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PETERMAN: Burden of Depression in Peru: A Review

Burden of Depression in Peru: A Review

As public health efforts work towards eliminating infectious diseases and more countries

exit the age of receding pandemics in the epidemiological transition, the focus of health must

also shift from infectious disease to non-communicable diseases. Globally, chronic disease

contributes to the top six leading causes of death;1 however, it is also important to explore the

daily burden of chronic illness by looking at the disability adjusted life year (DALY).

Mental disorders, one non-communicable disease of interest, contributed an estimated

total of 7.4% to global DALYs.2 The disorders with the greatest burden on health are

schizophrenia, anxiety disorders, bipolar disorder, and depression, the focus of this paper.1

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5),

depression is characterized by symptoms like depressed mood, loss of interest in activities, and

fatigue, which last all day for nearly every day for at least a two week period.3 Although suicidal

ideation is a characteristic of depression and does cause death by suicide, depression does not

contribute to leading causes of death worldwide.1 Instead, the chronic nature of depressive

symptoms means that we can better estimate the burden of depression through DALYs.

Globally, depression contributes an estimated 2% of the world’s DALYs4 and was the

sixth leading cause of DALYs and the fourth leading cause of non-communicable DALYs in

2016. Because the burden of chronic disease differs depending on country income, it is important

to note that in low-middle income countries, depression contributes about 1% of the burden;

whereas in high-middle income countries, depression is the third leading cause of DALYs,

capturing 2.69% of the burden.1 As a region, Latin American has shifted away from infectious

disease and into non-communicable diseases and contains countries from low to middle-high

income, as well as areas of great income and health inequalities.5 Although mental disorders are
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PETERMAN: Burden of Depression in Peru: A Review

the fourth non-communicable cause of DALYs in Latin America, in Peru, they are the second

leading cause of non-communicable DALYs.4 Further, according to the Pan American Health

Organization, depression was the second leading cause of DALYs in 2012.6 Because depression

contributes to a large portion of DALYs in Peru, the goal of this paper is to review the burden of

depression in Peru.

Depression can affect the entire population, though different groups in Peru experience

different rates. A review of the occurrence of mental disorders in the five largest cities in Peru

found that the prevalence of having at least one mental disorder at some point in life was 29%,

whereas depression alone had a prevalence of 6.4%.7 There is a higher rate of DALYs due to

depression in women (459 DALYs per 100,000) than men (287 DALYs per 100,000), with

women having 172 DALYs per 100,000 in excess of men in Peru.4 Women also experience a

gender difference in developing maternal depression related to pregnancy. A study found that

40% of the pregnant women attending a clinic in Lima had depression,8 which is especially

important because of the association between maternal depression and childhood stunting and

underweight.9 Despite the gendered difference in rate of depression, men are more likely to die

by suicide than women, by a 2:1 ratio.10 Depression accounts for a higher percentage of DALYs

for 15-25 year-olds in both men and women; however, the rate of DALYs per 100,000 increases

with age, with 65 year-olds and older having the highest rate.11

There are less available data on how socioeconomic status is related to depression in

Peru. One study found that education level was a protective factor against late-life depression in

urban areas.12 A study looking at the factors associated with depression across Latin America

and the Caribbean found that among older adults, illiteracy or lack of schooling, childhood

hunger, and insufficient income were all associated with depression, in addition to being
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PETERMAN: Burden of Depression in Peru: A Review

female.13 These factors were found to be associated with depression across all six cities in the

study, so there is plausible evidence that these factors are true for Peru as well. A study on the

prevalence of mental disorders in different regions of Peru compared mental health in a rural

area, urban area, and in rural-to-urban migrants. The prevalence of common mental disorders

was highest in the rural area and lowest in the urban area; however, after adjusting for education

and income, the differences in prevalence were non-significant.14 These findings suggest that

income and education affect mental disorders more than location; however, the prevalence of

mental disorders is higher in rural areas because there is less access to higher education.

These data provide an idea of the burden of depression in Peru, but much of the data

could be improved. While the Global Burden of Disease Study from 2010 and other studies

previously discussed provide information on the prevalence of depression in Peru, a study found

that in late-life depression, the prevalence ranged from 5.5% to 23%, depending on the scale

used.12 It is possible that the prevalence rates are missing people with clinically significant

depression, depending on which scales are used. Additionally, there are few studies that research

socioeconomic status in relation to depression. Overall, there is a lack of research available from

Peru: a review found that from 1961-2010, less than 1700 papers with first authors from Peru

were published and that on average, only 40% of the papers published across Latin America

studied non-communicable disease.5 The CRONICAS research group, based in the Universidad

Peruana Cayetano Heredia and formed in 2009, is the first center for chronic disease research in

Peru. While it has studied mental health,15 the group also studies a variety of chronic diseases;

thus, more research should be done on mental health, specifically depression.

