0:13
I would like to do that with the following outline four different topics.
First looking at if depression looks the same across the world.
And then asking ourselves
the question, whether depression is really a
relevant issue in low and middle income countries.
And then talk a bit about what predicts depression in low and middle income
countries, as well as how we can treat and prevent depression in those settings.
0:59
the knowledge has been collected in what we call high income countries.
And, I've put a map here of, of countries that are considered high income countries.
That's the, the darkest
green color. This is, a classification used by the
World Bank, based upon the gross national income, in countries.
And even though a small minority of people in the world live in such countries.
By the far the majority of research has
been conducted on mental health in those countries.
If you look at that map, you'll see that the the
low income and the, and the middle income countries, it's a wide geographic area.
Including countries in, in Latin-America, Africa, Asia, and the, and the Pacific.
So that phenomenon is referred to as the, as the 10/90 Gap.
1:53
loosely referring to idea that 90% of
research, focuses on 10% of the population.
Actually the numbers are, are, are slightly different.
Patel and Kim looked at this, in 2007.
And they found that less than 4% of research, on
psychiatry in leading journals was from the least developing countries.
Whereas, they represented over 80% of the world's population.
So I think it's really important that we keep, in the back of our minds,
the fact that, what we know about mental health.
Really is built upon research with, with people from the western part,
the industrialized part of the world, the minority of the world population.
And that means that we have to be very careful
in, in trying to generalize that knowledge, and assuming that.
The knowledge that we have about mental health applies to other cultural contexts.
So, one aspect of
that transition has to do with categories.
So when we talk about depression, it's important to, to keep
in mind that we could be committing what's called, category fallacy.
And a category fallacy means that we apply a category, in this
case depression, a category that makes
sense for people in industrialized settings.
In most industrialized settings, I would say.
And apply that category to another group,
for whom it might not necessarily immediately make sense.
Question is, when we talk about depression in different parts of
the world as if we're actually committing that kind of of fallacy.
3:28
Now there are largely two opinions, and two ways of doing
research on depression and mental health in general, in in international context.
and those can be
termed the, the Etic versus the Emic, approaches.
I've heard various pronunciations of this problem,
but I'll stick with Etic versus Emic.
An Etic perspective talks about disease, and really assumes that
what we know in industrialized countries can be generalized to other countries.
Also can be called a universalist approach.
So these are people that believe, that the way that mental health looks in
one setting might be very similar to
what mental health looks like in another setting.
And therefore, people talk about disease rather than illness, which is
more often often a perspective used by people from Emic approach.
So it's, when we talk about disease, we really talk
about the way that your doctor would describe your problem.
And he would use
an international classification system.
The diagnostic statistical manual, the DSM, is one example.
Or the ICD, the international classification of disease, that
WHO, the World Health Organization uses is another example.
And those are textbooks that assume that specific disorders have
a number of symptoms and that they can be classified similarly across the,
the world.
So when, when people from an ethic approach try to think
of solutions for mental health problems in different parts of the world.
They would start with existing evidence based interventions that
have proven effective in, let's say, western or industrialized settings.
Where as people who think more from emic approach would be
more inclined to look first that what people locally are doing themselves,
to do with their mental health problems.
People who think from an emic approach one of the first things
that they would want to do when working in a new setting.
They would want to know what are the local terms that people use.
What kind of words do people use to to describe mental health problems.
5:44
And I'd like to just give an illustration of, of both these types of thinking.
First an example of an, of an Emic approach, this research was
done by, by Patoventofoco and published in the journal of Conflict and Health.
And that paper focused on local concepts
of illness in four conflict-affected African communities.
And these were communities in the countries of
Burundi, and South Sudan, as well as the DRC.
Consistent with an emic approach, the authors first started
off with asking what kind of terms people use locally.
To describe, the mental health problems that they might be facing.
And they did that through more open-ended, what they called, qualitative methods.
So rather than coming in with a survey with existing
symptoms and asking if people have been bothered by those symptoms.
They ask the open question, well what kind of problems
to you have when it comes to mental health?
And they did that in focus group discussions.
And where they talked with with people
in the communities, the, living in those settings.
And they did key informant interviews.
In other words, they tried to find
people who were particularly knowledgeable about mental health.
For instance traditional and religious healers,
and people working in in health care.
7:06
if you look at what they found, they found that
in each of the four settings in which they did research.
People had a term for a depression-like form of illness.
For instance, in Kwajena, in South Sudan, people
talked about nger yec, or literally, cramped stomach.
And in Yei in South Sudan, people talked about yeyeesi, having many thoughts.
And in Butembo in the DRC,
people talked about amutwe alluhire, or having a tired head.
And in Kibuye in Burundi, people talked about ibgonge.
And what was common across all of these categories,
was that people, were feeling an overwhelming form of sadness.
And were suffering from social isolation, social withdrawal.
