Knowledge and attitudes toward depression among community members in rural Gujarat, India.

ORIGINAL ARTICLE

Knowledge and Attitudes Toward Depression Among Community Members in Rural Gujarat, India Michelle C. Liu, MD,* Seth Tirth, MBBS,† Raghu Appasani, BA,‡ Sandip Shah, MBBS, MD,§ and Craig L. Katz, MD† Abstract: Limited data exist regarding community attitudes and knowledge about clinical depression in rural India. We administered 159 questionnaires and 7 focus groups to Gujarati villagers to explore knowledge and beliefs about clinical depression. Quantitative data were analyzed for frequencies, nonparametric correlations, and principal components, whereas qualitative data were coded for prominent themes. Two groups of subjects emerged from our analysis: one “medically oriented” group that viewed depression as a medical condition and expressed optimism regarding its prognosis and one “spiritually oriented” group that expressed pessimism. Correlations emerged between etiological belief, degree of optimism, and associated stigma. The subjects were pessimistic when they attributed depression to a traumatic event, punishment from God, or brain disease but optimistic when depression was attributed to socioeconomic circumstances. Overall, the subjects were knowledgeable and open-minded toward depression and demonstrated curiosity and willingness to learn more. This study will help to inform future clinical and educational outreach in rural Gujarat. Key Words: Depression, Gujarat, knowledge, stigma, rural India (J Nerv Ment Dis 2014;202: 813–821)

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orldwide, mental illnesses contribute significantly to the global burden of disease, accounting for major disability, morbidity, and mortality annually. Mental illnesses are frequently more disabling than physical illnesses. In the 2010 Global Burden of Disease study, mental disorders and substance use disorders accounted for 7.4% of disability-adjusted life-years (DALYs) worldwide and depressive disorders accounted for a substantial portion of these DALYs (40.5%) (Whiteford et al., 2013). Of all major illnesses, mental and behavioral disorders are the largest contributor to years lived with disability (YLDs), accounting for 22.7% of all YLDs (Montico et al., 2012). Major depressive disorder is a chronic, recurrent, and debilitating condition characterized by significant personal suffering and functional impairment. The core features of major depression include a depressed mood and/or anhedonia, accompanied by cognitive and somatic disturbances (Soleimani, et al., 2011). Suicide is 20 times more common among the clinically depressed compared with the healthy population (Soleimani et al., 2011). Major depression in people with medical illness is particularly dangerous, with a fourfold increase in mortality (Bruce and Leaf, 1989). For example, comorbid depression consistently predicts adverse outcomes in patients with prior cardiovascular disease and can increase all-cause mortality (Prince et al., 2007). Clinical depression in India has historically been underrecognized and undertreated. Current prevalence rates of depression reported in the literature vary on the basis of demographics: rates in rural

*New York University School of Medicine; †Icahn School of Medicine at Mount Sinai, New York, NY; ‡The MINDS Foundation, Boston, MA; and §Department of Psychiatry, Sumandeep-Vidyapeeth University, Vadodara, India. Send reprint requests to Michelle C. Liu, MD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1527, New York, NY 10029. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20211–0813 DOI: 10.1097/NMD.0000000000000199

India are as high as 30.1% (Kohli et al., 2013), whereas rates in urban India are lower, at 15.1% (Poongothai et al., 2009). Among the elderly, prevalence rates in rural India range from 12.7% (Rajkumar et al., 2009) to 21.7% (Barua et al., 2010). Before the late 1970s, epidemiological studies indicated that clinical depression was nearly nonexistent in India (Nieuwsma et al., 2011), for which there are many possible explanations. First, depressed patients in India frequently present with somatic, rather than psychological, symptoms (Andrew et al., 2012; Pereira et al., 2007). Research in primary care settings in India has shown that somatic symptoms are the presenting complaint in 97% of depressed patients (Nieuwsma et al., 2011), and patients with unexplained somatic symptoms are often found to experience depression or other psychiatric disorders (Nambi et al., 2002). Indian patients may present with somatic complaints to avoid social repercussions; compared with somatic symptoms, depressive symptoms are associated with greater stigma and are perceived as socially disadvantageous (Raguram et al., 1996). Stigma toward mental illness is prevalent and widespread in India. Compared with Americans, Indians are more likely to display stigmatizing attitudes toward depression and to attribute depression to personally controllable factors, such as personal failure or unfulfilled expectations (Nieuwsma et al., 2011). India is a multicultural society with diverse religions (Hinduism, Buddhism, Jainism, Sikhism) and beliefs about health. Rural Indians have access to varied health care providers, including spiritual and religious healers; traditional, complementary, and alternative medicine providers; Aryudevic medicine practitioners; and allopathic practitioners (Khandelwal et al., 2004; Ramakrishnan et al., 2014). Limited data suggest that clinical depression is often thought to be best addressed with interpersonal and financial support. If a professional is sought out, he/she is likely to be a village health worker or a faith healer, rather than a psychiatrist (Kermode et al., 2009a). There remains a tremendous need for mental health resources, particularly in rural India. Rural Indians have been found to be at higher risk for affective disorders than their urban counterparts (Ganguli, 2000), and the rural elderly seems to be at highest risk, with the prevalence of depression as high as 47% (Swarnalatha, 2013). Approximately four psychiatrists serve every million Indian inhabitants, and these providers are primarily concentrated in urban areas (Khandelwal et al., 2004). The nonprofit organization, the MINDS Foundation (www.mindsfoundation.org) has partnered with Sumandeep-Vidyapeeth University (SVU) to improve mental health awareness and resources for the villages surrounding Vadodara, Gujarat. The SVU Department of Psychiatry and the MINDS Foundation have established relationships with many of these villages, making periodic visits, bringing villagers to the on-campus mental health clinic, and conducting a psychoeducational campaign. This campaign (2011–2012) involved mental health awareness workshops in 17 villages, featuring a Gujarati video on mental health, a discussion, and a question-and-answer session led by a psychiatric team. Topics such as suicide, substance use, postpartum depression, and learning disability were addressed (Byer et al., 2014).

