BY DIANA GONZALEZ AND MAURICIO ALVAREZ
The Vice-Minister of Integration and Development of the Health Sector of the Mexican Ministry of Health, Eduardo González Pier, claims that “an important segment of the population with a mental health problem does not seek medical attention, simply because they do not consider it an illness; however, this is not a minor problem. In Mexico, …depression-related disability represents 9.8% of the total [burden of disability-adjusted life] years…in the country.” He says, “If I had to implement only one change, it would be to fortify the proactivity of the National Health System for the identification and treatment of mental illnesses… [and] raise the awareness [among] the population and the decision-makers in the health sector regarding mental health problems in the whole country.” 1
DEPRESSION AND ITS RELEVANCE FOR PUBLIC HEALTH
Depression is a common mental illness that is characterized by negative changes in mood, cognition, and behavior.2 Such changes may include increased sadness or irritability, loss of appetite, weight changes, insomnia, reduced energy, loss of interest in pleasurable activities, feelings of guilt and hopelessness, difficulty concentrating, and/or suicidal thoughts.3,4 Depression is one of the leading causes of disability, morbidity, and mortality in the world, and is a major risk factor for suicide and physical health problems such as heart disease, diabetes, arthritis, and respiratory diseases.5,6,7,8
Contrary to common belief, depression can be diagnosed at all ages, even as early as one’s preschool years.9 Children and adolescents are more prone to anxiety and anger, but they are less likely than adults to verbalize any helplessness they may feel.10 Despite these differences, the course of depression seems to be consistent among all age groups.11 There is also a greater tendency for comorbid aggressive and antisocial behaviors during adolescence, as well as an increased risk for suicide, possibly due to the late maturation of the prefrontal cortex of the brain, greater emphasis on social status, reduced adult supervision, lack of sleep, and increased risk-taking behavior.12,13 Furthermore, suffering from depression before 13 years of age is thought to have a long-lasting effect on development, potentially creating a “cognitive scar” that may predispose children to depression, antisocial behaviors, substance abuse disorders later in life and increase resistance to treatment.14,15,16,17,18,19,20
Depression and depressive disorders are highly treatable with competent care. If treatment is begun early, there is a 20-60% remission rate after 1-2 years of treatment and a 70% rate after 5 years.21 However, despite the relatively high recovery rates, once a person has suffered an episode, he or she is more likely to relapse and suffer long-lasting negative effects in his or her relationships, self-esteem, and physical health.22,23 Furthermore, increased severity of depression, the presence of suicidal thoughts during adolescence, and comorbidity with other disorders worsen the prognosis and increase the likelihood of relapse.24
There are multiple risk factors for developing depression, including young age, low education, and history of trauma, especially during childhood.25 Low socioeconomic status has also been related to a greater risk.4,22 Negative life experiences, such as ethnic or sexual discrimination, are also highly associated with depression, particularly among adolescents and young adults.4 Women have a greater risk for depression than men, with a 2:1 female-to-male ratio of prevalence.26 This may be because women have been found to have a greater tendency to ruminate on symptoms of distress, and more negative self-inferences when facing undesirable outcomes, compared to men.27 However, further evidence is needed to understand this gender disparity.
DEPRESSION IN MEXICO
Mental health in Mexico is recognized as one of the main unresolved issues within the government’s health policy agenda. Recently, the subject has been gaining relevance due to the increasing prevalence of mental disorders and its correlation with increased prevalence of other issues within the country, such as violence, inequality, and poverty. In addition to this correlation, mental disorders have been shown to increase the risk of other communicable and non-communicable diseases, and are strongly associated with the prevalence of chronic diseases.28 Individuals with chronic diseases are more prone to suffer from depression or other mental health disorders. Mental disorders also affect the physical and professional development of individuals, directly decreasing their economic productivity. Discrimination might further prevent patients from accessing the labor market, lowering their household income and making their reinsertion into society more difficult.
Statistics from the National Institute of Statistics and Geography (INEGI) showed that the number of deaths due to mental and behavioral disorders decreased by 29% between 1998 and 2008, but then increased by 33% between 2008 and 2014. During this latter period, there was a decrease in mortality associated with these disorders among individuals between 0 and 29 years old and an increase in mortality among 50 to 54 year olds. Additionally, the mortality associated with mental health disorders increased during the same period for both men and women, at 17% and 18% respectively.29 The global financial crisis of 2008 and the Mexican government’s war against drugs, which started in 2006, may have created an atmosphere of social unrest that led to these trends.
