by Dr Jan Klimach, ST4 Psychiatry, Manchester, UK
In November 2015, I was involved in the first week of a new continuing professional development (CPD) programme for primary health care workers in Hossana, Southern Ethiopia, set up as part of the Glan Clwyd Hospital – Hossana Hospital link. The topic discussed at one of the three health centres was depression. Before the session I observed clinics with the Health Officers at this health centre and saw several patients for whom depression was high amongst my differential diagnoses. One which sticks out in my mind was a widowed man in middle age who complained of nonspecific physical symptoms and being off his food. He was managed with injections of Diclofenac and Vitamin B. The Health Officer and I were able to screen this gentleman for mental illness using the ‘Golden Questions’, then take a more thorough history of depression as indicated.
In the teaching session, I asked the Health Officers how many patients they thought they had seen in in the last month with depression. The unanimous answer was zero. I showed figures for prevalence of depression in Ethiopia I had found, which were roughly equivalent to other countries. There was a collective shrug of the shoulders and someone said, “It must be in other parts of Ethiopia…”
I returned a year later, mainly to work with medical students and the nursing staff at the psychiatric clinic, but two recently qualified Health Officers requested I attend their health centre to do some teaching on depression. I found they were already knowledgeable and we discussed some patients they had seen whom they suspected had depression. We focussed on distinguishing mild depression – which they could manage themselves – from moderate and severe depression, which could be referred to the clinic at the hospital.
At the clinic, there are two psychiatric nurses who are able to accurately diagnose depression and have access to tricyclics and SSRIs. I saw many patients with depression there managed successfully. However, there are problems. One is that in most consultations, the staff are aware that patients have already been to – or are considering going to – a religious or traditional healer who will inevitably have a treatment to offer. These treatments are not always harmful, and in depression may actually have some benefits, but in effect it creates competition with the nurses. This results in them feeling pressure to prescribe antidepressants when they know they are not necessarily indicated. Another is the costs of medication, and physical monitoring such as ECGs, which are prohibitive for many patients.
A strong reason for optimism, however, is evidence of increasing awareness of depression and other mental illnesses both amongst the public – attendances at the clinic continue to increase – and among healthcare professionals – as well as the Health Officers mentioned above, staff in other departments at the hospital requested training on mental health topics while I was in Hossana the second time. Both of these factors can only increase the importance attached to depression as a priority illness, and in time, reduce the currently considerable treatment gap that exists in Hossana.
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