Research Article: Packages of Care for Depression in Low- and Middle-Income Countries

Date Published: October 6, 2009

Publisher: Public Library of Science

Author(s): Vikram Patel, Gregory Simon, Neerja Chowdhary, Sylvia Kaaya, Ricardo Araya, Graham Thornicroft

Abstract: In the first in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Neerja Chowdary and colleagues discuss the treatment of depression.

Partial Text: This is the first in a series of articles highlighting the delivery of “packages of care” for mental health disorders in low- and middle-income countries. Packages of care are combinations of treatments aimed at improving the recognition and management of conditions to achieve optimal outcomes.

Depression is the leading cause of disease burden in most regions of the world [1]. The International Classification of Disease (ICD) 10 diagnostic criteria for depressive episode are shown in Box 1. Somatic presentations are very common, especially tiredness, sleep problems, and aches and pains. Of these, only tiredness is considered a “core” feature in current classifications. Anxiety symptoms often coexist with depressive symptoms, particularly in community or primary care samples. The term “common mental disorders” is used to describe the heterogeneous presentation of anxiety, depressive, and somatic symptoms in these contexts [2].

Depression screening and outcome questionnaires appear to perform well across a wide range of settings. Conventional depression treatments, including medications, structured psychotherapies, and ECT appear to have therapeutic benefits. Although the evidence base for the efficacy of depression treatments is not large in LMICs, the evidence we reviewed suggests that depression treatments are just as effective in more disadvantaged patient populations or under-resourced systems of care. All treatments seem to achieve about the same degree of benefit, with combination treatments (both medication and psychotherapy, and ECT for selected individuals), having greater effect in more severe or monotherapy-resistant cases.

Depression is clearly a global health priority. Improving the recognition of this disorder in clinical populations in LMICs is aided by the successful adaption of depression-screening instruments from HIC settings into settings with few resources and weaker health systems. Our review suggests that evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression; it is important, however, that such treatments are adapted when used in LMICs to increase their acceptability, accessibility, and manage their costs. We propose two packages of care on the basis of the availability of mental health specialist resources (Table 3). The delivery of these treatments should ideally be carried out through an integration of depression programs into existing health services or community settings with task-shifting to nonspecialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers.