Editorial: Treating depression in the developing world

Despite the contention by the WHO (2001a) that depression is a major cause of disability in the world, this illness receives little programmatic and research attention in developing countries. There are several reasons for this. First, it is believed in many circles that depression is a ‘Western’ diagnostic entity with limited public health relevance in other cultures. This belief persists despite evidence of numerous studies across the developing world which have shown that depression is highly prevalent and associated with disability and poverty (WHO 2001a). Qualitative studies have confirmed the clinical validity of the illness construct of depression in non-Western cultures (Bolton 2001; Rodrigues et al. 2003; Wilk the numbers of psychologists and social workers working in the field of mental health are even smaller. As a result of this scarcity of mental health resources, the overwhelming majority of persons with depression have little chance of specialist treatment. Studies in primary-care settings typically show that the vast majority of patients do not receive evidence-based treatment for depression (Linden et al. 1999). Until recently, all evidence for effective treatment of depression was derived from randomized-controlled trials in developed countries, and the cross-national applicability of these studies had been questioned on a number of grounds (Patel 2000). These include cultural factors such as the local acceptability of specific interventions; health system factors such as the availability of human resources to implement interventions; costs and availability of medications; and individual patient factors such as pharmacodynamic variations between populations – all of which could influence the cross-cultural validity of treatment evidence. Thus we know that millions of people suffer with depression and that there is a strong association with poverty and disability, but there was little research on what developing countries with meagre mental health resources and low awareness could do for depressed patients. Last year, three randomized-controlled trials were published on the efficacy and cost-effectiveness of the treatment of depression in India, Uganda and Chile (Araya et al. 2003; Bolton et al. 2003; Patel et al. 2003). These trials shared a number of features, including preparatory work in which measures for depression were translated and validated for the local culture; and epidemiological studies undertaken to estimate prevalence and risk factors (Araya et al. 1994; Patel et al. 1998; Bolton however, only the two trials which employed a group-based intervention found that it was efficacious. The individual psychological intervention used in India was no better than placebo; this lack of efficacy was, in all probability, due to the culturally unacceptable nature of a purely ‘talking’ intervention by a professional therapist. However, group therapy that emphasizes support and sharing between members of the same community was highly effective in Uganda and Chile. These group interventions were also part of a bottom-up approach in which people from the local area led the intervention. Anti-depressants were used in two trials: as a discrete treatment (in India), and as part of a multi-modal intervention along with group therapy (in Chile). The Indian trial demonstrated the superiority of antidepressants over placebo, particularly in facilitating an early recovery. However, adherence to treatment declined rapidly after 2 months, which may have caused the absence of any significant effects at the 6- and 12-month timepoints. In the Chilean study, most patients in both groups received medication, the main difference being that the stepped-care group received appropriate doses for longer periods of time. Four factors might have influenced this: structured guidelines for medication, advocacy on behalf of the patient by the group leader when approaching the prescribing doctor, peer support, and empowerment of patients to take an active role to ensure that guidelines were enforced. The Ugandan trial employed no drug therapy at all. All trials had a measure of function or disability which showed significant improvements in the treatment group; the Indian trial showed that treating depression produces a significant reduction in total health care costs. At each study site, we found evidence for efficacy of depression interventions that we believe are locally feasible and cost-effective among the poorest people in that setting. The associated improvement in function suggests benefits beyond mental health and beyond the individual who was treated, as improved function benefits both family and community and enables the person to cope better with their social and economic difficulties. The studies demonstrate that some interventions found to be effective in developed countries are in low-income countries too, while others were not, perhaps due to local factors such as low adherence and lack of acceptability of specific treatments. Both elements suggest that it is worth trying interventions found to be effective in other cultures, but that their effectiveness needs to be tested when applied to new populations. The studies also demonstrate that scientific evaluation of interventions, in the form of adequately powered randomized-controlled trials, with relatively high response rates, are feasible in developing countries both from a practical and ethical viewpoint. While we acknowledge the need for more studies among other populations, in order to determine the cross-cultural applicability of these approaches and to identify other interventions likely to be effective, we also believe that the new evidence obliges physicians, policy makers and donors to take action to reduce the burden of one of the most common and disabling illnesses in developing countries. Above all, it is time to use the new evidence to actively combat the skepticism of policy makers that there is nothing to be done against depression in developing countries.