METHODS Researchers from the Icahn School of Medicine at Mount Sinai collaborated with the local team from the MINDS Foundation as well

The Journal of Nervous and Mental Disease • Volume 202, Number 11, November 2014

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as psychiatry residents and professors from the SVU Department of Psychiatry. From August 26 to September 20, 2013, we visited seven villages near Vadodara to administer surveys and conduct focus group interviews on each community. The villages included Kasumbia, Hareshwar, Ranchhodpura, Morakhala, Malu, Manroj, and Kali Talawadi. These villages were selected for their accessibility from the SVU campus and their existing relationship with the MINDS Foundation. A social worker from the MINDs Foundation contacted local village leaders to facilitate the recruitment of subjects. The study was approved by the Program for the Protection of Human Subjects at the Icahn School of Medicine at Mount Sinai and the institutional review board at SVU.

Subjects Subjects included 159 local residents from seven villages. The subjects were provided with a description of the study, and oral consent was obtained from those willing to participate. No restrictions were placed based on age, sex, or occupation. For the written portion, the subjects who were illiterate had the survey read out loud to them, and they responded verbally.

Quantitative Questionnaire The survey was a 41-item, multiple-choice questionnaire (Appendix 1) modified from a previous questionnaire used in 2011 and in 2013 by our lead investigator (Almanzar et al., 2014; Winer et al., 2013). Five questions assessed demographic information: age, sex, profession, level of education, and marital status. One question (“What do you understand by the term depression?”) was open ended. The remainder of the survey consisted of closedended statements, with five Likert-scale answer choices that ranged from strongly agree to strongly disagree.

Focus Groups Focus groups were conducted on a village-by-village basis. The subjects were presented with a vignette (Appendix 2) describing a woman in the village with symptoms of clinical depression that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria, including depressed mood, decreased motivation, sleep disturbances, poor appetite, cognitive deficits, and suicidal ideation. After the vignette, the group was guided through a series of open-ended questions that asked subjects to identify the woman’s condition and to discuss the cause, prognosis, and treatment of her condition. The subjects were also asked about their personal experiences with anyone who had experienced a mental illness. A psychiatry resident and a social worker facilitated the surveying process and focus groups; both were culturally and linguistically fluent with the local traditions and dialect of Gujarati.

Data Handling One hundred fifty-nine deidentified surveys were collected, and the responses were transcribed into an electronic database. Focus group responses were audio recorded, later translated by the psychiatry resident into English, and recorded electronically.

Data Analysis Quantitative Analysis Statistical analysis was performed using the SPSS Software. Statistical analyses of the questionnaire data included a) computing frequencies, b) Spearman’s rank correlation coefficients between every pair of statements, as well as c) principal components analysis (PCA)—to further organize the data and generate broader themes that arose from survey responses. 814

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Qualitative Analysis The transcripts from the focus group sessions were separately read and coded by three investigators (M. L., T. S., C. L. K.) for salient themes according to methods described previously (Winer et al., 2013). Responses to the open-ended question (“What does the term depression mean to you?”) were read by the three investigators and coded for salient themes. The investigators then met to reach a consensus and to generate a list of common themes.

RESULTS Demographics Of the 159 subjects surveyed, 63.9% were male (n = 101). The mean age was 37 years, with a range of 13 to 78 years. The most commonly reported occupation was farmer (64.3%, n = 101), followed by housewife (18.5%, n = 29). The vast majority (72.6%, n = 111) did not complete intermediate school. Most of the subjects were married (81.7%, n = 124). Table 1 provides a sociodemographic breakdown of the subjects.

Qualitative Results Survey Responses to the open-ended question (“What does the term depression mean to you?”) highlighted diverse beliefs regarding depression. Many participants (n = 68) did not know what depression meant. Others equated depression with “weakness” or “hopelessness” as both a cause and a symptom of depression. One villager wrote, “When a person becomes mentally burned out, he becomes hopeless and then goes into depression.” Several subjects associated depression with somatic ailments such as dyspepsia, ringworm, and body aches. Some explained this relationship: “People who have dyspepsia and itching over the scalp will enter a depression, because they become tired of these symptoms.” Finally, the subjects mentioned that depression could lead to addiction. One subject wrote: “In depression, people become disorganized, and because of this, he/she is inspired to take tobacco, guttha, biti, and becomes addicted.” Another wrote: “[A depressed person] will have lots of thoughts and will not understand what to do. Then he will look for some addiction and become addicted. In depression, people become addicted to tobacco, alcohol, and this causes more illness.”

