The sections below describe: (1) patient perspectives on the causes, symptoms, and treatments for varying levels of depression; (2) the appropriateness of integrated services; and (3) the role of the patient-provider power dynamic.
Patient Perspectives on Causes, Symptoms, and Treatments for Depression
Patients agreed upon the causes and symptoms of depression, noting that it is often caused by interpersonal conflict (i.e., arguing with a family member) or worries regarding unemployment and financial strain. Regarding symptoms, patients consistently described depressed individuals as withdrawing from friends and family, developing exacerbated NCD symptoms, and experiencing suicidal ideation. The vast majority used social support (i.e., talking to a depressed individual about their problems to improve their mood) and prayer as helpful strategies for addressing depression, with prayer described as supplemental to social support. While 17 patients mentioned prayer at a Christian church, only 5 described it as a priority over other treatments. For instance, when asked how she would respond if experiencing moderate depressive symptoms, a hypertension patient noted:
I would go to church and pray even if it were for three days, I would definitely go for all the said three days so that whatever is in my heart, should come to an end. (Female, age 35).
Social support itself was the most commonly reported treatment for moderate depression symptoms. For instance, a diabetes patient explained the process of treating depression through a supportive group of friends:
I am saying that these [depressed] people, mostly they don’t like to be open to their friends...Among [a group of friends], there can be someone who may have experienced the problem that you are going through and knows how to handle that problem. Such a person may help you to overcome the problem you are going through (Male, age 40).
A hypertension patient similarly discussed the use of social support to treat a man dealing with depression symptoms:
[A man dealing with depression] should be among other people so that they can chat with him and encourage him so that maybe he can stop the crying that he is doing. If they leave him alone, he can think of killing himself but they should be with him and assist him the way they can (Female, age 45).
In addition to social support and prayer, 17 patients described the hospital as a source of depression treatment, but only for individuals with severe depression and significant functional impairment. Less than half described medical intervention for treating moderate depression, suggesting the belief that medical intervention is more appropriate in cases of severe depression.
Appropriateness of Receiving Depression Services at an NCD Clinic
Although patients initially stated preferences for social support or prayer to treat depression, when asked about the integration of depression services within NCD clinics, every patient described integration as appropriate.
During the interview with the hypertension patient that prioritized prayer as a depression treatment, the interviewer discussed psychosocial counseling and asked the patient’s views regarding counseling at their NCD clinic:
It would be helpful because they will be able to disclose all their problems, if that specific person would guide and counsel him on what to do (Female, age 35).
When the interviewer described screening and medication, and similarly asked for the patient’s thoughts:
The medicine would be effective since they will be examined to reach a diagnosis. The reason why people are told to go to a health facility is for them to be examined so that a diagnosis can be ascertained. So it would be nice if that can be endorsed, if medicine would be made available (Female, age 35).
Here, the patient stated their initial preference for depression treatment as prayer at a Christian church. Once the interviewer described screening and treatment as a medical process delivered through the NCD clinic, the patient responded that the services would be appropriate.
After describing the integration of depression screening, psychosocial counseling, and anti-depressant medication within the NCD clinic, other participants who prioritized prayer as a treatment for depression symptoms similarly described appropriateness for integrated services. Initially stating:
It’s very difficult to deal with [depression symptoms] because you can go and associate with friends, but when you get back home you’ll still meet the problems. The most important thing that you can do is just to pray (Female, age 60).
And later reacting after the interviewer discussed depression medication at their NCD clinic:
When you are thinking a lot on something, that’s when you get depression. If there can be some medications for that that’s okay. We can all accept it (Female, age 60).
We noted a similar trend in patients who valued social support as a primary means of treating moderate depression. When the interviewer introduced depression screening for co-morbid patients at the NCD clinic, the same diabetes patient noted:
They would feel very happy because they would know that there is a way to diagnose their problem and get treatment. You know when a problem is diagnosed, you know there is treatment. So, diagnosis is very important (Male, age 40).