And when asked what could cause these kind
of these kind of depression like illness categories,
people talked about having experienced losses, losing a loved one.
They talked about poverty, not being able to meet the needs and disputes with, with
other community members, being worried and having experiencedtraumatic events.
So looking at this study only you would
say um,well it seems that depression then might
be a universal problem.
Because people in all these different
settings, with, with quite different coastal backgrounds,
they all talked about depression, but
8:34
they were important differences between the settings.
So for instance in, in Kwajena Padam, in South Sudan.
People did mention all of the symptoms that are described in the, in the DSM,
in the Diagnostic Statistical Manual.
8:50
except guilt, but participants mainly When they talked about this depression
like category, they talked about somatic symptoms, so having bodily complaints.
And they particularly emphasized having a
pressure on the stomach and having diarrhea.
They did not really emphasize the emotional features of, of depression.
So, yes, there was this, this universal category and the four settings,
but people talked about these things, these categories, in very different ways.
And the authors show this in in the following picture which
I think is a very insightful way to think about this.
If you look at the middle circle where
you'll see that all the circles overlap there.
So sadness and social isolation are the two symptoms that people
talked about in all four of those settings.
But if you look, for instance, at the top left, then Nger Yec.
That's the only category where not working and having green diarrhea and, and
falling on the ground, and talking to yourself when you're alone were mentioned.
So those were unique symptoms mentioned only there in in South Sudan.
10:02
So,
I think if you look at depression like this, it you
could conclude that there are both aspects that most people will mention.
And aspects that are unique to specific cultural settings.
So to transition to, the other approach that I mentioned, the the ethic approach.
that's a highly common approach I, I think its probably the
most popular approach in terms of what research has been published.
Its the, the approach that has the strongest research, funding backing.
If you look at one example, for instance the world mental health survey initiative.
You can see that it's implemented in, in 28 different countries.
It's an initiative of the, the World Health Organization
which is the public health agency of the United Nations.
10:51
really with the aim of, of assisting countries to
conduct, community epidemiological studies.
To find out what are the major mental
health problems that different countries have to face.
And in all of those studies, they
use the, the CIDI, the Composite International Diagnostic
Interview, which is based upon the ICD,
another international classification system for, for health problems.
See they, they use the same tool and, and
assume that depression would look similar across these different countries.
And they found that, that mood disorders the larger
category within the ICD of which depression is part.
That mood disorders were generally the
second most frequent category after anxiety disorders.
And if we look at that more precisely
then you can see that if you use that, that CIDI, that international instrument.
If you use that in a standardized way you will find that there are, that there
are some level of depression in all of the countries in which they did this study.
But the prevalence rates varied. So in the United States it's quite high at
10% Whereas, for instance, in Nigeria, it's closer to to 1%, and then
quite a bit of variation in between.
Depression in these countries had a prevalence between one and and 10%.
12:40
a new way of looking at what kind
of impacts health problems have on people's lives.
This is a, a metric introduced to, to
move beyond just thinking of health problems, causing mortality.
So this is a way of, of expressing, in numbers,
that health problems can also have impacts on, on people's lives.
It can cause
them to, to miss out on work, and have relationship problems et cetera.
And if you look in that different way, if
you don't, if you stop looking at health problems only.
Prioritizing heatlh problems only, because they can increase mortality.
Then you'll see that mental health problems rise to the
top ten of health issues that are associated with disability.
If you look in high income countries only, that's what this slide shows.
The blue color in the, in the coming three slides shows you the mental health issues.
You could see that unipolar depressive disorders are the number
one contribution to disability adjusted life years in high income countries.
Alzheimer and alcohol use disorders are also
top ten contributors to disability adjusted life years.
In middle income countries,
unipolar depressive disorders are also important.
13:57
And if you look in this situation in low income countries, you
can see that unipolar depressive disorders are still part of the top ten.
But infectious diseases, such as
respiratory infections, diarrheal diseases, and HIV/AIDS
are now, the top three contributors to disability adjusted life years.
But still,
depressive disorders play an important role in in
contributing to disability also in low income countries.
So before we move to the next section, where we go more deeply into
the question, whether depression is a relevant
issue in low and middle income countries.
I just wanted to summarize what we talked about just now.
In trying to answer the question of section a,
whether depression looks the same across the world.
And I've presented two different ways of thinking about death.
one was an emic approach where researchers start with asking people
the open question of, what does mental health look like to you?
And then we saw that in four African
communities people did mention a depression like category.
But that that
they emphasize different aspects of the depression for instance somatic symptoms.
And then we talked about the ethic
approach, where using the same instrument, the same
standardized questions, same depression symptoms we found that
you could find depression in very different countries.
And we also looked at the the global burden of disease studies.
How depression contributes
to disability in daily life.
In the next section, we're going to look at that more closely.
We're going to ask ourselves whether depression is
relevant by looking more at maternal mental health.