Focus Group The focus groups conducted throughout the seven villages revealed several salient themes, as follows: 1. Most of the participants recognized the woman’s problem as a clinical condition; many were able to identify it as “depression.” Most agreed that the woman’s situation was not self-imposed but rather a consequence of external circumstances. 2. When identifying causes for the woman’s condition, the participants often distinguished between psychological stressors (citing the fights with her husband) versus mental illness. However, some did deem her as “mad.” 3. Some believed that the woman’s condition could be due to black magic or spirits borne of jealousy. One participant replied, “It is possible that someone wanted to harm her. […] Yes, it’s possible, and if someone wanted to harm or kill her, they could definitely do that too with black magic. Jealousy is one reason why someone might want to harm her.” 4. There was variable mention of faith healers and prayer, and faith healers were often recommended in conjunction with medical treatment. However, many were skeptical of traditional methods. One replied, “If she was taken to a hospital and takes medicine daily, she will definitely be cured. I personally do not believe in faith healers.” © 2014 Lippincott Williams & Wilkins



TABLE 1. Demographic Characteristics of Subject Population n Age, yrs Mean (SD) Median Sex Male Female Occupation Housewife Farmer Professional Other Highest level of education Less than intermediate Intermediate graduate College/university graduate Marital status Single Married Separated/divorced Widowed

N = 159 37.0 (15.1) 35 n = 158 101 57 n = 157 29 101 5 22 n = 153 111 26 16 n = 153 23 125 2 3

% — — 63.9 36.1 18.5 64.3 3.2 14.0 72.6 17.0 10.5 15.0 81.7 1.3 2.0

5. The participants emphasized the role of grief and stress (either work related or from interpersonal conflict) cumulating in a psychological “shock” that ultimately triggered this woman’s condition. One villager believed that she was likely “suffering from a psychological shock due to family related problems, such as a quarrel with her husband.” 6. The participants unanimously agreed that this woman would need interpersonal support to get better and that she could not improve on her own. Many believed that loneliness would further aggravate her condition and that her husband’s help would be crucial: “If her husband is open-minded, he will take care of her and will explain her situation to others. If she interacts with others, she can get out from her situation quickly. If she remains alone, then she will not come out of her situation.” Some mentioned the need for support by extended family members: “She should live with her extended family. If she has company, she will not have these negative thoughts. If she is living alone, she will have more of these bad thoughts and this will worsen her situation.” Indeed, most believed that her family had a responsibility to help her. One villager said, “Whoever is the superior in the family should look after the whole family and take responsibility for whatever the disease is, whether it is mental or

Depression in Rural Gujarat

physical.” However, not all were optimistic about her family’s ability to provide support: “Because she is mad, [her family] will not take care of her.” Several villagers acknowledged the possibility of physical abuse by the woman’s family (e.g., by her husband or mother-inlaw) for failure to complete her housework. Similarly, the participants were divided in whether the community would be supportive, unhelpful, or hurtful in this woman’s situation. 7. There was universal agreement that the woman was at risk for suicide. One villager explained, “She might be so exhausted and frustrated. It might be better for her to end her own life rather than to continue to suffer.” 8. The participants had variable personal knowledge or experience with people with mental illness. Of those who did report personal experiences, they referred to other villagers, rather than family members. These stories, likely of undiagnosed mental illness, tended to be of villagers whose problems were well known to the community.

Quantitative Results Response frequencies to the 35 Likert-scale questions are presented according to three thematic categories: knowledge of the etiology of depression, perceptions of depression, and knowledge of the treatment of depression (Tables 2, 3, and 4, respectively).

Knowledge of the Etiology of Depression Of the questions relating to the etiology of depression (Table 2), the subjects tended to agree that depression could be caused by a “traumatic event or shock” (60%) or by “brain disease” (54%). Other responses were less definitive.

Villagers’ Perceptions of Depression The participants tended to agree with both the favorable (e.g. “People with depression can live in the community”) and stigmatized (e.g. “Depression is a sign of weakness and sensibility”) statements toward depression (Table 3). Of the stigmatized statements, several (“You would be afraid to have a conversation with someone who has depression,” “People with depression are hard to talk with,” “A person with depression has only himself/herself to blame for his/her condition,” and “You would be ashamed to mention if someone in your family has depression”) elicited divided opinions, with an equal portion of subjects who agreed and disagreed.

Villagers’ Knowledge of Treatment The subjects were more homogenous in their opinions regarding depression treatment (Table 4). Only one statement (“Medications to treat depression will cause addiction”) elicited divided views, with nearly equal numbers who agreed (41%) and disagreed (38%). Overall, the participants were unenthusiastic toward traditional healers. The villagers doubted that traditional healers could

TABLE 2. Villagers’ Knowledge of Etiology of Depression Yes Statement (Question No.) A traumatic event or shock can be a cause of depression (8) Brain disease can be a cause of depression (9) Genetic inheritance may be a cause of depression (10) Depression can be punishment from God (11) Poverty can be a cause of depression (12) Depression is due to possession by evil spirits (13) Only people who have a family history of depression can experience depression themselves (14) Do you think that depression is caused solely by unfavorable social circumstances? (41)

