At the age of 70, Carmen Suárez* is finally coming to terms with an event that happened five decades ago. It was a trauma that changed the course of her life and left her with depression. “I used to cry uncontrollably,” she says.
“I was told to seek help, but I had neither the time nor the money. I realise now that I was stuck reliving the incident.”
Over the course of a year, the Diada project (detection and integrated care for depression and alcohol use), an innovative project aimed at identifying people with or at risk of developing a mental health or alcohol use disorder, helped her recover.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
Suárez has several chronic ailments, including high blood pressure, and was regularly in and out of treatment. “Together with my church, the programme helped me begin processing the trauma I’d been living with and made me understand how my mental health was affecting my physical health. It was a huge help,” she says.
Until 2018, the Javesalud medical centre in El Toberín, northern Bogotá, where Suárez is a patient, had no system of detection.
“Patient diagnostics of mental health were zero,” says Dr Isabel Zapata, the centre manager. “That doesn’t mean they didn’t exist, we just didn’t have any way of identifying them, so they’d fall through the system.”
Working with the Pontifical Javierian University, the non-profit medical centre provides outpatient primary care to 10,000 patients monthly, out of a catchment area of 58,000 people. It has no psychiatrists. Between 2018 and 2020, 7,000 patients participated in Diada. One in ten were diagnosed with a mental illness and 1% with an alcohol abuse problem. To date, there have been 16,000 patients screened.
Diada works by directing people – typically visiting the medical centre for a different health matter – toward an interactive screen with a series of questions. Algorithms help identify at-risk patients. “It’s a very simple but effective way of screening people,” says Zapata.
After the two-minute survey, a ticket is issued, which is given to the doctor and those who register “positive” go to the next phase. Computer software helps guide clinicians towards possible interventions, depending on the patient’s score which reflects the severity or likelihood of illness. Treatment can range from the loan of a smartphone with a therapy app that registers mood or alcohol consumption, to regular evaluations or medicines. Practitioners say symptoms significantly improve within three months of diagnosis.
Depression affects 4.7% of Colombians, making it secondonly to cardiovascular disease in prevelance in Colombia, according to the health ministry, and slightly above the global average. Most of those affected (80%) do not have access to specialist care. The rates of women with depression are 5.4% compared with 3.2% of men.
There are only 1,200 psychiatrists to serve a population of 51 million – equivalent to 2.5 psychiatrists for every 100,000 people, a quarter of the WHO recommended 10 for every 100,000. Alcohol is another leading contributor to the disease burden and the two are often linked.
Persistent underinvestment, followed by a global pandemic, has worsened the situation, leaving mental health problems to be a drain on the health system and, with many sufferers unable to work, an economic burden.
Dr Carlos Gómez-Restrepo, who oversaw the national mental health survey, was concerned that despite a significant proportion of the population reporting symptoms of depression, too few were being diagnosed, much less treated. “We realised that primary care doctors in Colombia weren’t equipped to deal with this. Only the most severe cases of alcohol abuse or depression were being detected, by which time most people would find themselves in the emergency department,” he says.
Diada results from a collaboration between the Pontifical Javerian University (where Gómez-Restrepo is the dean of medicine and the project’s lead researcher), and Dartmouth College in the US. With funding from the National Institute of Mental Health, the pilot was launched in six locations across the country. There is a further planned launch in Leticia, the capital of Colombia’s Amazonas , later this year.
“Diada has proved its efficacy and cost-effectiveness,” says Dr José Miguel Uribe, co-researcher, and director of the department of psychiatry Pontifical Javerian University. For an estimated cost of $2 (£1.65) for each person treated, according to Uribe, Diada offers an economical model of mental health provision. More psychiatrists are not the solution, much less a quick fix, says Uribe. Instead, equipping primary care centres to enable early detection and prevention, such as with the Diada project, is the way forward.
Other Latin American countries, including Peru and Chile, have been watching the Diada project in Colombia and expect to adopt similar programmes. “It’s a two-way process, where we all learn from each other,” says Uribe. Scaling up will need long-term funding from the government, which last week presented its health reforms, claiming they will expand healthcare access. As part of these reforms, President Gustavo Petro has promised up to 20,000 new primary care teams.
“The pandemic laid bare the importance of our mental wellbeing,” says Uribe. “There has never been more interest shown from as many different groups as there is now – not only governments and health authorities, but also schools, universities, families and communities. It is a golden opportunity. Mental health concerns us all.”
*Name has been changed
