Depression in developing countries: lessons from Zimbabwe

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Vikram Patel, Beit research fellow (vikpat@goatelecom.com)a,
Melanie Abas, lecturera,
Jeremy Broadhead, lecturera,
Charles Todd, senior lecturerb,
Anthony Reeler, lecturerc

^a University of Zimbabwe Medical School, Harare, Zimbabwe
^b Department of Community Medicine, University of Zimbabwe Medical School
^c Department of Psychiatry, University of Zimbabwe Medical School

Correspondence to: V Patel, Sangath Centre, 841/1Alto Porvorim, Goa 403521, India

Accepted 11 October 2000

Depression is one of the most important causes of morbidity and disability in developing countries.1 Zimbabwe, in common with other developing nations, has absolute poverty, economic reform programmes, limited public health services, widespread private and traditional healthcare services, civil unrest, cultural diversity, and sex inequality. We have conducted research on depression in Zimbabwe over the past 15 years, covering ethnographic and epidemiological studies in a range of populations. We compared our findings with research from other developing countries and with evidence from industrialised countries. In the context of developing countries we examined the validity of World Health Organization classifications and medical concepts of depression, the public health implications of depression, and the implications for clinical practice and research.

Summary points

Depression is common in developing countries, especially in women, with a vicious cycle of poverty, depression, and disability

Depression typically presents with multiple physical symptoms of chronic duration, though simple questions can often elicit psychological symptoms

Anxiety often coexists with depression, and multiple diagnostic categories for common mental disorders have limited validity

Low recognition and treatment of symptoms rather than cause are the hallmarks of current practice in general health care

The validity of Western biomedical models of depression

In Zimbabwe, multiple somatic complaints such as headaches and fatigue are the most common presentations of depression. 2 3 On inquiry, however, most patients freely admit to cognitive and emotional symptoms.4 Many somatic symptoms, especially those related to the heart and the head, are cultural metaphors for fear or grief. Most depressed individuals attribute their symptoms to “thinking too much” (kufungisisa), to a supernatural cause, and to social stressors. Our data confirm the view that although depression in developing countries often presents with somatic symptoms, most patients do not attribute their symptoms to a somatic illness and cannot be said to have “pure” somatisation. 2 5 6 This means …