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Undertreatment of people with major depressive disorder in 21 countries

  • Graham Thornicroft (a1), Somnath Chatterji (a2), Sara Evans-Lacko (a1), Michael Gruber (a3), Nancy Sampson (a3), Sergio Aguilar-Gaxiola (a4), Ali Al-Hamzawi (a5), Jordi Alonso (a6), Laura Andrade (a7), Guilherme Borges (a8), Ronny Bruffaerts (a9), Brendan Bunting (a10), Jose Miguel Caldas de Almeida (a11), Silvia Florescu (a12), Giovanni de Girolamo (a13), Oye Gureje (a14), Josep Maria Haro (a15), Yanling He (a16), Hristo Hinkov (a17), Elie Karam (a18), Norito Kawakami (a19), Sing Lee (a20), Fernando Navarro-Mateu (a21), Marina Piazza (a22), Jose Posada-Villa (a23), Yolanda Torres de Galvis (a24) and Ronald C. Kessler (a3)...
Abstract
Background

Major depressive disorder (MDD) is a leading cause of disability worldwide.

Aims

To examine the: (a) 12-month prevalence of DSM-IV MDD; (b) proportion aware that they have a problem needing treatment and who want care; (c) proportion of the latter receiving treatment; and (d) proportion of such treatment meeting minimal standards.

Method

Representative community household surveys from 21 countries as part of the World Health Organization World Mental Health Surveys.

Results

Of 51 547 respondents, 4.6% met 12-month criteria for DSM-IV MDD and of these 56.7% reported needing treatment. Among those who recognised their need for treatment, most (71.1%) made at least one visit to a service provider. Among those who received treatment, only 41.0% received treatment that met minimal standards. This resulted in only 16.5% of all individuals with 12-month MDD receiving minimally adequate treatment.

Conclusions

Only a minority of participants with MDD received minimally adequate treatment: 1 in 5 people in high-income and 1 in 27 in low-/lower-middle-income countries. Scaling up care for MDD requires fundamental transformations in community education and outreach, supply of treatment and quality of services.

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Copyright
Corresponding author
Graham Thornicroft, King's College London, HSR Department – Box PO29, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London SE5 8AF, UK. Email: graham.thornicroft@kcl.ac.uk
Footnotes
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The paper is submitted on behalf of the World Health Organization World Mental Health Survey collaborators – see the Appendix for details.

Declaration of interest

In the past 3 years, R.C.K. received support for his epidemiological studies from Sanofi Aventis, was a consultant for Johnson & Johnson Wellness and Prevention and served on an advisory board for the Johnson & Johnson Services Inc. Lake Nona Life Project. R.C.K. is a co-owner of DataStat Inc., a market research firm that carries out healthcare research.

Footnotes
References
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Undertreatment of people with major depressive disorder in 21 countries

  • Graham Thornicroft (a1), Somnath Chatterji (a2), Sara Evans-Lacko (a1), Michael Gruber (a3), Nancy Sampson (a3), Sergio Aguilar-Gaxiola (a4), Ali Al-Hamzawi (a5), Jordi Alonso (a6), Laura Andrade (a7), Guilherme Borges (a8), Ronny Bruffaerts (a9), Brendan Bunting (a10), Jose Miguel Caldas de Almeida (a11), Silvia Florescu (a12), Giovanni de Girolamo (a13), Oye Gureje (a14), Josep Maria Haro (a15), Yanling He (a16), Hristo Hinkov (a17), Elie Karam (a18), Norito Kawakami (a19), Sing Lee (a20), Fernando Navarro-Mateu (a21), Marina Piazza (a22), Jose Posada-Villa (a23), Yolanda Torres de Galvis (a24) and Ronald C. Kessler (a3)...
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eLetters

Re: Western depression is not a universal condition

Emily R Kruger, Assistant Psychologist, Child and Adolescent Mental Health Service (CAMHS)
03 April 2017

I am in complete agreement with this piece informatively written by Derek Summerfield, of whom has made a valid point regarding the issue of generalising 'depression' in the same manor, within non-western countries. Not only does this not take into account people's individual cultures and their way of living, but it fails to recognise the varying risk factors that are diverse across the world that we live in.

In view of the DSM-5, the biomedical approach contends that depression is a universal condition that can be applied across many different cultures; however, for years people have been debating this (1) by arguing that symptoms of depression manifest differently across cultures. It is therefore important to note that this is not an original argument, and there are many views on this matter.

