Widely used screening tools proved highly effective in identifying patients suffering from depression in rural communities in Chiapas, the poorest state in Mexico, according to a study conducted by clinicians and volunteers working with Compañeros En Salud, as Partners In Health is known locally.
The 2014 study was the first time such tools, known in the mental health field as the PHQ-2 and the PHQ-9, had been used in a rural, marginalized community in Mexico, and indicates how powerful these brief screening tools can be for identifying and diagnosing common mental disorders.
“The study demonstrated that these were valid tools and brought to surface the urgency of mental health issues arising from social and economic factors in rural Mexico,” says Dr. Jafet Arrieta, the former director of operations for PIH in Mexico and principal investigator on the study.
What Arrieta and her team found was shocking. Nearly 26 percent of residents surveyed were diagnosed with depression, compared to 7 percent across Mexico and 4 percent globally. This news is particularly alarming considering Chiapas has only one psychiatrist for every 200,000 people—far below Mexico’s overall average, according to the World Health Organization.
Arrieta and her co-authors published their findings in the Journal of Clinical Psychology in 2017, following six months of research conducted in 2014 as part of her master’s degree program in Global Health and Social Medicine at Harvard Medical School.
By the time of Arrieta’s study, PIH had already been using the screening tools as part of its mental health program, which was launched in 2012 and integrated into the activities run by doctors completing their social service year, in partnership with Mexico’s Ministry of Health. Medical students went door-to-door to talk to residents about depression, and used the PHQ-2 for screening and then, if necessary, a PHQ-9 for basic diagnosis. Those residents who received a high PHQ-9 score were referred to a nearby clinic for further diagnosis and treatment.
Arrieta wanted to prove the effectiveness of this strategy in rural Mexico, and so wrapped the work into her graduate degree studies. To conduct the research, she recruited seven medical students to visit 152 households in the Fraylesca region in the community of Laguna del Cofre, a five-hour drive from Tuxtla Gutiérrez, the capital of Chiapas.
“This was a mix of research looking to better understand the experience of people in Chiapas living with and seeking care for depression, and to assess this diagnostic screening instrument for depression,” says Arrieta.
The results complemented similar PIH findings in rural primary care clinics in Haiti, Liberia, and Rwanda, highlighting the importance of investing in community-based mental health screening, diagnosis, and treatment.
In Mexico specifically, doctors across 10 PIH-supported clinics have incorporated the PHQ-9 as a depression screening and follow-up tool used during check-ups. As a result, they have learned that an enormous number of their female patients have lived with, or continue to live with, domestic violence in their homes.
Maria* was one of the first patients who benefited from community-based screening for depression. She wasn’t able to finish primary school, was married by age 20, and widowed by 27—just six months after a car accident killed her two siblings. She felt devastated and was forced to raise seven children on her own in the coffee-growing community of Laguna del Cofre. Then her 14-year-old son, Ramon*, had a seizure and began exhibiting psychotic behavior.
As Ramon grew more violent, Maria searched everywhere for answers—first with a number of traditional healers and then a physician, who incorrectly diagnosed her son with a brain tumor. Heartbroken and exhausted, she started experiencing headaches and body aches, then persistent vomiting.
“The situation is common,” Arrieta says. “Mental health disorders go untreated and when other symptoms appear individuals look for some supernatural explanation. That creates a cycle of normalization of their mental health issue.” Without local access to mental health care, patients are left with few options to help understand the origin of new behaviors.
Eventually, Ramon was diagnosed with schizophrenia at the age of 20 and put on a costly treatment plan. To pay for his care, Maria left her other children with extended family to look for work in Tuxtla Gutiérrez. But the money she earned still wasn’t enough, and Ramon was forced to stop treatment.
Maria coped by taking four naps a day, while doctors dismissed her symptoms as stress. She felt powerless; she now knew the source of Ramon’s suffering, but could do nothing to help him. She couldn’t afford the costly medication he required, much less find it on a regular basis. She had no immediate family to share the responsibility of caring for her son. Hopeless and without any other option, she resorted to chaining up Ramon to prevent him from hurting himself and others.
When PIH brought mental health services to Laguna del Cofre in 2012, Maria met with the local doctor, who had received basic training in how to properly screen and treat patients for a variety of mental disorders. Ramon was unchained, placed on medication to treat his schizophrenia, and received regular checkups to ensure his recovery remained on track.
What resulted was nothing less than a transformation. Ramon stabilized and was soon well enough to return to work on the family coffee plantation.
“’I was very grateful, because no other doctor had helped us before,” Maria told Arrieta at the time of her study. “It was as if he had pulled us out of a quagmire.”
Maria’s story echoed that of many other patients Arrieta and her team came across throughout their study. Thanks to access to a quick screening tool, families dealing with mental illness finally had a name for what plagued their loved ones. That diagnosis came accompanied by regular medication and the support of trained, compassionate clinicians who held their best interests in mind. Suddenly, patients who had suffered for years—sometimes decades—could participate in daily activities and enjoy much fuller, healthier lives.
“We are trying to break the stigma of mental illness by demonstrating that with appropriate care people can get better and be reincorporated into their communities,” says Arrieta. “It’s important to educate rural villages about symptoms of depression in response to life’s triggers in order to stop the notion of being crazy, and that sadness is something that can’t be cured.”
*Names have been changed for privacy.