|Year : 2017 | Volume
| Issue : 3 | Page : 225-232
Concept of depression in rural community of Chandigarh
BS Chavan, Sukhtej Sahni, Subhash Das, Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||14-Sep-2017|
Department of Psychiatry, Government Medical College and Hospital, 5th Level, D-Block, Sector 32, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Lack of awareness about mental illness prevents patients from getting appropriate mental health care. This is more so in places where there is dearth of adequate mental health professionals. These factors highlight the importance of conducting research to assess public knowledge and attitudes toward mental illness. Hence, the aim of the present study was to assess the prevailing concept of depression in the community. Methods: Two villages in the periphery of Chandigarh were selected and local “Panchayat” of the villages were told to select the local members in the community who were regarded as socially responsible. A total of 48 members were selected and a workshop was conducted by the experts in mental health and the cohort was asked about prevailing concept of depression in the local community. The whole workshop was videotaped and the verbatim of the same was recorded. Results: It was found that majority had beliefs that depression is caused by stressful circumstances or substance use and the depressed individual has decreased interaction, fights and sleeps less. It was also noted that the prevalence was perceived to be low. The first treatment preferences were religious/faith healers or the local practitioners. Reasons for treatment gap were cited as ignorance and misguidance in the community. Conclusions: It was interpreted that depression is mainly linked with stressful events and symptoms being behavioural only. The understanding of somatic and biological symptoms was lacking along with the endogenous risk factors and its causes. Treatment gap exists at the grass root level and reasons such as ignorance and misguidance emerged during the discussion with the community leaders.
Keywords: Community, depression concept, rural, treatment gap
|How to cite this article:|
Chavan B S, Sahni S, Das S, Sidana A. Concept of depression in rural community of Chandigarh. Indian J Soc Psychiatry 2017;33:225-32
|How to cite this URL:|
Chavan B S, Sahni S, Das S, Sidana A. Concept of depression in rural community of Chandigarh. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Sep 16];33:225-32. Available from: http://www.indjsp.org/text.asp?2017/33/3/225/214589
| Introduction|| |
Epidemiological findings indicate that some 10–15% of primary care patients suffer from major depressive disorder (MDD),, with most depressed patient's presenting to primary care practitioners with somatic symptoms of depression or help-seeking behaviors related to physical concerns. MDD may become a chronic, recurrent mood disorder, which is associated with significant morbidity, mortality and thus results in the excessive utilization of medical services and infrastructure. Depression may go unrecognized in up to 70% of the cases and even when it is recognized and treated, fewer than 50% of the cases receive adequate dose or duration of treatment.
A descriptive study from India reported that a large number of people in the community had poor knowledge regarding mental illness, and only a few had average knowledge. More than half of the subjects could mention common mental disorders, and this shows that there may be a high prevalence of mental illness in the community.,
It has been recognized that obstacles to the recognition and successful treatment of depression include inadequate knowledge of depression as a disease, its treatment, and pathways of care. Although attitudes toward depression are better than those toward schizophrenia, there are negative attitudes toward depression that interfere with its presentation, recognition, and treatment.,,,, In Great Britain, the figure of approximately 10% expressing the negative perception that depressed people are often mad or unstable did not change during the Defeat Depression Campaign. The most unfavorable attitudes toward depression are toward its treatment and the use of antidepressants., The general trend of the studies carried out in India so far indicate mixed results and highlight the fact that lay urban public is largely misinformed about the various aspects of mental health, and the information possessed by it remains uncrystallized.
Better knowledge is often reported to result in improved attitudes toward people with mental illness and a belief that mental illnesses are treatable can encourage early treatment seeking and promote better outcomes. In addition, reluctance to seek professional psychiatric help means late presentations are quite common. The extent to which patients benefit from improved mental health services is influenced not only by the quality and availability of services but also by the knowledge and belief systems of the people.,
Another factor posing a challenge in the dissemination of mental health care in the community is the lack of trained mental health-care professionals, especially in the peripheral areas, and hence, there is a need to increase access through primary care by increasing the involvement of nonspecialist health workers including medical and nursing professionals and nonmedical health workers. Thus, reducing the treatment gap will require more, and more widely distributed mental health professionals to lead the design, implementation, and evaluation of community-based mental health-care programs. While formulating mental health policies, it is important not only to involve the community members but also to know what the community thinks about the mental illness. In fact, key members of the community such as the village head, members of the “Gram Panchayat” (village governing council), and municipal councilors can play a positive role in sensitizing the community about psychiatric illness and also encourage community participation in the therapeutic process. Thus, it is of paramount importance to conduct research in the community setting and to assess public knowledge and attitudes toward mental illness. Few studies are there in India which have explored the community's idea and general understanding about mental illnesses in general and depression in particular. Hence, the aim of the present study was to assess the prevailing concept of depression in the community.
