1. Depression in Southern Africa: Lessons from Zimbabwe Vikram Patel Senior Lecturer, London School of Hygiene & Tropical Medicine Sangath Society,Goa, India

2. The focus Depression: the commonest mental disorder Term used synonymous to Common Mental Disorders, i.e. Includes the broad spectrum of depressive and anxiety disorders Single most important cause of disability amongst mental disorders (Global Burden of Disease Report 1996)

3. The nature of the evidence Series of research studies conducted since the 1980s with the shared features: multidisciplinary intersectoral (academic, health services, NGOs) locally evolved agenda of priorities most studies based in Harare city

4. The authors of the evidence Melanie Abas, Jeremy Broadhead & colleagues Tony Reeler & colleagues Vikram Patel, Charles Todd & colleagues Sekai Nhiwatiwa

5. The type of evidence Ethnographic Studies explanatory models of primary and traditional care attenders explanatory models of nurses and traditional healers Shona models of depression

6. The type of evidence (2) Pathways to Care Pathways to primary care Pathways to traditional healers Pathways to tertiary care

7. The type of evidence (3) Clinical & Diagnostic Studies Phenomenology of depression Development of Shona measures of depression Comparison of emic and etic models of depression

8. The type of evidence (4) Epidemiological Studies Prevalence and risk factors in community, primary care and traditional healer populations Incidence and outcome in primary care, traditional healer and GP attenders Life events and depression in women

9. The type of evidence (5) Special Populations Motherhood and Post-natal depression Refugees from Mozambique & survivors of torture

10. The type of evidence (6) Interventions Training Program for City of Harare Health Department Nurses Psychotherapy for survivors of torture

11. The Lessons Learned The symptoms of depression are largely universal, but the construct is not Depression is commonest amongst marginalized populations Depression has a profound adverse impact on the lives of the sufferers

12. Lesson#1 Many symptoms are Universal... Somatic presentations typical, e.g. Tiredness, heart-ache and sleep problems On inquiry, emotional and cognitive symptoms can be elicited Local idioms common, e.g. Kufungisisa Some “typical symptoms” e.g. Loss of appetite not specific due to physical causes Some symptoms culturally explained, e.g. Visual hallucinations at night

13. ..but the construct is not No Shona term conceptually equivalent for depression Local models, esp. Kufungisisa, show high concordance with depression Causal attributions include relationship problems and supernatural causes; not a “mental” disorder

14. So What? Case finding measures developed in Western cultures can be used with emphasis on conceptual translation Include local idioms in research and training programs The clinical and cultural validity of categorical and “psychiatric” models of depression and anxiety not sustained

15. Lesson#2 The marginalized are vulnerable Women Refugees and torture survivors The poor

16. Women Risk in primary care populations twice that for men @16% of mothers and women living in the community suffer from depression Severe life events, e.g. Marital crises, violence, bereavement, infertility and unwanted pregnancy common Support from close family member protective

17. Survivors of Torture & Trauma Experience of violence common both as a result of war, civil conflict and crime Rates of depression high amongst those who had been victims as well as witnesses

18. The poor Hunger (due to lack of money) and low income risk factors for depression Incidence in those who had experienced hunger due to lack of money: 30% vs 12% Persistence in those whose economic problems had resolved compared to those who had new problems: 31% vs 56%

19. So What? Active efforts to remove the myths that depression are a luxury for the marginalized Integrate mental health into existing health and development activities targeted to the marginalized Potential strategies for prevention in high- risk groups e.g. the bereaved, women with infertility, for poor (micro-credit)

20. Lesson#3 The profound impact Under-recognition & inappropriate treatment Chronicity & Disability Costs of Illness

21. Recognition and Treatment More than 75% of morbidity not diagnosed by health providers, but often recognized Symptomatic treatments predominate (e.g. Vitamins for tiredness; hypnotics for sleep) Minimal efforts to link symptoms with psychosocial stressors Recognition linked to improved outcome in traditional and biomedical health attenders

22. Chronicity & Disability In primary and traditional healer attenders, 40% show morbidity at 12 months In community populations, 30% remain ill at 12 months Twice the number of days spent out of work or in bed both in cross-sectional and longitudinal studies

23. Costs of Illness Multiple consultations with range of health care providers Traditional healers and private GPs expensive Disability impairs economic productivity: A cycle of poverty, disability and depression

24. A Vicious cycle of poverty and mental illness Economic Deprivation: Malnutrition, Low Education, Domestic Violence, Indebtedness etc Ill-Health e.g. Depression & Anxiety, physical ill-health, Alcohol abuse Economic Impact Reduced productivity Disability Increased health costs

25. So What? Aggressive program to raise diagnostic and management skills in health providers Greater availability of antidepressants and non-medical counselors in health facilities Consolidate collaborative linkages between different health sectors (e.g. NGOs, traditional healers, GPs)

26. Secondary Prevention: Educating Health & Social Welfare Professionals Depression is a health priority because it is common, chronic, costly and disabling Patients are already flooding health services: providing care will not increase workload There are effective treatments for Depression Depression is a general health problem, not a psychiatric (or specialist) illness

27. Key Message to health workers Just as we treat other diseases associated with poverty, so too we must treat mental disorders for they are not the “natural” outcome of impoverishment… most poor people are mentally healthy

28. Implications for Policy To realize agenda of integrating mental health in primary health, there is limited scope for stand alone or add-on programs Linkages must be built with other health and social sectors, e.g. Women’s health, Violence prevention, Child Education Policies aimed at increasing gender equality and poverty alleviation will have a profound effect in improving mental health

29. Implications for Research Priorities must be intervention research and linkage research (to date, no trials for depression in primary care from Africa) Regional research priorities with participatory evolution of agendas Collaborations with other developing countries which share similar health systems to avoid reinventing the wheel

30. Shared Health System Characteristics of DCs History of Psychiatry Concepts of Mental Illness Communicable diseases burden Income and gender inequality Globalization and economic reform Medical Pluralism and few specialists Violence and Political Instability

31. Outstanding Research Questions What are the protective factors in those who remain in good mental health, despite stressful circumstances? What interventions speed recovery from depression?

32. Full reference list can be obtained from the paper based on this lecture: Patel, V et al (2001) Depression in Developing Countries: Lessons from ZimbabwePatel, V et al (2001) Depression in Developing Countries: Lessons from Zimbabwe. British Medical JournalBritish Medical Journal or from the author on vikpat@goatelecom.com vikpat@goatelecom.com