by Dr Ravi Paul, Head of Department of Psychiatry, University Teaching Hospital, Zambia, and Dr Subodh Dave, Associate Dean, Trainee Support, Derby, UK
Zambia – key facts
Zambia is a sub-Saharan African country with a population of about 15.6 million. Blessed with vast natural resources and home to Victoria Falls, Zambia remains a very poor country, ranking 137th of 186 in the Human Development Index (2014 data). 68% of the population lives on less than USD $1 a day (2010 data). With a very high prevalence of HIV, life expectancy at birth is mere 48.6 years.
Zambia – Psychiatric Morbidity
The most commonly diagnosed mental illness in Zambia is depression, alongside other neuropsychiatric disorders such as those relating to drug and alcohol abuse. The risk of mortality is significantly increased by the stigma attached to mental illness, the prevalence of HIV, high unemployment and socio-economic difficulties. Neuropsychiatric disorders contributed an estimated 4.1 per cent of the global burden of disease in 2008. Amongst the patients attending Psychiatry Clinic at the University Teaching Hospital (UTH is the only tertiary Hospital of the country) the diagnosis of depression was the highest at 34%44. The number of patients that present at the UTH Casualty with deliberate self-harm is on the rise and the leading cause for such behaviour is depression[1].
Prevalence of Major Depressive Disorder (MDD) in HIV patients is 2 to 3 times higher than general population with depression being the most common psychiatric condition in HIV+ patients[2]. Prevalence of depression was 57% in HIV+ patients and 70% in HIV/HCV co-infected patients. Lifetime risk of developing MDD is 2 times greater in women versus men in line with global figures. However, the prevalence of MDD in HIV+ women is up to 4 times higher than HIV-negative women and 3 times higher than HIV+ men.
Alcohol, cannabis, cocaine or amphetamine dependence may contribute to onset or exacerbation of MDD45. Patients with untreated MDD are less likely to adhere to medications and keep medical appointments and are more likely to engage in high-risk sexual behaviour and substance abuse.
Untreated depression is associated with increased morbidity and mortality in HIV patients. A local study from the University of Zambia suggests that women diagnosed with HIV during their pregnancy were at heightened risk for depression. This study reported that 85% of pregnant women had experienced a major depressive episode and/or significant suicidal ideation. For those who knew they were HIV+ prior to pregnancy, there was significant anxiety about their baby’s HIV status[3].
Another major illness related to psychological distress is tuberculosis with almost a quarter of tuberculosis (TB) patients reporting ‘severe psychological distress’. This has considerable public health relevance as this group is significantly less likely to complete the six-month course of treatment and be cured. This ‘non-adherence’ can lead to antibiotic resistance and developing more dangerous and resistant forms of the disease.
Zambia – Treatment Pathways
For patients with mental health problems, an estimated 70-80% patients consult traditional health practitioners before consulting with conventional health providers. In 2013, there were only three trained psychiatrists in Zambia. A Department for International Development funded programme helped set up a postgraduate training programme (MMED Psychiatry) and has led to a slow but steady stream of Zambian doctors acquiring postgraduate training in psychiatry. But it remains the case that there is a persistent shortage of trained personnel as well as facilities[4]. The only antidepressant drug available in Primary Health care centres is amitriptyline. Psychological care for patients with depression is lacking. There are no psychologists or counsellors across the health care system, with only a few psychologists at the tertiary level.
Zambia – Future
World Health Day and World Mental Health Day are important dates in the calendar of the Department of Psychiatry. Over the last few years we have run a psychiatry essay competition for medical students, which has been very successful. The Department also runs a very active undergraduate psychiatry training programme to ensure that the next generation of Zambian doctors are equipped to diagnose and manage a range of common mental disorders, including depression.
[1] Paul, R., Mwendaweli, N., Kusanthan, T. (2015) Levels of depression in cancer patients seeking treatment at Cancer diseases Hospital in Zambia. International Journal of Development Research. 5:11;6052-6056
[2] Murray, L.K., Haworth, A., Semrau, K., et al. (2006) Violence and abuse among HIV-infected women and their children in Zambia: a qualitative study.; J Nerv Ment Dis; 194; 610-5; ISSN: 0022-3018; PUBMED: 16909070
[3] Mayeya, J., Chazulwa, R., Mayeya, P.N., et al. (2004) Zambia mental health country profile. Int Rev Psychiatry; 16;63-72; ISSN: 0954-0261; PUBMED: 15276939
[4] Kwalombota, M. (2002) The effect of pregnancy in HIV-infected women. AIDS Care; 14;431-3; ISSN: 0954-0121; PUBMED: 12042089
SSL Valid: Nov 19, 2024 - Feb 17, 2025