There are two distinct trends when assessing the burden of depression in Peru: the trend

from 1990 to present, and the predicted trend from present into the future. In both sexes and all
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PETERMAN: Burden of Depression in Peru: A Review

ages, mental disorders rose from the fourth leading DALY in 1990 to the second leading DALY

in 2016.11 Since depression is a leading contributor to mental disorders, depression likely rose as

a cause of DALYs during this time as well. Indeed, according to the IHME data, the percent that

depression contributes to total DALYs increased from 0.85% in 1990 to 1.83% in 2016.11 When

looking to the future, depression is expected to increase from the fourth leading cause of DALYs

to the second leading cause of DALYs globally by 2030. Considering the burden of depression in

Peru, it is likely that depression will contribute a greater burden there in the future.16

Because depression is a leading cause of DALYs currently in Peru and projected to

remain a leading cause in the future, it is important to consider how depression affects welfare

and productivity. As a chronic disease, people with depression experience symptoms like fatigue

daily,3 for extended periods of time. These constant feelings of fatigue and sadness can affect

productivity. In a study on productivity and mental health, researchers reasoned that loss of

productivity can occur in two forms: taking time off work because of depression (absenteeism)

or going to work while experiencing symptoms of depression (presenteeism). In Brazil and

Mexico, absenteeism costs corresponded to 0.66% and 0.28% of the GDP, respectively, while

presenteeism costs accounted for 2.82% and 0.89% of the GDP, respectively.17 While this study

was not performed in Peru, the results were similar across eight countries, and with two countries

being in the same region as Peru, it is likely that Peru experiences similar loss of productivity

due to absenteeism and presenteeism.

Encouragingly, there are a number of programs being implemented countrywide to treat

depression. One such program is the Latin American Treatment and Innovation Network in

Mental Health (LATIN-MH) in Peru and Brazil, which aims to increase capacity for research, as

well as implement research studies on a mobile phone intervention for the treatment of
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PETERMAN: Burden of Depression in Peru: A Review

depression.18 However, the most feasible way to increase care for depression is to combine it

with primary care. Specialized mental health treatment centers are less common in Peru, and

only 0.27% of the health budget is allocated to mental health care.19 Thus, combining mental

health care with primary care would allow these services to reach more people. This is especially

true for people in rural areas, who may only be able to access a primary care doctor.20 A study

trained primary care physicians in Peru to better provide mental health care. At follow-up, the

physicians were more confident in diagnosing mental disorders and prescribing medication,

though their confidence decreased at the one-year follow up.21 These results suggest that with

repeated training, primary care physicians can also provide mental health care for patients.

Policy efforts have followed this model: a law passed in 2012 aimed to provide mental health

care to every citizen by focusing on a community-based model and improving mental health

services at the primary care level.19 In 2015, the Allillanchu Project attempted to integrate mental

health care with primary care by introducing a mental health screening app for primary care

providers, referring cases to psychologists, and using text messages to remind patients where to

seek care and motivate them to seek help. The study found that 21% of the patients had a

disorder, and of those patients, 72% sought mental health care after the screening.15

Though strides have been made to improve access to mental health care in Peru, barriers

to treatment still exist. One such barrier is stigma. Disapproving attitudes toward mental

disorders and mental health treatment can prevent access to care. In a series of interviews, people

from Peru reported their views of mental disorders to be tolerance, pity, and fear, while those

who had mental disorders experienced stigma based on gender. Men experienced stigma

publicly, while women experienced stigma from within the family unit.22 Another barrier is the

diversity of people in Peru. The majority of indigenous populations live in five countries, of
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PETERMAN: Burden of Depression in Peru: A Review

which Peru is one.5 In addition to the inequalities of health care that indigenous people receive,

there is also the question of medical pluralism. One study on indigenous health practices and

mental health found that biomedical care and traditional healers are the two sources of care for

mental disorders; however, there is a lack of follow-up and lack of trust towards the biomedical

care providers.23 Additionally, some 3.8 million people in Peru speak Quechua and 450,000

speak Aymara,24 whereas many care providers speak Spanish. Thus, finding mental health care

for indigenous populations that is both respectful to their culture and effective in treating their

mental health is a challenge. Finally, there is still considerable lack of access to care in Peru. In

the lowest income quintiles, only 14.3% of the population has access to health care services.5

Because low income is related to depression, it is likely that many of the people who most need

treatment for depression are underserved.