In regards to some noteworthy research, it has also been stated that a diagnosis of depression is based on western ideology regarding self and the internal state. Lewis-Fernandez and Kleinman (2) explain this further by stating that depression is viewed as an individualised, internal illness in the western world however; this cannot possibly be generalised to non-western cultures that thrive in a collectivist society, whereby the ‘self’ is viewed very differently. Within this, a clinical diagnosis of depression fails to incorporate the views of the self in collectivist cultures, whereby shared emotions may influence depression rather than one's internal thoughts.

I feel that on a whole, this present paper written by Summerfield links heavily to the medical model, and the debate as to whether depression should be viewed as a ‘disorder’, or whether individual symptoms one is suffering with should be treated separately. If this was the case, I believe that people in non-western cultures would be treated as individuals with personal experiences, rather than people who are required to fit into a westernised clinical check-list.

1)Chentsova-Dutton YE, Tsai JL. Self-focused attention and emotional response: The role of culture Journal of Personality and Social Psychology 2010; 98: 507-519

2)Lewis-Fernandez R, Kleinman A. Culture, personality and psychopathology. Journal of Abnormal Psychology 1994; 103: 67–71

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Conflict of interest: None Declared

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Huge economic burden of undertreated depression

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology, Private Clinic, Thessaloniki, Greece
14 March 2017

If all PMs and health policy strategists were informed on staggering costs of disregarding mental healthcare, things would be different.

The annual Global Economic Burden of mental illnesses was $2.5 trillion in 2010, and is projected to become $6 trillion by 2030. [5][4][6]

The total cost of all new cases of cancer worldwide in 2030 will only rise to $458 billion.
/>The total cost of all diabetes cases worldwide in 2030 will only rise to $700 billion.

References

[1] http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30024-4/fulltext

[2] http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf

[3] http://www.bmj.com/content/343/bmj.d6370 ... More

Conflict of interest: None Declared

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Western depression is not a universal condition

Derek A Summerfield, consultant psychiatrist, South London & Maudsley NHS Trust
07 February 2017

Thornicroft et al assume that ‘mental disorder’ is an entity essentially lying outside situation, society and culture, and is identifiable anywhere using a common (Western) methodology- here the CIDI (1). Biologically triumphalist studies like this simply have to be challenged because once something – in this case, depression as a unitary pathological entity arising naturalistically anywhere in the world- is declared real, it becomes real in its consequences.

The authors cite at the outset the WHO claim that depression is the first or second most burdensome disease disability-wise in the world. To me this is perhaps the most bizarre statement to come out of a major medical institution in the modern era: more burdensome than, say, AIDS or tuberculosis, which each take around 1.5 million lives per year, and with millions more disabled over years? The disability-adjusted life years metric (DALY) on which WHO claims rest is epistemologically lamentable applied in this way.

CIDI is described by the WHO as a survey instrument produced for standard use across cultures. This does not mean it is valid. The authors concede that “no attempt was made to go beyond DSM IV criteria to assess depression-equivalents that might be unique to specific countries”, and that “the reliability and validity of diagnoses made with CIDI may vary across countries”. This doesn’t appear to deter the authors yet it renders their conclusions risible.

Western psychiatric templates simply cannot generate a universally valid knowledge base since they fail the core test of validity, which relates to the ‘nature of reality’ of subjects under study. Invalid approaches cannot be redeemed by “reliability”- using a standard, reproducible method, as here- since the very ground they stand on is unsound (2). This is hardly surprising since, organic categories apart, diagnoses are merely descriptive constructions, conceptual devices, drawn up by us, not by nature.

Ironically there is a WHO study, reported by Sir David Goldberg et al, which showed that in 15 cities around the world those people recognised as depressed by doctors did no better (indeed they did slightly worse) than comparable others who were not so recognised (3).

Depression has no exact equivalent in non-Western cultures, not least because these do not share a Western ethnopsychology that defines ‘emotion’ as internal, often biological, unintentioned, distinct from cognition, and a feature of individuals rather than situations (4). Here we see the Western psychological discourse setting out abroad to instruct, regulate and modernise, presenting contemporary Western mentality and ways of being a person as definitive anywhere. Why should this imperialism suit the rest of the world? (5)

Half the countries surveyed here were poor ones. What is “mental health” in the poverty-haunted, near-broken parts of the world? Thinking of my own country, Zimbabwe, how would invalid approaches distinguish between depression and situational distress? Does Africa need the category of Western depression at all, and does it need the marketing of anti-depressants which will ride in on the back of papers like this in international psychiatric journals? I think not.