Aim of the study
To assess the prevailing concept of depression in the rural community of Chandigarh, and explore the existing community practices of helping a person with depressive disorder.
| Methodology|| |
For the purpose of the study, on the basis of convenient sampling, two villages in the periphery of Chandigarh were selected. The approximate population of these two villages is 12,500. The “Gram Panchayats” (village governing body) of these villages were involved in selecting 48 community leaders, who agreed to participate in a 4 h workshop on the occasion of World Mental Health Day (2012). It is worthwhile to mention here that in India “Gram Panchayats” are the local governing body in rural areas. It comprises elected local representatives from the same village (gram) or a few villages for which the “Gram Panchayat” has been constituted. The term for these elected members is for 5 years. These “Gram Panchayat” look after the local affairs of the villages such as agriculture, drinking water, rural housing, and so on and they often play a crucial role in molding public opinion in the rural areas.
The “Gram Panchayat” of each village was asked to select at least 25 community leaders from their respective village meeting the following criteria:
- A person with social recognition and reputation in the village, who is listened to and respected in the village
- A person involved in the social work relating to village well-being
- Representative of a social club, religious organization, or democratically elected body.
We selected community leaders rather than general population as these individuals were often consulted by the local population for the purpose of health advice. In majority of the cases, including mental health issues, these persons often guide the people when and where to seek help. The participating community leaders in the workshop belonged to the members of local “Panchayats,” “Mahila Mandal” (Women Commission), and Municipal Council.
The workshop was conducted in the community hall of one of the two villages. It was half a day workshop and lasted for approximately 5 h with two small breaks (of about 15 min duration) in between. The theme for the workshop as well as the questions for the participants was thought of after three rounds of brain storming by the mental health professionals (Psychiatrists and Clinical Psychologists) of the Department of Psychiatry, Government Medical College and Hospital, Chandigarh.
It was predecided that the Principal Investigator will be asking the questions to the participants. The participants were informed that the proceedings of the workshop will be video recorded and may also be used for research purpose. After obtaining verbal consent and giving a brief background, the interactive session was held in which all the participants were encouraged to express their personal views. The participants were requested to speak one by one so that it becomes easier to record the proceedings. Each question was explained in the local language, and the local word for certain technical words was agreed upon before the discussion.
Open discussion was held on the following themes:
- Can you identify a person suffering from depression?
- Is depression a common illness in your community?
- If someone has depression, then what does family or society would do?
- What are the causes of depression?
- Why do a large number of people suffering from depression are not seeking treatment?
- What can the community do about this treatment gap?
All the participants were asked to express their independent opinion. Three research staffs from Government Medical College and Hospital (M Phil, Clinical Psychology) were asked to write the responses verbatim. The whole proceeding was actively supervised by three consultant psychiatrists. While the Principal Investigator, who was also one of the consultant psychiatrists, put questions to the participants, the other two consultants were there to see that all the participants were involved actively and also voiced their opinion. The two consultants specifically kept track regarding who had spoken and who had not and would be actively involved in coaxing the less active participants to speak. In addition, these two consultants would make their own independent notes about the workshop and feedback provided by the participants. At the end of the workshop, all the three consultants discussed among themselves and prepared a final document of the responses. The proceedings were also video recorded to capture all the possible responses. It was done by a staff from the department. The write-up and video recording of the proceedings was reviewed by one of the consultant psychiatrists, and the final draft was prepared after independent review by all the consultants. In the final draft, the verbatim of the participants were translated into English language for the sake of global understanding.
As the workshop mainly involved interactive discussion of the participants and no intervention or treatment was provided, so the consultants did not seek permission from the Institutional Ethics Committee. However, it may be mentioned here that the Department of Psychiatry has been involved in activities such as this for several years (which are often a part of the program for different special days such as “World Mental Health Day,” “World Health Day,” and “World Schizophrenia Day”) and the institution is aware about it.
| Results|| |
The participants were socially active and were often involved in welfare activities of the villages. There were 48 participants in total, right from the start to the end of the session. Most of them were females (64.59%), and majority of the participants were between 41 and 60 years of age (62.5%). The participants belonged to middle class predominantly. It was not known whether any of them had someone with mental illness in their family.
