Under detection of depression in primary care settings in low and middle-income countries: a systematic review and meta-analysis

Abebaw Fekadu; Mekdes Demissie; Rahel Birhane; Girmay Medhin; Tesera Bitew; Maji Hailemariam; Abebaw Minaye; Kassahun Habtamu; Barkot Milkias; Inge Petersen; Vikram Patel; Anthony J Cleare; Rosie Mayston; Graham Thornicroft; Atalay Alem; Charlotte Hanlon; Martin Prince

doi:10.1186/s13643-022-01893-9

Under detection of depression in primary care settings in low and middle-income countries: a systematic review and meta-analysis

Syst Rev. 2022 Feb 5;11(1):21. doi: 10.1186/s13643-022-01893-9.

Authors

Abebaw Fekadu^{1

2

3

4}, Mekdes Demissie⁵, Rahel Birhane⁵, Girmay Medhin⁶, Tesera Bitew^{5

7}, Maji Hailemariam^{5

8}, Abebaw Minaye⁹, Kassahun Habtamu⁹, Barkot Milkias⁵, Inge Petersen¹⁰, Vikram Patel¹¹, Anthony J Cleare¹², Rosie Mayston¹³, Graham Thornicroft^{14

15}, Atalay Alem⁵, Charlotte Hanlon^{5

14}, Martin Prince^{13

14}

Affiliations

¹ Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia. abebaw.fekadu@aau.edu.et.
² Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. abebaw.fekadu@aau.edu.et.
³ Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK. abebaw.fekadu@aau.edu.et.
⁴ Center for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK. abebaw.fekadu@aau.edu.et.
⁵ Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
⁶ Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
⁷ Debremarkos University, Debremarkos, Ethiopia.
⁸ Division of Public Health, College of Human Medicine, Michigan State University, Flint, MI, USA.
⁹ School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, Addis Ababa, Ethiopia.
¹⁰ Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
¹¹ Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, MA, USA.
¹² Center for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK.
¹³ King's Global Health Institute, King's College London, NE Wing Bush House, 30 Aldwych, London, WC2B 4BJ, UK.
¹⁴ Centre for Global Mental Health, King's College London, De Crespigny Park, London, SE5 8AF, UK.
¹⁵ Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.

Abstract

Background: Depression is one of the commonest mental disorders in primary care but is poorly identified. The objective of this review was to determine the level of detection of depression by primary care clinicians and its determinants in studies from low- to middle-income countries (LMICs).

Methods: A systematic review and meta-analysis was conducted using PubMed, PsycINFO, MEDLINE, EMBASE, LILAC, and AJOL with no restriction of year of publication. Risk of bias within studies was evaluated with the Effective Public Health Practice Project (EPHPP). "Gold standard" diagnosis for the purposes of this review was based on the 9-item Patient Health Questionnaire (PHQ-9; cutoff scores of 5 and 10), other standard questionnaires and interview scales or expert diagnosis. Meta-analysis was conducted excluding studies on special populations. Analyses of pooled data were stratified by diagnostic approaches.

Results: A total of 3159 non-duplicate publications were screened. Nine publications, 2 multi-country studies, and 7 single-country studies, making 12 country-level reports, were included. Overall methodological quality of the studies was good. Depression detection was 0.0% in four of the twelve reports and < 12% in another five. PHQ-9 was the main tool used: the pooled detection in two reports that used PHQ-9 at a cutoff point of 5 (combined sample size = 1426) was 3.9% (95% CI = 2.3%, 5.5%); in four reports that used PHQ-9 cutoff score of 10 (combined sample size = 5481), the pooled detection was 7.0% (95% CI = 3.9%, 10.2%). Severity of depression and suicidality were significantly associated with detection.

Conclusions: While the use of screening tools is an important limitation, the extremely low detection of depression by primary care clinicians poses a serious threat to scaling up mental healthcare in LMICs. Interventions to improve detection should be prioritized.

Systematic review registration: PROSPERO CRD42016039704 .

Keywords: Depression; Detection; Low and middle-income countries; Primary health care; Review.

Publication types

Meta-Analysis
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Depression* / diagnosis
Developing Countries*
Humans
Income
Primary Health Care
Surveys and Questionnaires

Abstract

Publication types

MeSH terms

Grants and funding