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No

Neutral

n

n

%

n

%

n

%

150 149 151 152 138 149 140 150

90 80 51 58 66 57 65 67

60.0 53.7 33.8 38.2 47.8 38.3 46.4 44.7

28 33 54 68 51 58 58 47

18.7 22.1 35.8 44.7 37.0 45.6 41.4 31.3

32 36 46 26 21 24 17 36

6.7 24.2 30.5 17.1 15.2 16.1 12.2 24

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TABLE 3. Villagers’ Perceptions of Depression Yes Question (No.) Depression is a sign of weakness and sensibility (7) People with depression can live in the community (15) People with depression can work in regular jobs (16) People with depression can be as successful at work as others (17) You would be afraid to have a conversation with someone who has depression (18) You would be willing to maintain a friendship with someone who has depression (19) You would be willing to share a room with someone who has depression (20) People with depression are unpredictable (21) People with depression are hard to talk with (22) A person with depression has only himself/herself to blame for his/her condition (23) A person with depression could pull himself/herself together if he/she wanted (24) It is shameful to have depression (25) You would be ashamed to mention if someone in your family has depression (26) Depression is a sign of failure (27) People who attempt suicide are weak (31)

successfully treat depression (63%), and 58% reported that they would not take a depressed person to a faith healer. However, the villagers expressed optimism toward allopathic treatment forms, including “psychotherapy,” “psychiatrists,” and “medication,” and they were optimistic about the possibility for a depressed person to improve if given treatment, to recover, and to lead a normal life.

Correlations Between Individual Statements We computed Spearman’s rank correlation coefficients (R) between every pair of statements (questions 7 through 41). Because of our large sample size (n = 139), all pairs were found to be minimally correlated with statistical significance (p < 0.05). We selected a minimum R-value of 0.400, a moderate correlation, as our cutoff threshold. This generated five correlated pairs, with R-values ranging from 0.41 to 0.55 (Table 5). Two of these five correlations related to understanding depression through a spiritual framework. The statements “Traditional healers can successfully treat depression” and “If someone close to me were showing signs of depression, I would take him/her to a faith healer” were most strongly correlated (R = 0.55). Likewise, “Depression is due to possession by evil spirits” was moderately correlated with “If someone close

No

Neutral

n

n

%

n

%

n

%

153 144 136 145 143 144 147 144 153 143 146 141 142 142 147

74 71 74 69 62 83 72 63 62 52 79 47 64 74 72

48.4 49.3 54.4 47.6 43.4 57.6 49.0 43.8 40.5 36.4 54.1 33.3 45.1 52.1 49.0

43 36 37 51 62 39 53 48 60 52 42 67 60 36 47

28.1 25.0 27.2 35.2 43.4 27.1 36.0 33.3 39.2 36.4 28.8 47.5 42.3 25.4 32.0

36 37 25 25 19 22 22 33 31 39 25 27 18 32 28

23.5 25.7 18.4 17.2 13.2 15.3 15.0 22.9 20.3 17.1 17.1 19.1 12.7 22.5 19.0

to me were showing signs of depression, I would take him/her to a faith healer” (R = 0.41). The remaining three correlations reflect a medical framework. “Treatment can help people with depression lead normal lives” was correlated with “Psychiatric illness deserves as much attention as physical illness” (R = 0.44) and “People with depression can eventually recover” (R = 0.42). Finally, recovery (“People with depression can eventually recover”) was linked to treatment by a psychiatrist (“If someone close to me were showing signs of depression, I would take him/her to a psychiatrist”) (R = 0.43).

Optimism vs. Pessimism Regarding Depression Our data suggested that our subject group was composed of two distinct groups that differed in their level of optimism regarding depression and its prognosis. One group understood depression under a “medical” framework, whereas the other understood depression under the “spiritual” framework. We separately examined these two groups to detect differences in optimism. Three “optimistic” statements were examined: “A person with depression would improve if given treatment and support,” “Treatment can help people with depression lead normal lives,” and “People with depression can eventually recover” (30).

TABLE 4. Villagers’ Knowledge of Treatment Yes Question A person with depression would improve if given treatment and support (28) Treatment can help people with depression lead normal lives (29) People with depression can eventually recover (30) People with depression can be successfully treated with medication (34) Medications to treat depression will cause addiction (35) People with mental illness can be successfully treated using psychotherapy (36) Traditional healers can successfully treat depression (37) If someone close to me were showing signs of depression, I would take him/her to a healer (38) Psychiatrists can successfully treat depression (39) If someone close to me were showing signs of depression, I would take him/her to a psychiatrist (40)

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No

Neutral

n

n

%

n

%

n

%

146 143 146 145 141 144 145 146 149 148

105 103 102 111 58 96 34 39 101 107

71.9 72 69.9 76.6 41.1 66.7 23.4 26.7 67.8 72.3

24 12 22 17 54 21 91 84 29 11

16.4 8.4 15.1 11.7 38.3 14.6 62.8 57.5 19.5 7.4

17 28 22 17 29 27 20 23 19 30

11.6 19.6 15.1 11.7 20.6 18.8 13.8 15.8 12.8 20.3





TABLE 5. Statements Found to Be Moderately Correlated (R > 0.4) via Spearman’s Rank Correlation Coefficient Statement 1 Traditional healers can successfully treat depression Treatment can help people with depression lead normal lives People with depression can eventually recover Treatment can help people with depression lead normal lives Depression is due to possession by evil spirits

Statement 2

Correlation Coefficient (R)

If someone close to me were showing signs of depression, I would take him/her to a healer Psychiatric illness deserves as much attention as physical illness If someone close to me were showing signs of depression, I would take him/her to a psychiatrist People with depression can eventually recover

