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

Abstract

ABSTRACTObjectiveDepression is the commonest mental disorder in primary care but is poor 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-and middle-income countries (LMICs).MethodsDesignSystematic review and meta-analysis. Review protocol was registered in the PROSPERO database (CRD42016039704).DatabasesPubMed, PsycINFO, Medline, EMBASE, LILAC and AJOL.Quality assessmentRisk of bias within studies evaluated with the Effective Public Health Practice Project (EPHPP).Synthesis“Gold standard” diagnosis for the purposes of this review were based on the 9-item Patient Health Questionnaire (PHQ-9; cutoff scores of 5 and 10), structured interview or expert diagnosis. Meta-analysis was conducted excluding studies on special populations. Analysis of pooled data were stratified by diagnostic approaches.ResultsA total of 2223 non-duplicate publications were screened. Ten publications, from two multi-country studies and eight single country studies, making 18 country level reports, were included. One of the multi-country studies used an enriched sample of screen positive participants. Overall methodological quality of the studies was good. Depression detection was 0.0% in five reports and <12% in another five. The pooled detection for 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 the 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%). For the enriched sample, the pooled detection was 43.5 % (95% CI: 25.7%, 61.0%). Severity of depression and suicidality were significantly associated with detection.ConclusionsThe 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.Strength and limitation of study▸This is the first review of detection of depression in LMIC settings▸The review was comprehensive in terms of databases searched▸Screening tools were used as gold standards, which may lead to overestimation of prevalence and underestimation of detection▸The small number of studies and the use of different instruments and cutoff▸points precluded exploration of sources of heterogeneity▸The review does not include studies on distress or sub-threshold depression