A FEKADU, ADDIS ABABA UNIVERSITY-IMPROVING DETECTION OF DEPRESSION IN PRIMARY CARE IN SUB-SAHARAN AFRICA (IDEAS STUDY)

1. Context: No society is exempt from depression. On average about 1 in 10 individuals in the community and about 1 in 5 attendees in primary care may have depression. Depression causes significant personal distress; interpersonal relations, day to day function and work suffer. Depression often occurs with other medical conditions reducing the chance of recovery from the medical condition. Depression is the leading factor that sets people up for suicide. More broadly, depression also increases the risk of dying early in both high income and low income countries. Depression is also expensive--described as the most costly brain disease in Europe. All these make depression an important health priority in all countries.
2. Aims and objectives: Although depression is treatable, over half of those with depression do not get treatment. In low income countries like Ethiopia, over 9 in 10 individuals with depression do not get treatment. There is consensus, led by the WHO and supported by many governments in low income countries, including Ethiopia, that if treatment for depression is to be widely available, it has to be provided at the primary care. This makes sense because, 9 in 10 individuals with depression get their treatment in primary care and prefer to be treated there. Yet only about half of those presenting with depression to primary care are recognised to have depression in high income countries. In low income countries, it is even worse. Studies from Kenya, Tanzania, Malawi and Ethiopia indicate that almost all of those presenting with depression to primary care are not recognised. Many factors contribute to this low rate of recognition. (1) The symptoms and presentation of depression are affected by local culture; (2) Organisation of health systems favouring acute care; (3) Patient factors and provider factors that influence recognition that have to be taken into consideration. There is no evidence that simple trainings, even when intensive, improve recognition. Although recognition does not equate to good clinical care, it is the critical step in the process of care. Improving the recognition of depression will be a substantial contribution to increase treatment accessibility.
3. Aims: The main aim of the IDEAS study is to develop intervention programme that may improve recognition (detection) of depression. In order to achieve improved detection, the first crucial step is to understand what the manifestations and presentations of depression are in the local context (culture) (aim 2). The second step is to understand the factors that may affect detection, for example how the health system and health facilities are set up, how the actual clinical encounter is facilitated, the attitudes and expectations of provider and receiver, and the broader social context (aim 3).
4. Study location: The study will be conducted in the Sodo district (90% rural) in Ethiopia. The site is chosen because of our ongoing research project called Programme for Improving Mental Healthcare (PRIME), a multi-country study funded by DFID. We have established an excellent collaboration with the district and the administration. We have established a community advisory board that will support the IDEAS project.
5. What does the study involve? The study has three major parts. Part 1 (inception): Evidence will be collected about the nature of depression and its detection in primary care, specifically in the local context. Part 2 (Development): An intervention package for improving detection will be put together. Part 3: The intervention package will be tested to see if it is locally acceptable, feasible to deliver, that it improves detection affordably and can be replicated widely.
6. Benefit: The study can potentially be a game changer in the implementation of depression care in primary care. It has the potential to make substantial contribution to our understanding of depression. Will serve as an input in international classification systems

Depression is established as a major public health problem owing to its high prevalence, association with high disability, premature mortality and cost burden. 90% of patients in high income countries get treatment from primary care (PC) as a matter of preference or opportunity. However, nearly half with depression go undetected. The situation is much worse in low income countries. For example, studies from African countries indicate a detection rate close to 0%. Simple training does not improve detection. The current plan for scaling up of mental healthcare, task-shifted care in PC, advocated by nations, WHO and NGOs, will not succeed unless detection of depression improves drastically. There is no intervention that can be implemented in low income countries to improve detection of depression. Such intervention should be based on a solid understanding of the construct of depression, and the interactive contextual factors that impact on detection. The intervention also has to be affordable and scalable. The primary aim of this study is to develop an intervention that improves the detection of depression in PC in Ethiopia. We will use a multi-phase mixed methods approach. Initially, we will develop a comprehensive understanding of the construct of depression and of factors that hinder and facilitate detection. In the next phases, using data from the first phase, we will collate an intervention package, which will be tested for feasibility, acceptability, affordability and scalability in a pilot implementation. The study will be a major departure to what has been done in the past to understand the construct of depression or develop interventions to improve its detection. The study will be a major contribution to the effort of scaling up mental healthcare in Ethiopia as well as other low income countries. The study may also contribute to international classification systems, particularly given the contention around the validity of depression in other cultures.

a.Who will benefit from this research?
The study has the potential to impact local and international stakeholders. The local society where the study is being implemented will benefit directly from a locally developed intervention project. The Ministry of Health of Ethiopia will benefit directly because the results will serve as inputs for the scale up of mental healthcare in the country, for which the government is fully committed. Indirectly, lessens from the process of implementation and from the findings of the study may serve as templates for improving the healthcare system more broadly. The government of Ethiopia will benefit from the potential of having a healthy and productive citizen with improved quality of life. Local researchers may have an enhanced understanding of depression and can use the research findings to develop new research tools of intervention packages. Better understanding regarding the potential role of traditional healers would also be useful in planning health services for depression. Researchers and clinicians from Africa and other low income countries can use the findings to develop or adapt psychotherapeutic modalities relevant for the settings. Findings regarding symptom construct might also inform drug therapy through matching drugs with symptom profiles and may even in the long term support work around drug trials. The WHO would benefit from the findings, which will serve as key input for scaling up mental healthcare. The findings are also likely to inform future development of classification of depression, particularly by the international disease classification systems (WHO and the American Psychiatric Association). Both NGO funders, international funders and UK funders benefit from a more realistic understanding of what could be done to improve scale up of care.
b.Pathway to impact
We have experience of working with diverse stakeholders that may benefit from the research. Locally, we have excellent relationship with the district and zonal administration. We have excellent infrastructure and framework, for example the Community Advisory Board. We will use these links to share the findings and influence local policy. There is clear evidence already that our engagement with the local authorities has influenced policy. For the first time in the country, a psychiatric nurse is assigned in the district to coordinate mental healthcare in the district and to work in the district health centres. This is as a result of the awareness raising work in PRIME. We also work closely with the Ministry of Health in various programmes. We have opportunities to influence policy, for example the implementation of the mental health strategy, and planning. The ARL has worked with the Ministry to support the implementation of the mhGAP and has done the initial costing for the scale up plan of the mental health strategy. We have experience of leveraging the local and national media outlets. The ARL has access to these outlets. We will use international links and forums. We will prepare regular policy briefs and disseminate to our local and international partners. We will use the King's College London media platform to publicise the results of our work.
The study is the first of its kind in Africa and any low income country. One of the main flaws of studies on depression has been the lack of contextualised understanding of depression. Most of the anthropological work done to understand depression was conducted by people who were unfamiliar to the cultural. Growing up in the same culture and speaking the same language is a major advantage in understanding the subtleties of a culture. The ARL brings this into this study. But his training and most of his research work has focused on affective disorders. The combination of the cultural knowledge and the knowledge of affective disorders provides credibility to the findings of the study.