Emily Mendenhall

Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.

Syndemics and the biosocial conception of health

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Association of somatoform disorders with anxiety and depression in women in low and middle income countries: A systematic review

Abstract Background: Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC). Methods: We reviewed two databases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both quantitative and qualitative studies were included. Results: A total of 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5–3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms. Conclusion: The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.

Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations.

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

Depression and type 2 diabetes in low- and middle- income countries: A systematic review

Eighty percent of people with type 2 diabetes reside in low- and middle-income countries (LMICs). Yet much of the research around depression among people with diabetes has been conducted in high-income countries (HICs). In this systematic review we searched Ovid Medline, PubMed, and PsychINFO for studies that assessed depression among people with type 2 diabetes in LMICs. Our focus on quantitative studies provided a prevalence of comorbid depression among those with diabetes. We reviewed 48 studies from 1,091 references. We found that this research has been conducted primarily in middle-income countries, including India (n = 8), Mexico (n = 8), Brazil (n = 5), and China (n = 5). There was variation in prevalence of comorbid depression across studies, but these differences did not reveal regional differences and seemed to result from study sample (e.g., urban vs rural and clinical vs population-based samples). Fifteen depression inventories were administered across the studies. We concluded that despite substantial diabetes burden in LMICs, few studies have reviewed comorbid depression and diabetes. Our review suggests depression among people with diabetes in LMICs may be higher than in HICs. Evidence from these 48 studies underscores the need for comprehensive mental health care that can be integrated into diabetes care within LMIC health systems.

Applying syndemics and chronicity: interpretations from studies of poverty, depression, and diabetes.

Medical anthropologists working with global health agendas must develop transdisciplinary frameworks to communicate their work. This article explores two similar but underutilized theoretical frameworks in medical anthropology, and discusses how they facilitate new insights about the relationships between epidemiological patterns and individual-level illness experiences. Two cases from our fieldwork in New Delhi and Chicago are presented to illustrate how syndemics and chronicity theories explain the epidemic problems of co-occurring depression and type 2 diabetes. We use these case studies to illustrate how the holistic agendas of syndemics and chronicity theories allow critical scholars to attend to the macrosocial factors contributing to the rise of noncommunicable diseases while still honoring the diversity of experiences that make individual illness experiences, and actual outcomes, unique. Such an approach not only promotes a more integrative medical anthropology, but also contributes to global health dialogues around diabetes, depression, and their overlap.

Co-occurring epidemics, syndemics, and population health

As originally theorised, three concepts underlie the notion of a syndemic: disease concentration, disease interaction, and the large-scale social forces that give rise to them. The concept of disease concentration holds that two or more epidemics co-occur in particular temporal or geographical contexts due to harmful social conditions. This aspect of the theory of syndemics is not necessarily what makes its contribution distinctive. For example, anthropologists have long called attention to the manner in which large-scale political, economic, and cultural forces have given rise to clustered epidemics of various infectious diseases, most prominently HIV and tuberculosis; and the theory of fundamental causes highlights the roles of these forces in driving concentrated health disadvantage. Rather, what makes the theory notable are its predictions about how interactions between epidemics amplify disease burden and about how public health planners can (or cannot) effectively intervene to mitigate this burden. Although the theory of syndemics is principally a theory about population health, the past two decades’ worth of quantitative literature motivated by the theory has generally focused on studying individuals rather than populations—and consequently has had very little to say about population health. Our aim in this Viewpoint is to critically review the literature on syndemics and to introduce key concepts for measuring their effects on population health. The concept of disease interaction in the theory of syndemics holds that co-occurring epidemics interact at the level of populations and individuals, with mutually enhancing deleterious consequences for health. Compared with the other tenets of the theory, this concept has received less empirical support in the literature, perhaps owing to its complexity. At times, its framing language has focused specifically on interaction or synergism: the disease burden attributable to health risks in combination exceeds the sum of the disease burden of the health risks when considered separately. The most highly cited précis of the theory of syndemics describes numerous exemplars that draw exclusively on the language of interaction—eg, the risk of hepatocellular carcinoma is greater among people with chronic hepatitis C virus infection who also consume alcohol (than among people who either have hepatitis C or consume alcohol, and people who neither have hepatitis C nor consume alcohol). Other statements of the theory have instead adopted the language of mutual causality or bi-directionality. The canonical elaboration of the unhappy triad of substance misuse, violence, and HIV, for example, focuses on the ways in which substance misuse increases the risk of violence and HIV acquisition, violent victimisation increases the risk of HIV acquisition and begets further substance misuse, and people with HIV are often subjected to violence specifically because of their seropositivity. These two different models of co-occurring epidemics are represented, without reference to the social forces conditioning exposure, in the figure. Notably, these two models imply different treatment or prevention strategies—but the conceptual distinctions between the two have largely been blurred. In the field of HIV treatment and prevention, appeals to the theory of syndemics are near-universally used to justify calls for complex and integrated or multicomponent interventions, or both, targeting all of the co-occurring epidemics in concert. Operario and Nemoto, for example, have argued that “Multicomponent interventions are necessary to mitigate the HIV syndemic dynamics in transgender communities... In order for multiple services to form a meaningful bundle, they must be complementary, synergistic in their health benefit, cost-effective, and accepted by target audiences”. Two important observations can be made about such recommendations. First, the empirical foundation underlying enthusiasm for multicomponent interventions is weak. Since its original conceptualisation, the theory of syndemics has received scant empirical support either for its concept of disease interaction or for the model of mutually causal epidemics. Rather, the overwhelming majority of studies have used an empirical specification similar to that which has predominated in the literature on childhood adversity— ie, a sum score of exposures. Although helpful, in some instances, for understanding the health effects of cumulative adversities, the sum score sheds light on the co-dynamics of neither interaction nor mutual causality. Lancet 2017; 389: 978–82