According to the Institute for Health Metrics and Evaluation, depressive disorders represent 4.19% of the total Disability-Adjusted Years (DALYs) in Mexico—a measure of the country’s burden of disease—for both sexes.30 DALYs are globally-recognized indicators that account for the gap between a country’s current health status and the ideal health situation, in which the entire population lives to an advanced age, free of disease and disability.31 Depressive disorders in Mexico create a comparable disease burden to that of interpersonal violence, road injuries, or congenital anomalies, and a greater burden than that of cerebrovascular disease, HIV/AIDS, or some types of cancer. This evidence indicates that, in addition to the medical relevance of the subject, the individual and societal costs associated with mental disability must be considered when prioritizing policies in the health sector’s agenda.
In 2002, a Mexican National Comorbidity Survey employed the World Mental Health Composite International Diagnostic Interview (WMH-CIDI), a comprehensive interview developed by the World Health Organization (WHO), to assess the epidemiological profile of mental disorders in Mexico.32 The survey found that 1 out of every 8 Mexican citizens suffered a depressive disorder, and about half of that population had suffered a depressive episode within the past year. They also found that low income was strongly correlated with increased severity of mental disorders, and that widowed, separated, and divorced individuals had an increased risk for depressive disorders. Other studies found the prevalence of depressive disorders is even higher in individuals over 80 years old at 21.7-25.3%.33,34 In 2012, among the total number of hospital discharges of people over 60 years old, 12.3% were related to depressive disorders.34 This suggests that mental health issues in Mexico will become more relevant as the country undergoes a demographic transition to an older population.
Despite this already high prevalence, it is possible that even more people suffer from depression in Mexico than have been accounted for. This is mainly because studies do not usually account for indigenous communities, and there are multiple factors—such as stigma against mental disorders and cultural differences—that can create significant report biases and lead to underestimations of the prevalence of depressive disorders. For example, Weller, Baer, Garcia de Alba, and Salcedo Rocha found that many Mexican communities call these disorders “nervios” (nervousness) or “susto” (fright), rather than using their medical names, which increases underreporting.35
Stigma and underreporting of depression is usually linked to the popular belief in “machismo” (male chauvinism). Some examples of the effects of this belief on stigma against mental health disorders are the popular misconceptions that depression is only in the mind and can be cured with positive thoughts; depression is a disease for weak persons, and strong and mature individuals do not suffer from it; men cannot suffer from depression; because nobody can die from depression, what does not kill you makes you stronger; and seeking mental health treatment is simply an escape for those who cannot handle their daily problems. The presence of this stigma deters individuals from seeking care and continuing treatment, and therefore contributes to the further underestimation of the prevalence of disorders.36
OBSTACLES AND CHALLENGES FOR AN ADEQUATE DIAGNOSIS AND TREATMENT OF DEPRESSION IN MEXICO
Mental health diagnosis and treatment face many obstacles and barriers in both high-income, and low- and middle-income countries. In high-income countries, between 35% and 50% of patients with mental health disorders do not receive treatment. In low- and middle-income countries, this percentage lies between 76% and 85%. To tackle this public health problem, the WHO issued the Mental Health Gap Action Programme (mhGAP) in 2008 and the Intervention Guide (mhGAP-IG) in 2010.39 In 2002, a “New Model of Care for Mental Health” was issued and authorized in Mexico to eliminate human rights violations caused by the old model, such as inhumane care and involuntary psychiatric treatment. In 2004, the “Secretariado Técnico del Consejo Nacional de Salud Mental” (STCONAME) was founded as an organization dedicated to establishing public policies and national strategies for mental health.37
While there is no current disease-specific policy for depression in Mexico, the government has recently given more emphasis to mental health. One of the main strategies that demonstrates this emphasis can be found within the Specific Action Program for Mental Health 2013-2018, which is aligned with the National Development Plan 2013-2018 and the Health Sector’s Plan. The strategy is called Miguel Hidalgo’s Model for Mental Health, and is focused on the promotion and prevention of mental disorders, with the aim of increasing early diagnoses, increasing quality of care, and reducing cost of care. The main actions of the plan include increased mental health promotion, the implementation of ambulatory care in “Centros de Salud” (primary care level clinics) and “Centros Integrales de Salud Mental” (specialized clinics open to the public with multidisciplinary teams of specialized professionals), the installation of psychiatric units in general hospitals and Transition Villas, and improved rehabilitation and social reinsertion through a “Protective Workshop”, where patients develop skills and competencies needed to relate to others, reintegrate themselves into the community, and engage in social activities, all while receiving a wage.38 Likewise, a new mental health policy implemented by Mexico City’s government leaves screening for depression in the hands of general physicians, while also promoting the use of a telephone line for psychological assistance.40 However, in addition to the stigma, discrimination, and low public awareness of mental health issues, Mexico faces two large problems that prevent the effective implementation of a large scale program for the treatment of these disorders: (1) the lack of specialized human resources and (2) the general budget restrictions on health care initiatives.
