In developing countries mental illness often goes unrecognised and the treatment of depression can be disorganised and ineffective.  The combination of high levels of depression, poverty and lack of resources can leave health workers feeling they face an impossible task.  The UK's Bristol University, together with the University of Chile, looked at the effect of an inexpensive programme of treatment on poor women in Santiago suffering from depression.

Depression is a major health problem in both developing and developed countries.  It is especially common in women, and in particular women living in poverty. In Chile the waiting list for a psychologist or psychiatrist is over two months.  Treatment for the poor is usually provided in local primary care clinics.  Clinics in Chile are under-funded and lack resources.  They are staffed by nurses, social workers, midwives, and doctors, who typically see between six and ten patients per hour.  These clinics already have established programmes of treatment, led by nurses, for a number of long-term diseases.

Rather than introducing radical change to current treatment practice for depression, the Santiago programme aimed to make the best use of existing resources and provide a structured way of treating depression.  240 women suffering from depression were treated over a six month period.  Some were treated in the usual way while others followed the new programme of treatment.  The programme:

• provided nine group sessions for patients (up to 20 in each group) where they learnt, amongst other things, about the symptoms and causes of depression, what treatment was available, how to deal with negative thoughts, how to solve common problems, how to prevent a relapse, and most importantly share their worries and concerns with each other
• monitored the patients at regular intervals and prescribed drugs to combat the depression if necessary
• was sequential with components introduced at different time depending on the needs of patients. For instance, all patients attended the groups but only the more severe cases or those who did not improve over time were assessed for medication
• provided information and support for those who were started on medication with the group leader helping patients to get access to doctors if needed
• was innovative in using non-specialist staff at the clinics to work with the patients, freeing up doctors for other work.

The programme, both practical and affordable for developing countries, was successful in its treatment of depression. After six months 70 per cent of the patients had recovered in comparison with 30 per cent of women receiving standard care.

Policy-makers in Chile have now introduced a nation-wide pilot scheme based on the programme. Recommendations drawn from the programme are:

• For treatment to work, the patient’s progress must be regularly monitored and a number of different methods used, including drugs if necessary. However, in order to improve the efficiency with which scarce resources are used, these methods should be introduced sequentially according to the needs of patients.
• People with only mild forms of depression might only need support and monitoring but those with severe symptoms might need support, close monitoring by doctors and medication. There is a clear need to provide more structure to depression programmes ensuring that treatment is implemented properly.
• The efficiency with which human resources are being used is often less than optimal: there are ample opportunities to expand the roles of nurses and social workers to deliver some aspects of treatment.

Source(s):
‘Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial’, The Lancet 361: 995-1000, by R. Araya et al, 2003 Full document.

Funded by: US National Institute of Mental Health

id21 Research Highlight: 17 November 2003

Further Information:
Ricardo Araya
Division of Psychiatry
University of Bristol
Cotham House
Cotham Hill
Bristol BS6 6UJ
UK

Contact the contributor: R.Araya@bris.ac.uk

Bristol University, UK

University of Chile

Other related links:
'Sticking with tradition: patients with mental disorders seek help from healers' >

'Depressing news – psychological therapy fails to help Indian patients with common mental disorders'

'Economic depression: poverty and mental health in developing countries' >

'Feeling poorly? Poverty and depression in Goa, India' >

'Brain strain: the burden of persistent depression in Zimbabwe' >