Improving mental health in patients with diabetes in Malawi

Michael Udedi is an Assistant Director of Clinical Services responsible for mental health at the Ministry of Health and AMARI PhD Fellow based at the University of Malawi-College of Medicine in Malawi. AMARI (African Mental Health Research Initiative) is one of the eleven Developing Excellence, Leadership, and Training in Science in Africa (DELTAS Africa) programmes. DELTAS Africa funds Africa-based scientists to amplify the development of world-class research and scientific leadership on the continent while strengthening African institutions. DELTAS Africa is implemented through the AESA Platform. AESA (The Alliance for Accelerating Excellence in Science in Africa) is a funding, agenda-setting, programme management initiative of the African Academy of Sciences (AAS), the African Union Development Agency (AUDA-NEPAD), founding and funding global partners, and through a resolution of the summit of African Union Heads of Governments. DELTAS Africa is supported by Wellcome and the United Kingdom Foreign, Commonwealth and Development Office (FCDO formerly DFID).

Summary

Michaels’s study reveals that bridging the treatment gap by integrating depression screening and treatment into diabetes care in central Malawi is feasible and acceptable by health care workers. However implementation of such an intervention requires availability of resources, training and as workforce expansion.

Background

Most low- and middle-income countries (LMICs) have a large treatment gap for common mental disorders (CMDs), including depression. Physical, Non Communicable Diseases (NCDs) and depression are common and significant causes of morbidity, disability and mortality in Africa. NCDs account for a growing burden on the health systems in LMICs. Similarly, depression is projected to become a leading cause of disability in Africa by 2030. In Malawi, it is estimated that NCDs account for at least 12% of total Disability Adjusted Life Years (DALYs). In addition, NCDs are considered to be the second leading cause of death in adults, following only HIV-related diseases.  

In Malawi, the identification of people with depression is difficult and the treatment gap for depression in general health care is high. Furthermore, general primary care clinic studies indicate that it is likely that detection rates of depression in physical NCD clinics in Malawi are low and that this could be a contributing factor to poor control of diabetes. This is due to both limited resources for depression management and weak routine practices to identify and manage depression in NCD care.

Integration of mental health screening and treatment into other health care services is one way of reducing the treatment gap. Studies conducted in other LMICs show that this approach improves access to mental health services.  A systematic review of collaborative care of patients with comorbid conditions in higher income countries provides evidence to support the effectiveness of integrated care in improving depression outcomes and improved adherence to treatment for both depression and diabetes. However, in LMICs, evidence about effectiveness and implementation of appropriate interventions on depression care in diabetes clinics is rare.

The study

This study sought to evaluate the effectiveness, feasibility and acceptability of integrating depression management into routine care of NCDs on patient and service outcomes in central Malawi. The hospital-based, cross-sectional study was conducted with mixed methods in five districts in central Malawi. Our study was conducted in two phases namely an instrument validation study and pilot study. The validation study was conducted in one district and the pilot study was done in four districts. 

The objective of validation study was to investigate the screening properties of the patient health questionnaire (PHQ-9) in the detection of depression in diabetes care clinic. While the objective for the pilot study was to evaluate the acceptability, feasibility and effectiveness of integrating both screening for depression using PHQ-9 and depression management in diabetes care clinics.

Outcome of the study

For the first time, the validation study of the PHQ-9 to screen for depression in patients with type-2 diabetes mellitus in NCD clinics in Malawi was done. The study has demonstrated that the Chichewa PHQ-9 is a reasonably accurate screening tool to identify cases of depression in this setting. An investigation of the prevalence and detection rate of depression patients with diabetes showed that depression is common among NCD clinic patients with diabetes in Malawi and is poorly detected by NCD clinicians. Furthermore, a pilot study in which depression screening and management was integrated into routine NCD clinic practice demonstrated its feasibility and acceptability by health workers to screen for depression as part of diabetes care in NCD clinics in Malawi.

Findings will inform policy makers to plan to integrate depression screening and its management in diabetes care in NCD clinics in Malawi and other low resource settings. The next step is to transform these findings into actionable strategies to manage the patients with diabetes who have comorbidity with depression.

Lessons

The PHQ-9 effectively screen for depression in patient with diabetes in Malawi. There are many patients with diabetes who are suffering from depression however their depression is poorly detected. The NCD health care workers saw the need of integrating depression screening and treatment in diabetes care.

These findings provide insights on the impact of integrating depression management into routine care of diabetes within the NCD care setting. To integrate depression management, resources and capacity building of NCD healthcare workers in depression screening and management, training and workforce expansion are required.

Impact

This study provides evidence that the validated Chichewa version of the PHQ-9 is a useful screening tool for depression in diabetes clinics in central Malawi and that integration depression management is feasible. The study suggests that policymakers and clinicians must develop interventions to improve detection of depression among patients with diabetes. 

Much must be done to build the capacity of NCD health care workers in depression screening and treatment to provide holistic care for patients with diabetes. NCD care clinics must plan to include depression management with sufficient supply of resources including providers and medication.