In 2011, the WHO observed that Mexican mental health services were understaffed, underfunded, and not completely integrated with other public health programs. Multidisciplinary teams–composed of psychologists, physicians, social workers, and other non-mental health specialists–are scarce. Therefore, the majority of mental health problems are treated in psychiatric hospitals, which increase service costs and hinder early detection and prevention strategies. Furthermore, most mental health services are located in metropolitan areas, making them inaccessible to indigenous communities. According to the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), only 2% of the health sector budget is assigned to mental health services, and of that percentage, 80% is earmarked for psychiatric hospitals.43 There is also a lack of special mental health programs for children, adolescents, or older adults. Likewise, most public schools lack services for the prevention, assessment, and referral of mental health issues, including depression.
Within the mhGAP-IG, the WHO describes an effective program to assess and manage depression as one that: (1) promotes psychoeducation; (2) addresses current psychosocial stressors; (3) reactivates social networks; (4) considers antidepressants; (5) if available, considers interpersonal therapy, behavioral activation, or cognitive behavioral therapy; (6) if available, considers adjunct treatments such as structured physical activity programs, relaxation training, or problem-solving treatments; (7) does not manage the complaint with other ineffective treatments (e.g. vitamins); and (8) offers regular follow-ups.39 Moreover, the U.S. Preventive Services Task Force (USPSTF), an independent panel of health-care experts, recently recommended regular “screening for depression in the general adult population, including pregnant and postpartum women.”41 The USPSTF assigns one of five letter grades (A, B, C, D or I) to each recommendation, according to the level of certainty of obtaining a net benefit from the initiative, and recommends a level of provision for the specific service.41 In this case, USPSTF gave a B grade (high certainty of a moderate benefit) to this screening recommendation, which is the same as its grading for yearly mammograms, diabetes screening in overweight and obese patients, and lung-cancer screening for at risk patients. One article in the Atlantic stated that, “past research has shown that without any sort of systematic screening, general practitioners miss nearly half of all cases of major depression.”40 Much more effort is needed to ensure that the current mental health programs in place are effectively diffused and implemented, and that the expert-recommended screening, assessment, and treatment guidelines are adequately followed. Making primary care the articulating axis of mental health and establishing screening procedures is a first step. However, considering alternative strategies centered around prevention teams led by nurses or social workers rather than general practitioners, who are already saturated with other programs and only have around 15 minutes to see each patient, strengthening the construction of more specialized facilities to treat mental disorders, and establishing screening in schools can make an immense difference in how mental health is perceived and treated in Mexico.
The most relevant challenges for the Mexican mental health programs lay in strengthening prevention programs, establishing primary care as the articulating axis for mental health, improving the training of health workers, and improving patient rehabilitation and reinsertion. In order to improve the effectiveness of any new programs, investment in mental health services must first be increased, and both families and service users must be incorporated into the program planning and development, 44 In response to these unmet needs, multiple training and prevention programs—most of which are recognized by the Mexican National Commission of Science and Technology (CONACYT) with financial and research support—have been developed.42 Service users and family members are also gaining a greater voice in service improvement and research by being invited to collaborate in service user panels. However, the mental health system is still considerably understaffed and has not yet integrated multidisciplinary teams.42 Further work is needed to manage this burden of disease, which might become an even larger issue within the next decades.
Diana Gonzalez is a 2017 candidate for a Master of Public Health Degree in Health Policy and Global Health. She can be contacted at email@example.com.
Mauricio Alvarez is a 2016 candidate for a Master of Science degree in Developmental Neuroscience and Psychopathology at University College London and the Anna Freud Centre. He is currently a postgraduate fellow at the Child Study Center at the Yale School of Medicine. He can be contacted at firstname.lastname@example.org.
- E, González, personal communication, April 5, 2016.