Concept of depression and its prevalence
During the session, the experts explained that in addition to feeling sad, having disturbed sleep, suicidal ideas/attempt, remaining withdrawn, talking less, being irritable, “tension” as mentioned by the participants and so on, many patients of depression might have generalized weakness, aches and pains without any diagnosable medical illness, and negative thoughts. After this, many participants started mentioning that similar incidences were there in their family or relatives, and gradually a number of participants agreed with the experts. The experts stressed that a depressed patient does not have to be socially withdrawn or stuck to bed the whole day, and it was further stressed that self-expression of depressive thinking is there in most of the cases. It was also mentioned that despite having depression, some of the patients still continue to work with reduced efficiency. When one asks such a person, “How are you feeling inside?” The person will mostly say that he is not feeling well. The participants realized that in their village, if somebody say that he is not feeling well, he is generally not listened to and family feel that either he is having some physical illness, or he is presumed to have some sort of evil curse or black magic. Such a person is at times accused of giving lame excuses to avoid working.
It was suggested to the participants that depression is a common illness but frequently goes unrecognized. To this, the participants again had mixed response and wanted the experts to tell them more about it. The experts briefed the participants about the prevalence study and calculated the number of people who could have depression in their village. The figure came to be a big surprise, and the participants wanted to know why they are not able to see them. The participants were explained that many patients of depression might have physical symptoms, and thus, they might seek help from physicians who prescribe them medicines for physical ailments. Some of them might abuse alcohol and drugs, and thus depression is masked with the substance abuse. Since the acceptability of depression is much less in the rural areas of the country, many patients may not directly report sadness of mood.
When the community leaders were inquired about their overall concept of depression, they mostly mentioned that a depressed person would get tensed very easily, would remain withdrawn and alone, and would interact less. However, none of the participant mentioned somatic symptoms (including bodily and anxiety symptoms), appetite disturbances, low confidence and self-esteem, hopelessness, death wishes, and suicidal ideas. The closest word for depression for them was “tension.” The general perception among the participants was that it is not a common illness and does not affect everyone equally.
Causes of depression
The experts added that in addition to the environmental factors (such as psychosocial factors which were mentioned by the participants) that caused depression, there were other causes of depression too, such as hereditary factors and something (neurotransmitters in the brain) inside the brain going wrong. While trying to find out what was the community's view regarding the causes of depression, most of them felt that depression occurs due to financial problems, marital or familial issues and interpersonal conflicts, drug abuse, unemployment, tragedy, poverty, and problems related to workplace and study. Surprisingly, no one mentioned that depression is an illness which can result from internal causes (genetic and biological). The participants did not have much knowledge regarding this, and they agreed that this was some new information for them.
Reasons for treatment gap and remedial measures
During the discussion with the community participants, the experts too agreed that lack of awareness about the illness, stigma and not receiving proper, timely care attributed to the delay in taking the appropriated treatment. Thus, by increasing awareness, creating appropriate facilities in the village level with some amount of additional training regarding psychiatric illness to the doctors in the village dispensaries, may help the villagers in getting proper treatment.
Pathways to care
In an attempt to explore the pathways used by the people whenever someone in the community has mental illness such as depression and interesting facts were revealed. The participants preferred to visit “local faith healers” even though they did not have a proper qualification. The doctors in the dispensaries do not give much explanation to their problems. On the other hand, these “local faith healers” at least listen to their problems and give them some explanation. Many participants also added that the local practitioner prefer injections for every ailment, and the injections give temporary relief but no cure and felt that this would make them dependent on such medicines in future.
The participants agreed that usually people do not take treatment promptly as there was a lack of awareness and ignorance for such disorders in the community. This could be a reason for the treatment gap. They added that even the doctors in their area did not guide them well in matters related to mental illness in general and depression in particular. The participants suggested that there should be awareness about such illnesses in the community, adequate facilities should be available in the communitnd the wrongful practices by the local practitioner should be stopped.
