Regional Health Forum WHO South-East Asia Region(Volume 5, Number 1)

Is Depression a Disease of Poverty? Vikram Patel *

     Introduction

Poverty was termed many years ago as ‘the mother of all diseases’. Governments and donors such as the World Bank give priority in policy and funding to diseases associated with poverty. This is a prudent choice, for the poor are least able to access appropriate quality health care. Further, in most Asian countries, the majority of the population belong to the lower income group. In making choices for health funding, policy-makers are therefore guided by the epidemiological evidence which indicates the burden of disease on the population as a whole, and on the poor in particular. So far, policy on health and poverty has almost entirely skirted the issue of mental health. It has been assumed that mental illness is not a relevant health concern for the poor because they are faced with the considerable burden of ‘physical’ diseases. These attitudes are strengthened when one considers that the vast majority of mental health professionals are urban-based, and in many countries work in the private sector which caters to relatively wealthier sections of the population. Public health facilities and primary care centres report very low figures of mental illness, further reinforcing the stereotype that mental disorders are rare and mainly a problem identified in urban, middle or high income groups.

This paper focuses on depressive and anxiety disorders which are the commonest of all mental illnesses but are almost entirely seen in the general health care system as opposed to the specialist mental health care system. The paper presents evidence that these disorders pose a tremendous public health burden in all societies, irrespective of their overall level of economic development. Evidence is then presented demonstrating the relationship between these disorders with poverty and inequality. The paper concludes that depression is a disease of poverty and considers some of the public health strategies which can be implemented in Asian countries to reduce its burden on the poorest sections of the population.

     Depression and Anxiety

The symptoms of depression and anxiety are common and reported in all populations of the world ⁽¹⁾. There is now professional consensus about the major symptoms of depression and anxiety. For example, depression is characterized by a number of symptoms, in addition to a lowering of mood. These are loss of interest, poor concentration and forgetfulness, lack of motivation, tiredness, irritability, poor sleep and changes in appetite. Anxiety is associated with a fearful feeling, worrying thoughts and physical symptoms such as palpitations, tingling sensations, headaches and chest pain. Depression and anxiety in the primary or general health care setting typically occur together. In this document, the term ‘depression’ is used to denote the clinical presentation of both depression and anxiety.

The evidence of high prevalence of depression has been building up over the past 20 odd years from a range of settings in Asia ^(2;2-5;5;6). These studies reveal community prevalence figures that vary between different countries but can be up to 50% in some studies from Pakistan⁽⁶⁾. Prevalence estimates in attendees at primary health care centres, catering to the poorest members of societies, show levels that can be as high as 40% ^(2;7;8). Depression often runs a chronic or recurrent course with nearly half of the patients in treatment settings remaining ill for 12 months or more ⁽⁹⁾.

There is now a large body of evidence demonstrating the considerable disabling effects of depression both in the community and primary health sector^(10;11). Depression and anxiety are exceptionally disabling conditions and the disability is often not widely acknowledged, in part because of the stigma associated with these illnesses. Depression is disabling for a variety of reasons. The symptoms of depression such as poor concentration and lack of motivation impair the ability to carry out everyday tasks. Irritability combined with these can affect the relationships with other family members and fellow workers. The "negative" attitudes of depression can impair judgement and reduce problem-solving abilities. It is perhaps this latter aspect of depression that is especially worrying in relation to socioeconomic inequalities. It is likely that depression impairs the ability of poor people to deal with the difficult circumstances they experience. Arguably, for the poorest people in the world, problem-solving abilities are essential in order to deal with their circumstances.

In addition to disability, there is evidence that depression can also lead to increased mortality. There is growing concern over the rising rates of suicide in many developing countries, particularly amongst adolescents and young adults in whom suicide is one of the three leading causes of death. In India, for example, the suicide rate increased by 6.2% per annum between 1980 and 1990, during which period the population growth rate was 2.1%; the highest growth in suicide rates was for young adults ⁽¹²⁾. Deliberate self-harm (i.e. self-harm which does not lead to death) is far commoner than completed suicide and is fast becoming the commonest reason for emergency medical treatment in some developing countries such as Sri Lanka ⁽¹³⁾.

