Mapping the treatment gap : a mixed methods exploration of barriers to treatment-seeking for depression in rural India

Abstract

Background: Depression is a major contributor to the global burden of disease. However, only 1 in 4 of those affected in low- and middle-income countries (LMIC), and just 13% in India, seek treatment. This project investigated factors that impede treatment-seeking for depression. Methods: I undertook a global systematic review of factors associated with treatment-seeking for common mental disorders. I tested the association between travel distance to the nearest public mental health service and likelihood of seeking treatment for depression in rural India, and described treatment-seeking behaviour, using data from a population-based survey. Finally, I used qualitative methods to explore barriers to treatment-seeking for depression among affected individuals and their families. Results: Systematic review results showed that treatment-seeking is more consistently related to “need” factors, such as disability and chronicity, than “enabling” factors, such as income. However, evidence from LMIC was lacking. The hypothesised association between distance to services and treatment-seeking was not supported. Most adults with probable depression had some recent contact with health services, most often in the private sector, for reasons other than depression symptoms. Use of traditional services was low. Adults who were unmarried, had not discussed their depression symptoms, and had milder symptoms, were less likely to seek treatment for depression. Low demand for depression treatment arose because participants viewed depression symptoms as a response to their circumstances, not as medical issues. Conclusions: The burden of depression is unlikely to be reduced by decreasing travel distance to services without ensuring that interventions are aligned with local priorities. These priorities include action on the social determinants of health and improving the quality of general health care. Private practitioners must be considered in future research and service planning in India. The treatment gap does not adequately capture the needs of people with depression as they perceive them.