Responses from community leaders
The community leaders were asked to give their view on different domains of depression, and their responses were clubbed in a tabulated form [Table 1] in descending order as mentioned below. An attempt was made to quantify the response and a general consensus with all the mental health professionals in the department was reached, who suggested that if less than one-third of the participants agreed and commented on something then the term “few” is to be used, if one-third or more of the participants but less than two-third of participants agreed and commented on something then the term “many” can be used, and finally, if two-third or more of the participants agreed and commented on something then “most” can be used.
|Table 1: Domains of depression and its various aspects as perceived by the community leaders in rural area|
Click here to view
With whatever understanding related to depression that prevailed in the community, the experts tried to guide them. On explaining them that even somatic complaints such as body ache, headache, and general weakness could be the features of depression, one female readily agreed and told,
“My son had similar illness and did not do anything for 1 year. He would not talk to us and would start crying without any reason. He had become very weak. We took him to local doctors in the village (quacks) who prescribed injection for his weakness. We were also asked to see a faith healer in the village who told us that he is under the influence of black magic by a female in their neighborhood. He recovered on its own in 1 year, but we had wasted lot of money on his so-called treatment.”
Following the advice of the relatives and visit to the quacks was evident and one female told, “My brother-in-law was not provided with any treatment for similar complaints and was told by the other brothers to start using some opioids and this would take care of his problem and when he did not improve, he was sent to a faith healer in a far flung area and he never came back.”
It was also observed that while the visit to local faith healers for treatment was common, somehow the people would readily buy the explanation provided by these quacks. A female said,
“They tell us that English medicine causes excessive heat formation inside the body, it's just the gas in the abdomen which is causing all the symptoms and somebody has done black magic, and the medicine provided by them would reduce the impact of black magic by making the person strong.”
Understanding the detrimental consequences to such wrong practices, the “sarpanch” (village head) told, “I think the local doctors (quacks) from their village need to be educated about the common symptoms of depression and other similar psychological problems so that depressed person is not given wrong treatment and the family is advised to take the patient to a qualified doctor.”
The community participants were found wanting in many areas related to recognizing the features of depression and how to seek proper treatment. The experts who were discussing the various issues related to depression provided additional information as they proceeded from one theme to another.
| Discussion|| |
This study reflects that understanding of common mental disorder such as depression in the community leaders is inadequate on many grounds. In some of the other studies, similar results have been demonstrated, but these studies were carried out on general population and not on community leaders who have the final say in the pathway to care.,, These earlier studies were focused on mental illness as a whole and its perception relating to symptoms, need for treatment and outcome. In a study on rural American sample, which was based on the identification of depression in a case vignette, 53% of the sample had understanding about depression. The authors of this study further added that the depression literacy in their study was found to be less than that of a rural Australian sample (81%). A recent study from India on general population, which focused on common mental illness, found inadequate knowledge among the participants. In another community-based study from Maharashtra, the participants were able to recognize depression in a case presented to them. However, the case did not touch much upon the “somatic” symptoms and also directly used terms such as “… she was sad…” and “…didn't make her feel happy.” In this study, the participants could appreciate that a depressed person talks less, sleeps less, would remain idle, and be withdrawn. However, none of the participants had the understanding that features such as somatic complaints for long duration could be a manifestation of depression. Our finding on lack of understanding of somatic and biological symptoms has also been corroborated in the previous studies.,, These studies have also highlighted the fact that even most of the paramedical staff hold the opinion that somatic symptoms do not come under the spectrum of mental illnesses. This also suggests that community perceives these symptoms to be reflective of physical illness only. Thus, in view of these findings, it can be surmised that it is not uncommon for Indian rural population or even the community leaders to have inadequate understanding about the concept and features of depression.
Based on such a narrow concept of depression, the findings from previous studies revealed that a large number of subjects have belief that prayer or pooja or hawan can reduce the bad effects and that ghost can be removed by tantriks/ojha.,, In our study, such beliefs were not reported, and substance use or tragedies in life were regarded as major etiological factors. This difference could be explained on the fact that in our study, the participants were the community leaders, many of them were educated and holding key positions in their villages.
While exploring the issues related to pathways to care, it was noticed in the American study mentioned earlier that depression literacy did affect the utilization of services of a religious leader. In a study which was carried in four European countries (Germany, Hungary, Ireland, and Portugal), most of the participants were willing to seek professional help though about a half of the sample felt that professional help could be of any use. Our study highlighted that the pathway to care is the rudimentary health facilities available for the village population. In fact, for any health issues, these are the first contact “agencies” in the village which shape further care and referral. Majority of the participants agreed that local doctor sahibs (quacks) are the powerful force in the villages, who strongly determine the type of care to all the problems including depression. Since they are part of the village culture and are easily available at odd times and at a very cheap rate, it is very difficult to ignore their advice. These doctors have limited knowledge of common ailments but tend to offer help for all types of ailments including depression and other psychological problems. The treatment includes medications (combination of Allopathic, Ayurvedic, and Homeopathic), mostly injections and vitamins as well as magico-religious practices. The pathway of referral from them is mainly to faith healers and rarely to qualified doctors. Similar reasons have been described earlier in some studies., In addition, our study demonstrated the strong influence of the community on the pathways to care and that bypassing the prevalent social practices is very difficult for the person and the family.