0.55

If someone close to me were showing signs of depression, I would take him/her to a healer

0.41

Optimistic views accounted for the majority (50%–82%) of responses, whereas pessimistic responses accounted for less than 20%. More subjects indicated that they would bring someone with symptoms of depression to a psychiatrist (n = 107) than not (n = 11). Conversely, fewer subjects would bring someone to a faith healer (n = 39) than not (n = 84). The most optimistic subjects were those who would choose a psychiatrist and those who would not choose a faith healer. The most pessimistic subjects were those who would choose a faith healer; 52% of this group doubted that one could improve with treatment and support. Spearman’s rank correlation coefficients between the “optimistic” statements and willingness to visit a faith healer or psychiatrist revealed minimal-to-mild correlations (Table 6). Willingness to visit a healer was negatively correlated with optimism, whereas willingness to visit a psychiatrist was positively correlated. In particular, willingness to visit a psychiatrist was strongly correlated (R = 0.426) with believing that people with depression could recover.

Principal Components Analysis PCA was performed using the SPSS. PCA produced 13 components that accounted for 73% of the total variance. We included the first four components, which accounted for a significant portion of total variance (each contributing 6.5%–14.2% of the total variance). These components met criteria of a) forming a meaningful theme that we could make sense of for every component and b) having dual variance (both low and high loading factors to separate the contributory statements). Of the 35 statements, we extracted the statements that loaded most strongly onto each component (Table 7). The investigators generated thematic labels that best captured each component, leading to three “axes” around which each component seemed to revolve, as follows: a) the cause of depression, b) stigma toward depression, and c) level of optimism regarding the prognosis. Final themes that represented a composite of the how each component mapped onto these axes were generated (Table 8).

DISCUSSION Overall, the subjects were accepting and knowledgeable about depression and its treatment options. Our subjects seemed

0.44 0.43 0.42

more knowledgeable and optimistic about psychiatry’s role in treating mental illness and more doubtful of traditional healers than were prior populations. Previous studies elicited indigenous beliefs about mental illness that were highly superstitious, involving black magic and evil spirits (Joel et al., 2003). Indians often construed mental illness as God’s punishment or caused by factors such as polluted air, excessive masturbation, or decreased sexual desire (Kishore et al., 2011). Faith healers were frequently the initial provider of choice for treatment of mental illness, over psychiatrists (Naik et al., 2012), who were often perceived as eccentric as well as thought to know nothing and to do nothing. Many did not know that psychiatry was a branch of medicine (Kishore et al., 2011). Those who were aware of psychiatrists expressed fears of medication adverse effects and stigma associated with visiting a psychiatrist (Naik et al., 2012). Our subjects were enthusiastic about the prognosis of clinical depression, the efficacy of treatment, and the potential for recovery, particularly in the setting of appropriate psychiatric treatment and interpersonal support from family members. Interpersonal and socioeconomic support was cited as necessary for successful recovery; lack of this support was deemed critical to the pathogenesis of depression itself. Focus groups and survey responses emphasized interpersonal conflicts and socioeconomic stressors (such as living alone or poverty) to be an important precipitating factor in depression. Research in rural Maharashtra has demonstrated beliefs that depression is a product of socioeconomic factors (Kermode et al., 2010, 2007), and many Indians favor a social model of depression (Lawrence et al., 2006). There was some mention of evil spirits or black magic borne of jealousy as a possible cause of depression, although this was infrequent. Two distinct populations emerged from our findings, determined by preference for a psychiatrist or a faith healer: one group that understood depression as a psychiatric condition (“medically oriented”) and another that understood depression through a spiritual framework (“spiritually oriented”). These two groups differed in their views regarding etiology, stigma, and prognosis of depression: the medically oriented group believed that treatment could lead to recovery and normal functioning in the community, whereas the spiritually oriented group believed treatment to be futile.

TABLE 6. Spearman’s Correlations Between Healer vs. Psychiatrist and Optimism Q28: A Person With Depression Would Improve If Given Treatment and Support’

Q29: Treatment Can Help People With Depression Lead Normal Lives

Q30: People With Depression Can Eventually Recover

−0.156 0.052

−0.095 0.270

−0.245 0.426

Bring to healer Bring to psychiatrist


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TABLE 7. Principal Components With Statements Component

Statements (Question No.)

1

Poverty can be a cause of depression (12) You would be afraid to have a conversation with someone who has depression (18) A person with depression has only himself/herself to blame for his/her condition (23) Treatment can help people with depression lead normal lives (29) People with mental illness can be successfully treated using psychotherapy (36) Psychiatrists can successfully treat depression (39) Depression can be punishment from God (11) It is shameful to have depression (25) If someone close to me were showing signs of depression, I would take him/her to a healer (38) A person with depression would improve if given treatment and support (28) A traumatic event or shock can be a cause of depression (8) People with depression can work in regular jobs (16) You would be willing to maintain a friendship with someone who has depression (19) You would be willing to share a room with someone who has depression (20) Depression is a sign of failure (27) People with depression can eventually recover (30) People with depression can work in regular jobs (16) You would be willing to maintain a friendship with someone who has depression (19) People with depression can be successfully treated with medication (34) Traditional healers can successfully treat depression (37) Depression is a sign of weakness and sensibility (7) Brain disease can be a cause of depression (9)

2

3

4

Statements in bold load negatively into the component.