- Depression. (2016). American Psychological Association. Retrieved from http://www.apa.org/topics/depress/
- American Psychiatric Association. (2013). Diagnostic and Statistical manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What works for whom? A critical review of treatments for children and adolescents. New York, NY: The Guilford Press.
- Collins, P., Patel, V., Joestl, S., March, D., Insel, T., & Daar, A. (2011). Grand challenges in global mental health. Nature, 475(7354), 27-30.
- Hatcher-Kay, C., & King, C. (2003). Depression and suicide. Pediatrics in review, 24(11), 363-371.
- Ruiz, L., Colin, R., Corlay, I., Lara, M., & Dueñas, H. (2007). Trastorno depresivo mayor en México: La relación entre la intensidad de la depresión, los síntomas físicos dolorosos y la calidad de vida. Salud Mental, 30(2), 25-32.
- Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyer, I. (2011). Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). American Journal of Psychiatry, 168(5), 495-5019.
- Luby, J., Heffelfinger, A., Mrakotsky, C., Brown, K., Hessler, M., Wallis, J., & Spitznagel, E. (2003). The clinical picture of depression in preschool children. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 340-348
- Costello, E., Pine, D., Hammen, C., March, J., Plotsky, P., Weissman, M. Biederman, J., Goldsmith, H., Kauffman, J., Lewinsohn, P., Hellander, M., Hoagwood, K., Koretz, D., Nelson, C., & Leckman, J. (2002). Development and natural history of mood disorders. Biological psychiatry, 52(6), 529-542
- Costello, E., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of general psychiatry, 60(8), 837-844.
- Brodbeck, J., Abbott, R., Goodyer, I., & Croudace, T. (2011). General and specific components of depression and anxiety in an adolescent population. BMC psychiatry, 11(1), 1-12.
- Depression in children and young people: Identification and management in primary, community and secondary care: Clinical Guideline CG28. (2005). National Institute for Health and Clinical Excellence. London.
- Mezulis, A., Funasaki, K., Charbonneau, A., & Hyde, J. (2010). Gender differences in the cognitive vulnerability-stress model of depression in the transition to adolescence. Cognitive Therapy and Research, 34(6), 501-513.
- Harrington, R., Bredenkamp, D., Groothues, C., Rutter, M., Fudge, H., & Pickles, A. (1994). Adult outcomes of childhood and adolescent depression. III Links with suicidal behaviours. Journal of Child Psychology and Psychiatry, 35(7), 1309-1319.
- Daley, S. E., Hammen, C., Davila, J., & Burge, D. (1998). Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood. Journal of consulting and clinical psychology, 66(4), 595.
- Fichter, M. M., Kohlboeck, G., Quadflieg, N., Wyschkon, A., & Esser, G. (2009). From childhood to adult age: 18-year longitudinal results and prediction of the course of mental disorders in the community. Social psychiatry and psychiatric epidemiology, 44(9), 792-803.
- Fombonne, E., Wostear, G., Cooper, V., Harrington, R., & Rutter, M. (2001). The Maudsley long-term follow-up of child and adolescent depression. The British Journal of Psychiatry, 179(3), 210-217.
- Johnson, J., Cohen, P., Skodol, A., Oldham, J., Kasen, S., & Brook, J. (1999). Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Archives of general psychiatry, 56(9), 805-811.
- Lewinsohn, P., Petit, J., Joiner Jr, T., & Seeley, J. (2003). The symptomatic expression of major depressive disorder in adolescents and young adults. Journal of abnormal psychology, 112(2), 244.
- Richmond, T. K., & Rosen, D. S. (2005). The treatment of adolescent depression in the era of the black box warning. Current opinion in pediatrics, 17(4), 466-472.
- Rao, U. M. A., Ryan, N. D., Birmaher, B., Dahl, R. E., Williamson, D. E., Kaufman, J., … & Nelson, B. (1995). Unipolar depression in adolescents: clinical outcome in adulthood. Journal of the American Academy of Child & Adolescent Psychiatry, 34(5), 566-578.
- Rohde, P., Lewinsohn, P. M., & Seeley, J. R. (1994). Are adolescents changed by an episode of major depression?. Journal of the American Academy of Child & Adolescent Psychiatry, 33(9), 1289-1298.
- Curry, J., Silva, S., Rohde, P., Ginsburg, G., Kratochvil, C., Simons, A., Kirchner, J., May, D., Kennard, B., Mayes, T., Feeny, N., Albano, A., Lavanier, S., Reinecke, M., Jacobs, R., Becker-Weidman, E., Weller, E., Emslie, G., Walkup, J., Kastelic, E., Burns, B., Wells, K., & March, J. (2011). Recovery and recurrence following treatment for adolescent major depression. Archives of General Psychiatry, 68(3), 263-269.