Primary care is regarded as the cornerstone of health care in both the developed and developing world. Most cases of depression are treated in primary health care settings rather than in specialist clinics. However, despite the considerable evidence of the effectiveness of drug and psychological treatments for depression, albeit largely from the developed world^(14;15), the vast majority of patients in developing countries do not receive these treatments. Instead, they are prescribed a cocktail of medicines aimed at various symptoms, such as painkillers, vitamins and sleeping medicines ^(2;16).

The Global Burden of Disease study ranked depression as the fourth leading cause of burden among all disease, accounting for 4.1% of total burden⁽¹¹⁾. By 2020 it will rise from the fourth to the second leading cause of DALYs. It will then be second only to ischaemic heart disease for DALYS among both sexes. Taking the example of ischaemic heart disease, risk factors such as smoking and high blood pressure have been identified, and public health interventions target those risk factors and try to reduce their frequency in the population. We need such public health-oriented research into depression that will then lead on to primary preventive programmes and to improved access to efficacious treatment for people with depression.

     Socioeconomic Inequalities and Depression

There is now a substantial body of evidence, which demonstrates the relationship between poverty and socioeconomic inequalities with depression in developed countries ^(17;18).

Evidence is beginning to accumulate demonstrating a similar association between economic disadvantage and the presence of depression in Asian countries too. For instance, a community study from Indonesia found strong associations between depression and the presence of household amenities such as electricity, and ownership of a television ⁽¹⁹⁾. In this study, the rates of depression in the least developed villages were twice those in the most developed villages. A primary care study reported a strong association between indicators of poverty such as being in debt and being unable to buy food with CMD, even after adjustment for a range of sociodemographic variables ⁽²⁾. Association of CMD with other indicators such as unemployment and low income and social class groups have been reported in other studies ^(3;6;8;20). There is also evidence, from prospective longitudinal studies in less developed countries outside the Region, that economic deprivation is associated with incidence and persistence of depression ⁽²¹⁾. Education, which is strongly correlated with poverty, emerges as a factor strongly associated with the prevalence of depression in many developing countries ⁽²²⁾. The mechanism through which education might protect persons from depression is unclear. However, it is plausible that education is an important determinant of present and future life opportunities which promote mental health in later life.

Causal Pathways Between Socioeconomic Factors and Depression

     Do socioeconomic factors cause depression?

At present, there is little real understanding about the mechanisms or mediating factors between low socioeconomic status and depression. The following section gives some plausible ideas about the importance of various factors.

     Loss of social supports

There is evidence that lack of social supports may increase the risk of depression. Low socioeconomic status might decrease a person’s ability to engage in social activities. Unplanned urbanization has and is posing great strains on traditional social support systems across the developing world. The lack of social support and the breakdown of kinship structures is probably the key stressor for the millions of migrant labourers to the urban centres of Asia leaving behind millions of dependants in the rural areas whose only hope of survival are the remittances their relatives will send from distant cities. Brown and Harris, in their seminal work on the social origins of depression, identified factors such as having no one to confide in as one of the vulnerability factors for depression ⁽²³⁾. For young women who are married far from their parental homes and live for most of the year without their husbands, it is not hard to imagine why they may be more likely to be depressed.

     Lack of control on resources

There are the obvious material stresses, which accompany poverty. The daily worries about paying essential bills and being able to afford food in the face of inflationary pressures and insecure employment could be expected to wear down even the strongest mind. The ability to deal with new difficulties is harder for those with less money. One of the most consistent predictors of mental disorder in developing country studies is lack of education. Education might provide a means of escape from poverty or access to knowledge and other ways to resolve problems ⁽²²⁾. The lack of opportunity in a society where there is huge income inequality, high unemployment, and underemployment, and no social welfare provision can be expected to lead to feelings to hopelessness, anger and despair. There is the well-recognized association between poverty and a higher burden of physical ill health, particularly infectious diseases, and inadequate access to good, cheap health care. This may mean that many poor persons with mental health problems go untreated, and suffer for long periods as has been already described earlier.