Beyond Comorbidity: A Critical Perspective of Syndemic Depression and Diabetes in Cross‐cultural Contexts

This article examines the comorbidity concept in medical anthropology. I argue that the dearth of articles on comorbidity in medical anthropology may result from the rise of syndemic theory. Syndemics recognize how social realities shape individual illness experiences as well as distribution of diseases across populations. I discuss synergistic interactions foundational to the syndemics construct through my research of depression and diabetes comorbidity in vulnerable populations from urban United States, India, and South Africa. I argue that social and economic factors that cluster with depression and diabetes alone and together exemplify the biosocial processes that are at the heart of syndemics. In doing so, I illustrate how social, cultural, and economic factors shape individual-level experiences of co-occurring diseases despite similar population-level trends. Finally, I discuss the relevance of syndemics for the fields of medicine and public health while cautioning what must not be lost in translation across disciplines.

Psychological and Physical Co-Morbidity among Urban South African Women

Objectives There is substantial evidence for the links between poverty and both physical and mental health; but limited research on the relationship of physical and mental health problems exists in low- and middle-income countries. The objective of this paper is to evaluate the prevalence and co-morbidity of psychological distress among women with common physical diseases in a socio-economically disadvantaged urban area of South Africa. Methods Women enrolled in the Birth to twenty (Bt20) cohort study were evaluated for this paper. Bt20 was founded in 1990 and has followed more than 3,000 children and their caregivers since birth; this study evaluates the health of the caregivers (average age 44) of these children. Psychological distress was evaluated by administering the General Health Questionnaire (GHQ-28) and we evaluated the presence of physical disease by self-report. Results Forty percent of the sample presented with psychological distress using the GHQ scoring method. More than half of the women who reported a history of a physical disease, including diabetes, heart attack, asthma, arthritis, osteoporosis, epilepsy, and tuberculosis, reported psychological disorder. Presence of one physical disease was not associated with increased rates of psychological distress. However, women who reported two diseases had increased rates of psychological symptoms, and this upward trend continued with each additional physical disease reported (measured to five). Conclusions These data indicate high prevalence rates of co-morbid psychological distress among women with physical disease. This argues for the need of greater mental health support for women living with physical diseases.

Syndemics: a new path for global health research

www.thelancet.com Vol 389 March 4, 2017 889 How we think about disease pathologies affects how we design policies and deliver care to those most affected by social and economic inequities. Conventional frameworks in medicine and public health, such as comorbidity and multimorbidity, often overlook the effects of social, political, and ecological factors. As the papers in this Series and the linked Viewpoint show, the theory of syndemics improves on conventional frameworks in both theoretical and practical terms by illuminating how macro-level social factors promote disease clustering at the population level and impact disease pathologies at the individual level. The syndemics concept has three core features. Syndemics involve the clustering of two or more diseases within a population; the biological, social, and psychological interaction of those diseases; and the large-scale social forces that precipitate disease clustering in the first place. Originally developed by medical anthropologists to make sense of HIV/ AIDS, the theory of syndemics offers an innovative way of understanding why diseases cluster together in populations disproportionately affected by poverty, social exclusion, gender-based violence, climate change, displacement arising from agricultural or industrial waste or pollution, and other forms of social and environmental stress. The introduction of tobacco as a corporate commodity to Oceania precipitated one such syndemic. Tobacco use does not always interact syndemically— for example, plaque build up in the coronary arteries from tobacco use that impedes healing from a back injury may reveal a biological interaction but not reveal a macrosocial factor as a source of their clustering. Among Pacific Islanders, however, tobacco use clusters with the rapid escalation of non-communicable diseases (NCDs) such as coronary heart disease, cancer, diabetes, and chronic obstructive pulmonary disease. The rise of tobacco-related illness cannot be divorced from the introduction of industrially manufactured cigarettes to Pacific Islanders by tobacco companies. In this case, the concurrent rise in smoking and in this cluster of NCDs among smokers (as well as the biological impact of smoking on these conditions) comprises a syndemic. Syndemics involve more than simply co-occurrence of two or more diseases; they emerge when factors such as corporate exploitation, poverty, social trauma, environmental threat, and limited Syndemics: a new path for global health research