Need to Know: Screening for Depression in Haiti

Posted on Sep 5, 2014

Spend a day at any Partners In Health site and there’s a good chance you’ll hear a phrase you’re unfamiliar with. Perhaps it’s a clunky acronym or polysyllabic drug name. But don’t worry: Keeping up with the ever-evolving world of global health is hard, even for insiders. In Need to Know, we cut through the complexity and deliver the most pertinent and interesting information on a single subject. Today, we fill you in on the Zanmi Lasante Depression Symptom Inventory.

What is it?

The Zanmi Lasante Depression Symptom Inventory is a screening tool that helps clinicians identify depression in Haiti. The inventory lists the symptoms of depression using both universal and local descriptions of the illness. For example, symptoms such as trouble sleeping, loss of appetite, and feelings of sadness are signs of depression in developed countries and in Haiti. But the screening tool also includes three Haitian idioms for the symptoms of depression, such as de la la (low energy), kè sere (constricted heart), and kalkile twòp (thinking too much).

Why is it important?

Depression is sometimes thought of as an affliction that only affects people in developed countries. But in reality, the burden of disease is great in developing countries. The World Health Organization predicts that by 2030, depression will become the number one cause of disability globally. Eighty-five percent of people living with a significant mental health problem in poor countries don’t receive the treatment they need.

Mental health issues such as depression were in the spotlight after the 2010 earthquake in Haiti, but the truth is that many Haitians have struggled with depression long before the earthquake—and likely will long after. Depression is associated with the poverty that many people live in, and it also worsens patients’ ability to take care of their families and their own health—such as taking medicines for HIV.

Where does it come from?

Partners In Health clinicians, along with partners at Fordham University, New York University School of Medicine, Emory University, and Harvard Medical School and School of Public Health, conducted research to identify key descriptors of depression among rural Haitians. They used rigorous analysis to develop an inventory of symptoms that were most closely linked to depression in the Haitian context. The results were published in the July 30, 2014, online issue of Transcultural Psychiatry (see “recommended reading” at left/link).

How is it used?

PIH has worked with Zanmi Lasante, our sister organization in Haiti, to train a range of health professionals to screen patients for depression, following up with a thorough clinical evaluation. Haiti has less than 10 psychiatrists for the entire country of 10 million people, and nowhere near enough psychologists to meet the needs of Haitians. Without these specialists, it’s critical to train all health providers—nurses, physicians, community health workers, and social workers—to be able to identify depression and help patients access treatment. PIH/ZL has conducted trainings and established a system of clinical supervision for health professionals in the community, at clinics, and at hospitals to be able to use the tool to identify depression.

What happens after patients are screened?

Let’s take a community health worker as an example. Community health workers are local people trained to identify people in need and provide follow-up care, helping to ensure the health care system is accessible to everyone, no matter how poor or how far from health facilities they live.

A community health worker visits a person in their home who they suspect may be depressed. They use the screening tool to evaluate the person’s mental health. If the patient scores high on the inventory, indicating they are likely to suffer from depression, the community health worker will refer the person to a local clinic for further evaluation by a specialist. There, a PIH clinician will do a second evaluation to determine the patient’s condition. They may be treated with interpersonal therapy or medication, depending on the severity of the case.

For people scoring lower on the inventory, the community health worker will provide basic psychoeducation and psychosocial interventions, in addition to following up with the patient at home at a later date to provide additional focused support tailored to their needs.

Who else besides PIH/ZL is using this tool?

The Haitian Ministry of Health has been enthusiastic to expand access to mental health care at public facilities throughout the country. PIH/ZL has trained them on use of the tool so they can use it to identify depression around the country, not just in the Central Plateau and Artibonite regions where PIH/ZL works.