Therapeutic optimism and pessimism seemed to be linked to divergent beliefs about the cause of depression. The subjects who believed depression to be caused by poverty or socioeconomic factors expressed more optimism toward depression. Likewise, those who regarded depression as something other than a “brain disease” were also optimistic (although the term brain disease was not defined by the subjects, it likely reflects organic neurological conditions that the subjects have witnessed over the years, such as dementia, seizures, strokes, malignancies, and traumatic brain injury). The subjects who regarded depression as God’s punishment were more pessimistic regarding its prognosis, consistent with the finding that our spiritually oriented group believed treatment to be futile. Attributing one’s situation to God’s punishment has been linked to negative outcomes in similar populations. In Pakistan, earthquake survivors who attributed their traumatic experiences to God’s punishment

demonstrated more posttraumatic stress disorder symptoms and experienced higher levels of negative emotion than those who did not (Feder et al., 2013). Finally, our subjects who attributed depression to a traumatic event or shock were more pessimistic regarding the possibility of recovery from depression. Severity and reversibility of the perceived stressor may be the mediating factor. Economic issues or interpersonal conflict are potentially reversible, whereas a traumatic event, such as a sudden death in the family, could precipitate sadness and grief that seem impossible to recover from. Furthermore, our spiritually oriented group might favor therapeutic pessimism if they have personally seen others fail to improve after treatment by a traditional healer.

Stigma Overall, our subjects demonstrated sympathetic views toward those with depression. Stigma was evaluated indirectly via questions

TABLE 8. Themes for Principal Components Degree of Stigma Toward Depression

Optimism Regarding Prognosis of Depression

1 Poverty

High

Optimistic

2 Punishment from God

High

Pessimistic

3 Traumatic event/shock

Low

Pessimistic

4 Not medical condition or brain disease

Low

Optimistic

Cause of Depression

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Composite Theme Despite stigma around depression, there is hope for its treatment when it is attributed to economic circumstances or poverty. Stigma and therapeutic nihilism surround depression when it is viewed from a traditional or superstitious viewpoint (i.e., attributed to gods or spirits) Participants are sympathetic toward but pessimistic about depressed individuals when their depression is attributed to a traumatic event or shock Participants are sympathetic toward depressed individuals and hopeful for their treatment and recovery when their depression is not attributed to organic causes (a medical condition or brain disease).




that assessed “desired social distance,” a method that correlates stigma with how close subjects are willing to be to a depressed individual (Jorm and Oh, 2009; Link et al., 2004). Many reported willingness to maintain a friendship or share a room with a depressed person, and many believed that depressed people could work regular jobs and live in the community. Although prior research with rural Indians has demonstrated widespread fear and stigmatizing attitudes toward depression (Dietrich et al., 2004; Nieuwsma et al., 2011), stigma surrounding depression was far less common among our subjects than anticipated. Nevertheless, the villagers did acknowledge that the woman in the focus group vignette would face some degree of stigma. We detected a link between the perceived cause of depression and degree of stigma, which was unrelated to level of optimism. Previous studies have demonstrated similar associations between perceived cause of mental illness and degree of stigma; Dietrich et al. (2004) found that, globally, biological causes of depression and schizophrenia elicited greater stigma. Prior studies in rural Maharashtra have demonstrated a similar reluctance to be close to those who have brain disease, suggesting that promoting western biomedical explanatory models for depression might increase stigma (Kermode et al., 2009b). Research suggests that people who endorse the biogenetic cause of mental illness also believe that people with mental illness are more dangerous, lack self control, and are more unpredictable, perpetuating the fear associated with people with mental illness (Dietrich et al., 2006). These observations likely contribute to the tendency we and others have observed for people with depression to present with somatic complaints (Nieuwsma et al., 2011).

Implications and Future Directions Our results suggest that the communities we surveyed might be transitioning toward more open-minded and sympathetic attitudes toward depression, without the stigma that has traditionally existed in rural Indian populations (Nieuwsma et al., 2011). This might reflect increasing knowledge and awareness among villagers, perhaps resulting from recent campaign efforts by the MINDS Foundation to improve mental health care access and awareness in these communities. Our assessment has several limitations. We used a convenience sample of subjects from each village, which might have generated selection bias. Certain populations were likely overrepresented or underrepresented; for example, we surveyed fewer women than men in total because women were often preoccupied with household chores when we arrived. Subjects who were more wary and lacked knowledge about depression were potentially underrepresented in our study because of reluctance to participate in a study regarding mental illness. Subjects with more leisure time and/or who were particularly curious about mental illness might have been overrepresented in our study, as well as in previous campaigns conducted by the MINDS Foundation. Because the research team represented the psychiatry department at SVU, the MINDS Foundation, and Icahn School of Medicine at Mount Sinai, the subjects may have been motivated to report positive attitudes and confidence in psychiatry. Because the survey and focus groups were created in English and subsequently translated into Gujarati, there was possible misinterpretation of survey questions due to cultural discrepancies. We attempted to ensure that our survey and focus group vignette was optimally translated by checking both English and Gujarati versions with the resident psychiatrist from SVU, the social worker from the MINDS Foundation, and T. S., a researcher who grew up near SVU. All three verified that the translated versions accurately represented the original English versions and were culturally relevant to our sample population. Finally, we did not ascertain details of the types of traditional healing observed by our respondents and degree of pessimism. Healers range from traditional health practitioners and herbalists to faith healers who seek divine guidance, shamans, witch doctors, and © 2014 Lippincott Williams & Wilkins


fortune tellers (World Health Organization, 2000). If the subjects are indeed influenced by their personal experiences with healers, who inevitably possess varying degrees of efficacy in treating depression, then the observed levels of nihilism among the subjects may vary on the basis of their preferred type of healer.