     Social comparison

The potential stresses imposed by absolute poverty may be considerably different from those of relative poverty. One proposed mechanism is that of "cognitive comparison", whereby people are made aware of the vast differences in socioeconomic status that prevail. The knowledge of how the richer "other half live" affects psychosocial wellbeing and thus, overall health status ⁽²⁴⁾.

     Does depression worsen poverty?

There is a reason to support this possibility with evidence for two major mechanisms. First, the evidence that mental disorders lead to disability which has been described earlier. For example, studies of primary health care users in India showed that subjects with depression spent more than twice the number of days in the previous month in bed or were unable to do their daily activities as compared to others ⁽²⁾. Second, there is evidence that persons with depression receive more health care, especially in primary health care. Most people with depression consult for physical symptoms and in many health systems, both in developing and developed countries, this can lead to numerous costly consultations, investigations and polypharmacy ^(7;16). Often governments are not capable or willing to finance treatment and the costs are then transferred to the sufferers who resort to the private sector. No matter who pays the bill, depression drains away precious resources.

     Cycle of impoverishment and mental disorder

Thus, the nature of the relationship between impoverishment and mental illness is complex, bi-directional and dynamic, leading to a vicious cycle of impoverishment and mental illness (Figure 1). An example of such a vicious cycle could be as follows: an episode of depression is triggered by material deprivation and domestic violence; depression in turn robs the woman of the necessary coping skills and energy to overcome her problems and leads her to spend money and time seeking relief from various health practitioners, often without any benefit.

Implications for Health Policies and Programmes

The implication of the evidence is that policies and programmes aimed at providing education and reducing poverty, and socioeconomic inequalities are highly likely to help bring down the prevalence of depression. From a public health perspective, the evidence on socioeconomic determinants and depression can be used to consider a number of primary and secondary preventive strategies.

Figure 1: The Vicious Cycle of Improverishment and Mental Disorder

     Primary prevention

Primary prevention is used to describe policies aimed at reducing the prevalence of depression. The evidence to support the efficacy of interventions in this field is weak, mainly because few, if any, interventions have been tried and/or evaluated in terms of their impact on depression. It is difficult to persuade governments or international agencies to invest in these programmes rather than primary prevention programmes for malnutrition or infectious diseases. Based on the earlier discussions, we now consider examples of primary preventive strategies:

     Investing in education

The key factor may not be whether 100% of children are in primary school, but rather the proportion of children who fail to complete the minimum years needed to obtain a secondary school certificate [10-12 years in most countries]. Even though there are impressive gains in increasing school enrolment, there may need to be further emphasis on reducing school drop-out rates; in many Asian countries, less than half the children, particularly girls, who are in primary school go on to complete their 10 years of secondary education. Because education permits greater choices in life decisions and influences aspirations, self-image and opportunities ⁽²⁵⁾, it is likely that investment in education will lead to improved mental health of the population.

     Microcredit

In many Asian countries, indebtedness to loansharks is a consistent source of stress and worry. Indeed, it is not uncommon for the children of a family to spend their lives toiling to repay the interest of relatively small loans taken out by their parents. It is clear that here lies another potential preventive strategy in that local banks could step in and review their process of assessing credit-worthiness for persons who belong to the poorest segments of society. Radical community banks and loan facilities such as those run by SEWA in India and the Grameen Bank in Bangladesh could be involved in setting up such loan facilities in areas where they do not exist.

     Health promotion

Most public health campaigns such as WHO’s ‘Stop Exclusion: Dare to Care’ campaign are generally aimed at increasing awareness of mental illness, and knowledge about the effectiveness of interventions available in health services. There is also the potential to use health promotion to publicize "stress reduction" techniques that could be used more widely. Similarly, changing the characteristics of the workplace and working practices could have a beneficial effect on mental health. At present, these ideas are necessarily speculative but deserve further development and evaluation.

