Abstract
BackgroundThere have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). The aim of this study was to identify factors associated with functional impairment among people diagnosed with depression in PHC in Ethiopia as part of implementation of a task-shared model of mental healthcare.MethodsA comparative cross-sectional study was conducted. As part of the Programme for Improving Mental health carE (PRIME), PHC clinicians were trained to diagnose depression using an adapted version of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP). A total of 2038 adult consecutive PHC attendees were screened for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9). Those who scored five or above on the PHQ-9 (n = 131) were assessed by PHC workers. Of these, 92 were diagnosed to have depression (“PHC diagnosed cases”) and the remaining 39 people were PHQ positive but considered not to have depression (“non-diagnosed controls”). PHC diagnosed cases were also compared to a community representative sample of adult healthy controls (n = 197; “community controls”). The 12-item version of the WHO Disability Assessment Schedule (WHODAS-2.0) was used to assess functional impairment. Multivariable negative binomial regression models were fitted to examine the association of demographic, social, economic and clinical characteristics with functional impairment.ResultsNo significant difference in functional impairment was found between diagnosed cases and non-diagnosed controls. PHC diagnosed cases were found to have higher depressive symptom severity and suicidality, but lower social support compared to non-diagnosed controls (P < 0.05). In the multivariable model, greater functional impairment was associated with higher depressive symptoms (RR = 1.04; 95% CI 1.02, 1.05) and lower social support (RR = 0.96; 95% CI 0.95, 0.98). Diagnosed cases were found to have higher functional impairment compared to community controls (RR = 1.91; 95% CI 1.74, 2.09).ConclusionIn this study, PHC clinicians identified cases of depression with high symptom burden, suicidality and functional impairment. These findings support current initiatives to scale-up mental health services at the PHC level; and indicate that social support is an important target for intervention.
Highlights
There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs)
In the larger sample which combined PHC diagnosed cases and community controls, we found that older age and urban residence were independently associated with greater functional impairment
Our findings support the validity of depression diagnosis made by PHC clinicians after brief training in a rural African setting
Summary
There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). Depression accounted for 4.5% of the worldwide total burden of disease in 2007 and is responsible for the greatest proportion of burden attributable to non- fatal health outcomes, accounting for almost 12% of total years lived with disability worldwide [5]. In studies from both high income countries and lowand middle-income countries (LMICs), depression was found to be associated with significant functional impairment, decreased quality of life, increased use of health services, higher degree of morbidity, elevated risk for mortality [6, 7] and a compromised overall health status [8]. Depression brings about societal burdens [10, 11], including disability in terms of lost wages, low productivity and impaired interpersonal relationships
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