1.Thornicroft G, Chatterji S, Evans-Lacko S et al. Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry 2017;210:119-124.

2.Summerfield D. How scientifically valid is the knowledge base of global mental health? BMJ 2008;336:992-994.

3.Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on the outcome of major depression in primary care: A naturalistic study in 15 cities. Br J Gen Pract 1998;48:1840-1844.

4.Lutz C. Depression and the translation of emotional worlds. In: Culture And Depression. Studies In The Anthropology and Cross-Cultural Psychiatry of Affect and Disorder (eds A Kleinman, B Good) 63-110. University of California Press, 1985.

5.Summerfield D. Afterword: Against “global mental health”. Transcult Psych 2012; 49: 1-12.

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Conflict of interest: None Declared

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International suicide rates versus adequate treatments

Ross J. Baldessarini, Professor of Psychiatry, Department of Psychiatry, Harvard Medical School International Consortium for Mood & Psychotic Disorders Research, McLean Hospit
Leonardo Tondo, Professor of Psychiatry, Department of Psychiatry, Harvard Medical School International Consortium for Mood & Psychotic Disorders Research, McLean Hospit
14 December 2016

Sir:

Thornicroft and colleagues recently reported on undertreatment of people with major depressive disorder (MDD) in 21 countries [1]. Their conclusions suggest that better diagnosis and treatment of major depression worldwide, particularly in underdeveloped countries, should improve health outcomes. Such improvements should contribute, in particular, to reducing rates of suicide, which are closely associated with MDD [2].

Accordingly, we considered relationships between the reported national rates of treatment for MDD overall or for identified cases who wanted treatment [1], versus annual suicide rates as reported by the World Health Organization [3]. In data available from12 countries of greater versus 8 of lesser wealth listed by Thornicroft et al. [1], annual suicide rates averaged, respectively, 9.48 [95%CI: 6.80–12.2] versus 5.31 [2.23–8.40] per 100,000 (t=2.27, p=0.04). Rates of minimally adequate treatment of identified MDD cases differed correspondingly: 48.2% [40.9–55.5] versus 28.7% [14.0–43.4] among those who wanted treatment (t=3.01, p=0.008), and 23.4% [19.6–27.3] versus 7.36% [3.35–11.4] for MDD cases overall (t=6.28, p<0.0001). Moreover, there was a strong, direct, linear correlation of greater rates of treatment (by either measure) and higher suicide rates (rs = 0.644, p=0.005; slope for rates of treatment of those wanting it: 0.154 [0.049–0.260], t=3.09, p=0.006).

These observations are sobering in indicating: [a] surprisingly low observed rates of minimally adequate treatment for MDD, especially in less affluent countries, and [b] lack of lower suicide rates with greater rates of treatment. However, we propose that the various numerical estimates involved are susceptible to errors of ascertainment. Notably, the relatively low reported suicide rates in less affluent regions may, at least partly, reflect incomplete reporting. Low observed rates of treatment, instead, probably reflect complex differences that may include ascertainment errors, less access to care (lower clinician density and economic factors) and cultural factors, between relatively wealthy and poor countries. Efforts to reduce morbidity and mortality, including reduction of suicide risks, by improving recognition and treatment of MDD are highly laudable. However, their demonstration may require relatively challenging, within-region, outcome measures, such as valid comparisons of suicide rates before versus after interventions aimed at improving clinical care.

Ross J. Baldessarini, MD

Leonardo Tondo, MD, MS

Department of Psychiatry, Harvard Medical School

International Consortium for Mood & Psychotic Disorders Research, McLean Hospital

Boston, Massachusetts



References

1.Thornicroft G, Chatterji S, Evans-Lacko S, Gruber M, Sampson N, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Andrade L, Borges G, Bruffaerts R, Bunting B, Caldas de Almeida JM, Florescu S, de Girolamo G, Gureje O, Haro JM, He Y, Hinkov H, Karam E, Kawakami N, Lee S, Navarro-Mateu F, Piazza M, Posada-Villa J, Torres de Galvis Y, Kessler RC. Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry 2016; Dec 1. pii: bjp.bp.116.188078 [Epub ahead of print (1 Dec)].

2.Tondo L, Baldessarini RJ. Suicidal behavior in mood disorders: response to pharmacological treatment. Curr Psychiatry Rep 2016;18(9):88–99.

3.World Health Organization (WHO). Suicide rates: data by country. Accessible at: http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en, accessed 8 december 2016.

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