     Secondary prevention

The key to secondary prevention, reducing the disability consequent from the disorder, is to strengthen the treatment of depression in primary health care. There needs to be much greater cooperation and collaboration between mental health and primary care health workers.

Integration of mental health in primary health care

The integration of mental health into primary health care has been the mantra of WHO for over a decade. There needs to be greater emphasis on training general health practitioners to recognize and effectively treat depression. Just as clinicians must treat tuberculosis even if they cannot get rid of the overcrowding, so too we must challenge the mental despair of clinicians who argue that if their patients are poor, they must be depressed and there is little they can do about it. The best evidence that this belief is untrue is evidenced by the fact that the majority of the poor do not get depressed, they are merely at greater risk than the rich.

Medical pluralism in mental health care

Mental health manpower cannot meet the needs of all persons with depression, especially in developing countries. The population of India, now exceeding 1 billion people, has less than 4 000 psychiatrists. The vast majority of psychiatrists in developing countries work in large mental hospitals or in private practice. Most persons suffering from depression are treated, if at all, by general health care providers, traditional and religious healers, nongovernmental and voluntary organizations and families. The private medical sector is a major provider of general health care in many developing countries^{( 26)}. Their involvement in implementation of mental health programmes would be imperative.

Integration of mental health into existing health promotion programmes

Depression typically occurs in situations of extreme stress. There are several examples of existing public health priorities in which depression is of great relevance such as maternal and child health, reproductive and sexual health, adolescent health and violence prevention. Piggybacking mental health interventions onto these programmes would imply using existing resources and manpower and providing more comprehensive care, which reflects the broad concerns of health. Such integration can be implemented with minimal additional cost and would have the advantage of greater access to sufferers as a result of the lesser stigma than would be attached to seeking help from mental health services.

Intersectoral cooperation

In Pakistan, the Gujarkhan demonstration project involves community leaders, schoolteachers, and primary health care workers. Mass educational campaigns were launched and mental health issues introduced into the school curriculum as a means of reducing stigma as well as educating families on how best to protect their mental health ⁽²⁷⁾. These initiatives can help to increase the involvement of communities in deciding and implementing solutions for their own problems. Local participation is a fundamental requisite for the success of any such programmes.

Conclusions

This article has presented evidence, focusing on the Asian region, which demonstrates the public health importance of depressive and anxiety disorders. The evidence demonstrates a close association between socioeconomic adversity and depression, an association that is present in many societies, irrespective of the stage of economic development. Inasmuch as depression is caused by stressful life circumstances, and that the poor are more likely to face such circumstances and have less resources to adequately cope with them, depression is a disease of poverty. Furthermore, depression can impair economic productivity and drains precious resources due to untreated morbidity. Thus, the answer to the question posed in the title of this article is affirmative. Depression is, like most other diseases, a disease of poverty. Donors and governments concerned about improving the health of the poor must recognize that depression typically occurs along with other physical health problems which are already the focus of attention of programmes directed at the poor.

Despite the compelling evidence of an association between depression and economic deprivation, it is important to recognize that the majority of people living even in squalid poverty remain well, cope with the daily grind of existence and do not succumb to the stressors they face in their lives. Indeed, this is the real challenge for public health researchers; to identify the protective qualities in those who do not become depressed when faced with awful economic circumstances for therein lies a potential to help and prevent mental health problems. Could informal local community social networks protect some from depression? Could religious or spiritual involvement limit alcohol abuse in some men and help prevent suicide in women and teenagers? Could microcredit schemes which are challenging the existing notions on who knows how to handle money properly help prevent some from succumbing to despair? Could being close to one’s family provide the necessary confidence and support? Could a caring local councillor’s efforts to clean up a slum help reduce the suicide rate? These are the practical research questions arising from the relationship between poverty and mental illness.

* Senior Lecturer, LondonSchool of Hygiene and Tropical Medicine and Sangath Society, Goa, India