A recent article published in Cambridge Prisms: Global Mental Health sheds light on the lack of evidence for effective preventative interventions for depressive disorders in low and middle-income countries (LMICs) compared to high-income countries. Renowned psychology researcher Pim Cuijpers highlights the dearth of scientific data on preventing depressive disorders in LMICs as the primary reason behind this disparity.
While the current data suggests that resources may be better utilized elsewhere, Cuijpers argues that further research could provide a clearer understanding of the potential of preventative interventions in LMICs. Considering the limited options for managing depressive disorders through treatment, he strongly recommends conducting more research on prevention in LMICs and implementing evidence-based preventative measures as soon as possible.
“Prevention of depressive disorders is highly relevant from a public health perspective, but almost all evidence comes from high-income settings,” Cuijpers writes. “Although selective and indicated preventive interventions have been found to be effective in high-income settings, insufficient evidence is available for low- and middle-income countries. More research into the possibilities to prevent depressive disorders in low- and middle-income countries is very much needed.”
Preventative interventions are designed to halt the development of depressive symptoms before they meet the criteria for a depressive disorder, according to the Diagnostic and Statistical Manual (DSM). Cuijpers outlines three different types of preventative interventions:
- Universal preventative interventions are implemented for everyone, often in schools, universities, and workplaces. While these interventions do not create stigma, as they are received by all individuals regardless of their risk, they tend to show limited benefits for individuals.
- Selective preventative interventions are targeted at people in high-risk groups for developing depressive disorders. These interventions can be tailored to specific groups, but the ability of specific risk factors to accurately predict who will develop a depressive disorder is low. Most individuals in at-risk groups would never develop a disorder, even without preventative interventions.
- Indicated preventative interventions focus on individuals displaying early warning signs for depressive disorders yet do not meet the DSM diagnostic criteria. The downside of this intervention type is the potential stigma it may create, making it challenging for clinicians to convince individuals to participate.
Cuijpers writes that both selective and indicated preventative interventions for depressive disorders have been effective in high-income countries.
This particular research study aimed to examine the evidence for preventative interventions targeting depressive disorders in LMICs. To achieve this, Cuijpers analyzed data from a previous meta-analysis comprising 50 studies on preventative interventions for depressive disorders. Shockingly, only 3 (6%) of these studies were conducted in middle-income countries—2 in China and 1 in India. None of the studies were conducted in low-income countries. The two Chinese studies focused on middle-aged primary care patients, while the Indian study targeted older adults.
Based on the extremely limited data, preventative interventions in LMICs are reported to be “significantly less effective” than those in high-income countries. However, Cuijpers cautions that this finding may be inaccurate due to several factors.
Firstly, the lack of data from low-income countries and the scarcity of data from middle-income countries. Secondly, Cuijpers performed a subgroup analysis, which can be less accurate than a comprehensive meta-analysis due to the dearth of data on preventative interventions for depressive disorders in LMICs. Lastly, unmeasured factors could have significantly influenced the present research outcomes. For example, social factors such as poverty, inequality, education, etc., impact people’s mental health. Improving these social factors would likely improve all-around mental health.
While the study acknowledges that the current data does not favor the large-scale implementation of preventative interventions in LMICs, further research may yield different results for the reasons mentioned above. Cuijpers also presents several considerations that should be taken into account if preventative interventions are implemented in LMICs.
It is essential to consider the comparative benefits of treating and preventing depressive disorders. While treatment often receives more funding and is directed at more acute situations, prevention is suggested to be more cost-effective, according to some analyses.
Cuijpers argues that, while universal preventative interventions have not demonstrated significant effectiveness, they are easy to implement and can educate the general population about mental illness, reducing stigma. However, other researchers have questioned the efficacy of universal depression screening and suggest that attempts at universal prevention may lead to overdiagnosis and worsening mental health for the population.
Cuijpers points out that for preventative interventions to be effective, they must receive adequate funding, begin early in individuals’ lives, encompassing personal and environmental factors associated with mental health, and be integrated into existing social institutions.
Cuijpers acknowledges several limitations to this study. There is a substantial lack of evidence regarding preventative interventions for depressive disorders in LMICs. Due to this lack of evidence, a narrative review was conducted, which may have overemphasized personal views and selectively used supporting evidence. In addition, the study discusses LMICs as if they were a uniform entity, whereas, in reality, LMICs are highly diverse.
“Despite these limitations, this study made clear that prevention of depressive disorders is a highly relevant topic, in high- and lower-income settings, but that there is currently insufficient evidence from LMICs to recommend the dissemination of preventive interventions. More research in this area is very much needed.”
Other research has found a lack of data from low and middle-income countries, such as the lack of data on psychosis in sub-Saharan Africa.
Scaling up psychological interventions in LMICs, especially when that involves the administration of psychotropic drugs, may not be in the best interest of those countries. Instead, some researchers have argued that approaches such as mad studies, survivor movements, and experiential knowledge should be used to counter the scaling up of psychiatric interventions in LMICs.
While the current work indicates that universal preventative interventions can help combat stigma and educate the public about mental health, research has found that these kinds of universal interventions can be harmful to a minority of people exposed to them and are, therefore, not without risk.
Cuijpers P (2023). Preventing the onset of depressive disorders in low-and middle-income countries: An overview. Cambridge Prisms: Global Mental Health, 10, e28, 1–6 https://doi.org/10.1017/gmh.2023.22 (Link)