by alternative healers. Clinical implications are discussed and recommendations advanced, among them that physicians work with such healers in the recognition and treatment of 'nerves'.
The challenges presented by the Present State Examination (PSE) in a multi-cultural context are explored. The general approach to the use of this instrument, difficulties with rating items relevant to cultural or subcultural conditions, and particularly the assessment of psychosis are considered, as well as the possibility of additions to and modifications of the PSE-CATEGO system. Though disagreement exists as to whether the research model which the PSE represents is adequate to deal exhaustively with cultural factors, the instrument is useful in cross-cultural research and also in stimulating debate and crystallizing issues.
Non-psychotic mental disorders are very common in primary care settings in Zimbabwe. Sociocultural factors play a profound role in the manifestation of such illness, and local idioms and concepts of illness need to be understood and related to biomedical psychiatric concepts originating in EuroAmerican cultures. One such Shona concept is kufungisisa or thinking too much. This article describes some clinical correlates and the contextual meaning of this term summarising the findings of two studies and the details of a third. Kufungisisa is used to mean both a cause and a symptom of illness. Both patients and care providers view this term as being related to mental, social and spiritual distress. The term is strongly related to biomedical constructs of non-psychotic mental illness, but is not specifically related either to depression or anxiety. We suggest that the conceptual equivalent of this term is "feeling stressed" or, in psychiatric terms as a non-specific "neurotic mental illness". Using the term kufungisisa may increase awareness and recognition of non-psychotic mental illness by the community and primary health care providers.