By Crick Lund, Professor and Director of the Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town
Currently there are more than 300 million people around the globe living with depression. The failure to deliver treatments to tackle depression is not because they don’t exist, but because our health systems and those at the coalface are not equipped to provide the treatment and care required.
This is despite the fact that there is growing understanding of the scale, causes and treatment for the so-called ‘black-dog’. As World Health Day makes the call to talk openly about this illness, the global community needs to find ways to close the ‘treatment gap’ for depression.
There is good evidence for cost-effective interventions such as cognitive behavior therapy and antidepressants, but in most countries these interventions are not being delivered. This is particularly pertinent in developing countries, where health systems are disproportionately struggling under the burden of infectious diseases and maternal and child health challenges, as well as the growing tide of chronic non-communicable diseases. In developing countries, where most of the world’s depressed individuals live, the treatment gap exceeds 75 per cent according to World Mental Health Survey.
Within the Programme for Improving Mental health carE (PRIME), we have been working for 6 years to integrate mental health care into routine low resource care settings, for conditions like depression, alcohol use disorder, psychosis and epilepsy. PRIME focuses on establishing ongoing supervision and support systems, to supplement and sustain training of primary care workers; change management workshops to reorient primary care facilities to integrated chronic care; and improving information systems for better quality care.
In districts in Ethiopia, India, Nepal, South Africa and Uganda, we have worked with the Ministry of Health, the local district health management team, and local NGOs to develop a district mental healthcare plan. Through implementation of these plans we have seen a substantial increase in clinic attendance for these conditions, and in turn, improvements in patients’ mental health.
A case in point is PRIME’s work on improving community level demand for depression care through an innovative Community Informant Detection Tool (CIDT) in Nepal. The CIDT is administered by the Female Community Health Volunteers and members of local “mother groups” – known as ‘community health workers’ (CHWs). The tool includes case vignettes and illustrations which enable the CHWs to identify people in the local community living with depression and many other mental disorders.
The strength of this tool is that it is based on careful ethnographic and clinical research that has identified culturally valid idioms of distress in the Nepali setting. Equipped with this tool, CHWs who are familiar with the local community are able to identify and approach individuals who may be suffering from these conditions and encourage them to attend the local clinic where they can receive support in the form of counselling or assessment for medication. These referrals to the clinic are made discreetly and are entirely voluntary. In using this tool we have seen that the CIDT has accuracy comparable to common screening instruments in primary care clinics, and preliminary findings indicate that it leads to a substantial increase in service use.
The CIDT addresses a common challenge in narrowing the treatment gap, namely that people who suffer from mental illness may not seek treatment because of the stigma associated with their condition, or a belief that they cannot be helped in local clinic settings.
Depression is a highly stigmatised and often hidden health condition. This is why initiatives such as PRIME, which aim to reduce stigma and increase access to care integrated into routine primary healthcare settings are so important. Addressing this massive treatment gap for depression is challenging, but it is possible. The failure to deliver treatments to tackle depression is not because they don’t exist, but because our health systems are not equipped to provide this care. We need to strengthen our health systems so they are fit for the times in which we live. As members of Health Systems Global, we participate within the network to discuss, debate and dissect the challenges facing health systems and how we can address them.
We need greater public awareness, health system strengthening activities, and investment in care. The World Health Organization has shown a $3-5 return for every dollar invested in care for depression and anxiety. In other words we know more than ever before about what needs to be done about depression, how much it costs and what the benefits are. So, on World Health Day, we celebrate the fact that the WHO and many others are working to raise awareness and remove the stigma of mental illness. In doing so, we must and can take action to close the treatment gap.