- Lewinsohn, P. M., Roberts, R. E., Seeley, J. R., Rohde, P., Gotlib, I. H., & Hops, H. (1994). Adolescent psychopathology: II. Psychosocial risk factors for depression. Journal of abnormal psychology, 103(2), 302.
- Angold, A., Erkanli, A., Silberg, J., Eaves, L., & Costello, E. J. (2002). Depression scale scores in 8–17‐year‐olds: effects of age and gender. Journal of Child Psychology and Psychiatry, 43(8), 1052-1063.
- Kuehner, C. (2003). Gender differences in unipolar depression: an update of epidemiological findings and possible explanations. Acta Psychiatrica Scandinavica, 108(3), 163-174.
- Programa de Acción Específico Salud Mental 2013-2018. Mexican Ministry of Health. Retrieved from http://consame.salud.gob.mx//Descargas/Pdf/Salud_Mental.pdf.
- Estadísticas de Mortalidad, Consulta Interactiva de Datos. (n.d.). National Institute of Statistics and Geography. Retrieved from http://www.inegi.org.mx/est/lista_cubos/consulta.aspx?p=adm&c=4.
- GBD Compare, Viz-Hub. (n.d.). Institute for Health Metrics and Evaluation. Retrieved from http://vizhub.healthdata.org/gbd-compare/.
- Metrics: Disability-Adjusted Life Year (DALY). (n.d.). World Health Organization. Retrieved from http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/
- Medina-Mora, M., Borges, G., Lara, C., Benjet, C., Blanco, J., Fleiz, C., Villatoro, J., Rojas, E., & Zambrano, J. (2005). Prevalence, service use, and demographic correlates of 12-month DSM-IV psychiatric disorders in Mexico: results from the Mexican National Comorbidity Survey. Psychological Medicine, 35, 1773–1783. http://doi.org/10.1017/S0033291705005672
- National Institute of Statistics and Geography. Estadísticas a propósito del día internacional de las personas de edad (1 de octubre). Retrieved from http://www.inegi.org.mx/saladeprensa/aproposito/2014/adultos0.pdf.
- Garcia-Peña, C., Wagner, F., Sanchez-Garcia, S., Juarez-Cedillo, T., Espinel-Bermudez, C., Garcia-Gonzalez, J., Gallegos-Carrillo, K., Franco-Marina, F., & Gallo, J. (2008). Depressive symptoms among older adults in Mexico City. Journal of General Internal Medicine, 23(12), 1973-1980.
- Weller, S., Baer, R., Garcia de Alba, J., Salcedo, A. (2008). Susto and nervios: Expressions for stress and depression. Culture, Medicine, and Psychiatry, 32(3), 406-420.
- Mexico City’s Ministry of Health. (n.d). Mitos y realidades acerca de la Salud Mental. Retrieved from http://www.salud.df.gob.mx/portal/images/portal/inicio/general/archivo_pdf/INFORMACIO%CC%81N%20DE%20INTERE%CC%81S.pdf.
- Mexico City’s Ministry of Health. (n.d.). Programas y Acciones. Salud Mental. Retrieved from http://www.salud.df.gob.mx/portal/index.php/programas-y-acciones/84-ssp/pp0o0orogramas/309-sm.
- Berenzon, S., Saavedra, N., Medina-Mora, M., Aparicio, V., & Galván, J. (2013). Evaluación del sistema de salud mental en México: ¿hacia dónde encaminar la atención?. Rev. Panam Salud Pública, 33(4), 252-8.
- MhGAP Intervention Guide from mental, neurological and substance use disorders in non-specialized health settings. (n.d.). World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/44406/1/9789241548069_eng.pdf
- Khan, F., (2016). Why Depression Screenings Should Be Part of Routine Check-Ups. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2016/02/depression-screening-primary-care/462933/?utm_source=SFFB
- Grade Definitions. (n.d.). U.S. Preventive Services Task Force. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions.
- Medina-Mora, M. (2015). Mexico: Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Informe anual de autoevaluación 2014: Enero-Diciembre.
- Organizacion Mundial de la Salud, Organizacion Panamericana de la Salud, & Secretaria de Salud de Mexico. (2011). IESM-OMS Informe sobre sistema de salud mental en Mexico. Mexico.