Among the other hurdles in the pathways to care, the role of local medical practitioners also came into light. It was suggested by the participants that these local practitioners do not guide them adequately and put them on injectable sedatives and some tonics for their own profits. On the basis of a survey conducted in 1966, it was concluded that a mentally ill person is considered as dangerous, foolish, and bad in the society, and the same perception leads to their ill treatment, and no one objects to the kind of low or unsatisfying care they are receiving. Similarly, in the present study, most of the participants pointed out that depressed patients having sleep problems are being maltreated by local practitioners, but no one has ever tried to object or take the sufferer to a mental health care facility. Thus, even after more than half a century, nothing much have changed in terms of treatment meted out to those with mental illness in general and depression in particular. The practice of not seeking help from psychiatrists was there in Europe. A study had found that while 43% of the people having depression did not seek any treatment, and out of the rest, most of them sought treatment from a primary care physician. Among those who were being treated, 69% were not prescribed any treatment. Even when drug was indeed prescribed, only 25% were actually prescribed antidepressant.
The participants in our study perceived depression as a condition which is caused by environmental stressors and the common manifestations include poor socialization, patient starts remaining tense all the time, getting irritated easily, and some patients start using alcohol and other substances. Although the participants could illustrate the above symptoms, they failed to put these symptoms together and recognize it as a mental illness. The majority of the participants believed that depression is not a common illness and does not have an equal effect on everyone. This belief about mental illnesses is being recognized in earlier studies as well., None of the participants reported that depression can result from biological and genetic factors as well. In a study from Malaysia, only about 32.8% of the sample could appreciate that depression can be caused by chemical imbalance in the brain. This is also shared in other studies., These mentioned studies were on mental illness and schizophrenia, and in both of these works, it stood out that people were highly ignorant about the incidence/prevalence of these disorders. The majority of care providers and the general population believed that genetics and biology have no role to play in the causation of such disorders. Viewing depression as a result of some adversity only makes the picture narrower and this could instill the element of blame on the affected individual by the society. In our study too, the participants had the belief that family can treat a depressed individual with advice and disciplining.
The imperfect system of dealing with a person having mental illness makes the pathways to care all more misleading and unproductive. This has also been cited as a major reason for the treatment gap in a review of various epidemiological studies worldwide. The reasons cited during the discussion included central theme of lack of awareness or ignorance about mental disorders. The other reasons were being ashamed of illness, as perceived by the patient or the caregivers. Another major reason was the local practitioners in the community who maltreat these patients and do not guide them to mental care facility. These reasons strongly call for remedial measures to adequately address these issues. Moreover, further such work may elaborate the reasons for treatment gap and thus would help to plan and implement corrective measures to undo these factors.
Although the study gives us an opportunity to understand the perception about depression in the community, it has certain limitation. First, we have not used any scales or tools which could have quantified the findings and made them as much objective as possible. Second, India being a country of great diversity, this small sample may not be able to reflect the true picture prevalent in the different parts of our country and hence the study needs to be replicated from other sites.
| Conclusion|| |
To sum up, overall awareness about the causes and features of depression is not very robust in the rural community, and it is not regarded as a serious health issue. People, especially in the rural area often do not have access to proper mental health care facility and are misled by the very source which they would approach for help. As a result, the treatment gap is huge. To address the treatment gap, the 2001 World Health Report has laid out many recommendations and many nations have already started addressing these recommendations depending on the available resources., However, for any policy, service development and implementation, the participation, and acceptance of delivered message by the stakeholders are crucial. Our study has highlighted that in the rural setting of India, the community leaders still have the final say in what is to be practiced and these practices are hard to break. The patients and families of mentally ill persons, despite the knowledge and acceptance of efficacy of treatment, have to seek approval of significant people around them and ignoring them is difficult.
The target of intervention at the community level should be to engage all the stakeholders, most importantly, the community leaders, local medical practitioners, and religious and faith healers. Mass awareness programs involving the common people as well as these stakeholders can result in appropriate and timely treatment for the people having depression and thus significantly reduce the treatment gap.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
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