CONCLUSIONS Our study results were encouraging; among those villagers reporting limited knowledge about depression, most displayed curiosity and interest in learning more. We believe that the presence of a distinctly knowledgeable, accepting group of subjects, who are more optimistic about treatment outcomes and particularly enthusiastic about the role of psychiatric treatment in depression, might reflect prior education campaigns. The group of subjects who were more educated and enthusiastic about psychiatric treatment could be helpful in future awareness efforts; for example, they might be solicited to help as peer educators or contacts within the community. Future research should focus on naive villagers who have had no exposure to psychoeducational campaigns. The results will help inform the design of future clinical and educational outreach in rural Gujarat, if not India in general. ACKNOWLEDGMENTS The authors thank the MINDs Foundation, the Department of Psychiatry at SVU, and the Icahn School of Medicine at Mount Sinai Global Health Center for their partnership and support; Dr Bhavik Shah for his crucial role in the villages as focus group facilitator and interpreter; Dr John Doucette, from the Department of Preventive Medicine, for his expertise and guidance in the area of biostatics and data management and for his contribution to the statistical analysis; as well as the seven communities and the community members for their time, cooperation, and willingness to participate in this study. DISCLOSURES This study was supported by Icahn School of Medicine at Mount Sinai Global Health Center. The authors declare no conflict of interest. REFERENCES Andrew G, Cohen A, Salgaonkar S, Patel V (2012) The explanatory models of depression and anxiety in primary care: A qualitative study from India. BMC Res Notes. 5:499. Almanzar S, Shah N, Vithalani S, Shah S, Squires J, Appasani R, Katz CL (2014) Knowledge of and attitudes toward clinical depression among health providers in Gujarat, India. Ann Glob Health. 80:89–95. Bruce ML, Leaf PJ (1989) Psychiatric disorders and 15-month mortality in a community sample of older adults. Am J Public Health. 79:727–730. Barua A, Ghosh M, Kar N, Basilio M (2010) Distribution of depressive disorders in the elderly. J Neurosci Rural Pract. 1:67–73. Byer LE, Aggarwal NK, Shah S, Appasani RK (2014) Changing attitudes towards mental health and mental illness: Evaluation of an intervention in rural Gujarat. India Ann Global Health. 2014:85–89. Dietrich S, Beck M, Bujantugs B, Kenzine D, Matschinger H, Angermeyer MC (2004) The relationship between public causal beliefs and social distance toward mentally ill people. Aust N Z J Psychiatry. 38:348–354; discussion 355–357. Dietrich S, Matschinger H, Angermeyer MC (2006) The relationship between biogenetic causal explanations and social distance toward people with mental disorders: results from a population survey in Germany. Int J Soc Psychiatry. 52:166–174. Feder A, Ahmad S, Lee EJ, Morgan JE, Singh R, Smith BW, Southwick SM, Charney DS (2013) Coping and PTSD symptoms in Pakistani earthquake

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Ramakrishnan P, Rane A, Dias A, Bhat J, Shukla A, Lakshmi S, Ansari BK, Ramaswamy RS, Reddy RA, Tribulato A, Agarwal AK, Satyaprasad N, Mushtaq A, Rao PH, Murthy P, Koenig HG (2014) Indian health care professionals’ attitude towards spiritual healing and its role in alleviating stigma of psychiatric services. J Relig Health. [Epub ahead of print]. Soleimani L, Lapidus KA, Iosifescu DV (2011) Diagnosis and treatment of major depressive disorder. Neurol Clin. 29:177–193. Swarnalatha N (2013) The prevalence of depression among the rural elderly in Chittoor District, Andhra Pradesh. J Clin Diagn Res. 7:1356–1360. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, Charlson FJ, Norman RE, Flaxman AD, Johns N, Burstein R, Murray CJ, Vos T (2013) Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet. 382:1575–1586. Winer RA, Morris-Patterson A, Smart Y, Bijan I, Katz CL (2013) Knowledge of and attitudes toward mental illness among primary care providers in Saint Vincent and the Grenadines. Psychiatr Q. 84:395–406. World Health Organization (2000) General guidelines for methodologies on research and evaluation of traditional medicine. Geneva, Switzerland: World Health Organization.

Kermode M, Herrman H, Arole R, White J, Premkumar R, Patel V (2007) Empowerment of women and mental health promotion: A qualitative study in rural Maharashtra India. BMC Public Health. 7:225.