Similar to patients who prioritized prayer in treating depression symptoms, the patients who prioritized social support, or some combination of the two, all described the integration of screening and treatment at their NCD clinic as appropriate.
While all participants described depression service integration as appropriate, several expressed conflicting feelings regarding the effectiveness of anti-depressant medication. One patient first noted their preference for prayer and voiced skepticism regarding medication:
[Treating depression with medication] is not possible…because depression is something that you create through things that have happened to you, so it is up to you to accept and deal with (Female, age 43).
However, when asked what she would do if she had depression symptoms herself, the patient noted a preference for medical intervention in the form of screening:
[I would be] coming to the hospital so that the doctor should test me as if they test sugar or BP… They can identify that the illness is there because of the brain so they tell you what to do so you stop thinking too much (Female, age 43).
Despite the patient’s skepticism regarding medication, they were open to seeking depression care from their NCD provider. This openness reflects a flexibility in NCD patient attitudes given every patient described depression services as appropriate, despite initially voicing a preference for other treatment options. This flexibility appears grounded in a patient-provider power dynamic, rooted in patients’ respect for providers’ medical knowledge.
Respecting Medical Knowledge – The Patient-Provider Power Dynamic and the Importance of Communication
When the interviewers explained the process of screening and treatment at the NCD clinic, depression became a topic of medical knowledge. Patients discussed a great respect for medical knowledge. For instance, a hypertension patient highlighted the difference between the same dietary recommendations offered by community members and a medical provider:
There is a difference, [community members] tell us that “do not eat this or do not eat this,” and we do not listen. But, when a doctor tells us that “if you eat this you are putting your life at risk,” we listen (Female, age 60).
Patients also related a respect for medical knowledge when given hypothetical scenarios described in depression vignettes. A hypertension patient described a possible interaction with her husband, pretending that he is the man in the vignette with depression:
He will understand the counselling from a health worker because he is afraid of the health workers. But for me to tell my husband about counseling, he will say, "What do you know!” but he is afraid of the health workers. “These people know something, they are well trained” and so he just listens attentively, and he may also just take medications (Female, age 59).
The notion of accepting medical recommendations out of fear introduces the issue of power. Describing a patient-provider interaction as charged with fear acknowledges the provider’s power to shape how a patient feels. A different patient expanded on this dynamic:
If you look at someone who is the health worker and is putting on that uniform it adds some grain of believability unlike someone that is from the community where we live. We believe that the health worker will answer most of our problems…The other reason why a health worker is more believable than someone from the community is because the health worker had to go to school to do what he or she does unlike member of the community whose education will always be questionable…The moment the patient sees the health worker, psychologically he or she feels they have been helped (Male, age 48).
The importance of medical credibility and power became more pronounced when interviewers asked how a patient might react when receiving a depression diagnosis. Given depression services would be new to NCD clinics, and moderate depression was not viewed as a medical condition, the ability to transfer medical knowledge to the patient becomes critical. Patients cautioned that the initial depression diagnosis could be jarring “because we have never thought of it before, that sadness can also be a disease.” The way in which a provider explains depression as a treatable medical condition, could potentially exacerbate mental health issues, or provide comfort and a clear path forward. A hypertension patient discussed the importance of patient education:
She can be stressed out. Upon hearing that she has been diagnosed with a medical condition she will feel bad. She will be thinking that the medical condition is permanent. There are two possibilities. The first one you may go to the hospital and the clinician will tell you “sorry mum we have found you with a wound. However, the good news is that the wound will get healed soon.” Or you may go to the hospital and be told that you have been diagnosed with a disease that will take almost forever. The second one could leave you stressed out (Female, age 49).
A diabetes patient described the same issue and added importance to the way a provider speaks to a patient.
For someone who has come from the village to understand the diagnosis, it will get him even more depressed because he will say “is being depressed even a disease?” It also depends on the person conducting the test. They can either make the person more depressed or they can help end the depression the person already has. Explain to them properly, in a slow, soft tone, tell them that you have been found with this disease and these are the causes, explain to them properly and counsel them (Male, age 52).