Common mental disorders are major causes of disability in the developing world. Treatment for these conditions in wealthier nations includes drugs and psychological therapy. Would these strategies work in developing countries? Researchers from the UK Institute of Psychiatry, collaboration with the Sangath Society and the Directorate of Health Services, Goa, studied the efficacy and cost-effectiveness of these approaches in Goa, India.

More than 30 per cent of adults attending general medical outpatient clinics in developing countries have a common mental disorder, such as depression or anxiety. Most of this illness goes unrecognised and patients are given painkillers, vitamins or other drugs to treat the physical symptoms.

The researchers recruited 450 patients at the two main district general hospitals in Goa. 43 per cent had mixed anxiety depressive disorder and 53 per cent had depressive disorder. Patients received the antidepressant fluoxetine, placebo (a dummy pill), or psychological treatment. Their progress was monitored for a year. This revealed that:

• 61 per cent of patients stick with psychological treatment. Drop out is often due to time pressures, lack of improvement in their condition or dissatisfaction with the treatment.
• Adherence to antidepressant drugs is 46 per cent at two months and 26 per cent at six months. The corresponding figures for placebo are 56 per cent and 39 per cent.
• Common reasons for not sticking to drug treatment are side-effects, forgetting to take the medication, feeling better or feeling that they aren’t working.
• Similar numbers in each group feel that they benefit from it. But antidepressants give better short-term results than placebo for clinical and disability outcomes. Psychological treatment is no better than placebo for any outcome.
• Over a year, healthcare costs for people on antidepressants are substantially lower than for those taking placebo while healthcare costs for the psychological treatment subjects is no different from those taking placebo.

The lack of effectiveness of psychological treatment is different from results seen in wealthier countries. It may be that these patients are facing such severe problems in their lives that this therapy is unlikely to be of any value on its own. Many problems faced by patients in low-income countries have no equivalent in developed countries where comprehensive social welfare nets enable most of the population to meet basic material needs.

Anti-depressants have a significant cost-effectiveness advantage over placebo. The researchers recommend that:

• An affordable antidepressant, such as fluoxetine, should be used for treating common mental disorders in India because it produces a quick recovery from illness and leads to cost savings.
• Drug treatment should be combined with community-based measures to tackle patients’ severe social problems and improve adherence.
• Primary care providers and mental health specialists should collaborate with a wider range of professionals to develop this combined approach.

Source(s):
‘Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial’, The Lancet 361: 33-39, by V. Patel, et al., 2003 Full document.

Funded by: Wellcome Trust

id21 Research Highlight: 27 February 2003

Further Information:
Vikram Patel
Sangath Centre
841/1 Alto Porvorim
Goa 403521
India

Contact the contributor: vikpat@goatelecom.com

Institute of Psychiatry, King's College London, UK

Sangath Society, Goa, India

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

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

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