APPENDIX 1. SURVEY ON DEPRESSION

Khandelwal SK, Jhingan HP, Ramesh S, Gupta RK, Srivastava VK (2004) India mental health country profile. Int Rev Psychiatry. 16:126–141. Kishore J, Gupta A, Jiloha RC, Bantman P (2011) Myths, beliefs and perceptions about mental disorders and health-seeking behavior in Delhi, India. Indian J Psychiatry. 53:324–329. Kohli C, Kishore J, Agarwal P, Singh SV (2013) Prevalence of unrecognised depression among outpatient department attendees of a rural hospital in Delhi, India. J Clin Diagn Res. 7:1921–1925. Lawrence V, Murray J, Banerjee S, Turner S, Sangha K, Byng R, Bhugra D, Huxley P, Tylee A, Macdonald A (2006) Concepts and causation of depression: A crosscultural study of the beliefs of older adults. Gerontologist. 46: 23–32. Link BG, Yang LH, Phelan JC, Collins PY (2004) Measuring mental illness stigma. Schizophr Bull. 30:511–541. Montico M, Nelson RG, Nelson PK, Tonelli M, Tamburlini G, Tavakkoli M, et al. (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 380:2163–2196. Naik SK, Pattanayak S, Gupta CS, Pattanayak RD (2012) Help-seeking behaviors among caregivers of schizophrenia and other psychotic patients: A hospitalbased study in two geographically and culturally distinct Indian Cities. Indian J Psychol Med. 34:338–345. Nambi SK, Prasad J, Singh D, Abraham V, Kuruvilla A, Jacob KS (2002) Explanatory models and common mental disorders among patients with unexplained somatic symptoms attending a primary care facility in Tamil Nadu. Natl Med J India. 15:331–335. Nieuwsma JA, Pepper CM, Maack DJ, Birgenheir DG (2011) Indigenous perspectives on depression in rural regions of India and the United States. Transcult Psychiatry. 48:539–568. Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V (2007) The explanatory models of depression in low income countries: Listening to women in India. J Affect Disord. 102:209–218. Poongothai S, Pradeepa R, Ganesan A, Mohan V (2009) Prevalence of depression in a large urban South Indian population–the Chennai Urban Rural Epidemiology Study (CURES-70). PLoS One. 4. doi: 10.1371/journal.pone.0007185. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A (2007) No health without mental health. Lancet. 370:859–877. Raguram R, Weiss MG, Channabasavanna SM, Devins GM (1996) Stigma, depression, and somatization in South India. Am J Psychiatry. 153:1043–1049. Rajkumar AP, Thangadurai P, Senthilkumar P, Gayathri K, Prince M, Jacob KS (2009) Nature, prevalence and factors associated with depression among the elderly in a rural south Indian community. Int Psychogeriatr. 21:372–378.

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1. Please state your age: ________ 2. What is your sex? a. Male b. Female 3. What is your occupation? a. Housewife b. Farmer c. Professional d. Other: (please state: _____________) 4. What is your highest level of education? a. Less than intermediate b. Intermediate graduate c. College/university graduate 5. What is your marital status? a. Single b. Married c. Separated/divorced d. Widowed 6. What do you understand by the term depression? 7. Depression is a sign of weakness and sensibility. a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree 8. 9. 10. 11. 12. 13. 14.

A traumatic event or shock can be a cause of depression: Brain disease can be a cause of depression: Genetic inheritance may be a cause of depression: Depression can be punishment from God: Poverty can be a cause of depression: Depression is due to possession by evil spirits: Only people who have a family history of depression can experience depression themselves 15. People with depression can live in the community: 16. People with depression can work in regular jobs: 17. People with depression can be as successful at work as others: © 2014 Lippincott Williams & Wilkins



18. You would be afraid to have a conversation with someone who has depression: 19. You would be willing to maintain a friendship with someone who has depression: 20. You would be willing to share a room with someone who has depression: 21. People with depression are unpredictable: 22. People with depression are hard to talk with: 23. A person with depression has only himself/herself to blame for his/ her condition: 24. A person with depression could pull himself/herself together if he/ she wanted: 25. It is shameful to have depression: 26. You would be ashamed to mention if someone in your family has depression: 27. Depression is a sign of failure 28. A person with depression would improve if given treatment and support: 29. Treatment can help people with depression lead normal lives: 30. People with depression can eventually recover: 31. People who attempt suicide are weak: 32. People are generally caring and sympathetic toward persons with depression: 33. Psychiatric illness deserves as much attention as physical illness: 34. People with depression can be successfully treated with medication: 35. Medications to treat depression will cause addiction: 36. People with mental illness can be successfully treated using psychotherapy: 37. Traditional healers can successfully treat depression:



38. If someone close to me were showing signs of depression, I would take him/her to a healer: 39. Psychiatrists can successfully treat depression: 40. If someone close to me were showing signs of depression, I would take him/her to a psychiatrist: 41. Do you think that depression is caused solely by unfavorable social circumstances?

APPENDIX 2. FOCUS GROUP VIGNETTE In one of the villages in Vadodara, there lives a 25-year-old married housewife with three children, who began to feel differently 4 weeks ago. She began to experience the gradual onset of sadness, low mood, decreased motivation, difficulties falling and staying sleep, poor appetite, trouble concentrating, and trouble remembering things. She has lost some weight over these 4 weeks. Her housework has become an uncharacteristic burden for her. It does not interest her as it had before, and she cannot force herself to focus on it. She feels shame for being unable to take care of her family as she normally would. She had never tried to end her life and does not have a plan to do it but increasingly feels that her life has become worthless and finds that she cannot stop wondering if her family might be better off if she were dead. Her husband has been spending more and more time away from their home for work, and she has been feeling more isolated. She had visited a local traditional healer to get help twice and had sacrificed a red chicken cock once. But her condition is not improving. She also stated that she has been unable to manage how she feels on her own. There is no significant medical reason that can explain her current condition.

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