The next steps for reducing the burden of depression in Peru are first to increase research

on depression in Peru. The CRONICAS group is an established research group with experience

researching chronic disease; however, they cannot devote enough attention to depression by

themselves. Their research group should be expanded and funded to study the prevalence, risk

factors, and treatment efforts of depression. Another important step is repeated training of

primary care physicians, so they remain confident in their ability to diagnosis depression and

prescribe medication. Access to primary care must be extended to rural areas, low income areas,

and indigenous populations, so people who have depression and are currently being underserved

can better access care. More of the health budget should be allocated toward mental health and

toward accessing rural communities to ensure these goals are being met. And finally, health

literacy interventions would help to educate the public on symptoms to be aware of and would

help to reduce stigma, thereby encouraging more people to seek care for depression.
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PETERMAN: Burden of Depression in Peru: A Review

Specific Aims
As the global burden of disease shifts from infectious disease to chronic disease in Latin
America and the Caribbean, more resources should be shifted to the research and treatment of
mental disorders. Depression is one of the leading causes of DALYs in Peru,6 and those suffering
from depression experience symptoms such as fatigue, depressed mood, and increased risk of
death by suicide, reducing the of quality of life for those individuals.3 Additionally, depression
affects the country as a whole through GDP loss, as individuals take time off work due to
depression or come to work while suffering from the symptoms of depression.17
Current steps are being taken to alleviate the burden of depression on Peru. The
government passed legislation in 2012 to improve mental health services, guaranteeing
availability of mental health services and treatment for every citizen;19 following this law, mental
health care is being implemented into primary care. Some initiatives involve the use of screening
tools for depression and reminder and motivational texts to patients.15 Physicians are also being
trained to diagnose mental disorders so they can either provide basic treatment or refer the
patients to a mental health professional.21
These different interventions to improve mental health services are making progress to
reduce the burden of depression; however, rural and indigenous communities are missing from
the efforts.20 Rural and indigenous communities often have difficulty accessing primary care
services because they live in remote areas that can be difficult to access due to the geography of
the region.25 Additionally, some of the technology-based interventions that have been
implemented would not be effective in rural areas if patients do not have access to mobile phones
or internet to receive reminders.
People in rural and indigenous communities have higher risk factors for depression yet
are being underserved by current mental health pushes. People in these communities have higher
poverty rates and lower education levels, putting them at higher risk for depression.14
Additionally, those living with infectious disease have a high comorbidity with depression.
Patients with HIV have high rates of depression,26 and poor mental health can worsen
tuberculosis.27
Therefore, the overall objective of this application is to combine treatment for depression
with treatment of infectious diseases in rural communities. My central hypothesis, based on
research, is that diagnosis and basic treatment of depression through primary care providers will
reduce the burden of depression in rural areas. The SERUMS plan is an existing infrastructure of
doctors who spend a year working in rural and isolated areas of Peru;28 thus, combining mental
health care with their work will reduce the prevalence of depression. My long-term goal is to
create a mental health infrastructure that reduces the treatment disparities between rural and
urban areas of Peru. I am proposing to accomplish this goal with the following specific aims:

Aim 1: To improve primary care physicians’ abilities to diagnose depression and provide
basic mental health care for patients. Conduct an initial two-week training on depression
diagnosis, treatment, and referral in a cohort of 30 doctors in the SERUMS program using
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PETERMAN: Burden of Depression in Peru: A Review

randomized trial. Then, at six-month follow-up, conduct one day training for these doctors to
maintain their confidence in diagnosing depression. Confidence levels to be measured after each
training of doctors who received both trainings and doctors who did not.
Aim 2: Integrate mental health screenings and treatment in the SERUMS program. After
receiving training, doctors in the SERUMS program servicing rural areas will diagnose
depression through diagnostic screenings, added on to their existing screenings. Doctors will
follow up with patients who have been diagnosed with depression. Researchers will measure the
prevalence of depression with a cohort study design.
Aim 3: Evaluate the efficacy of depression screenings and treatment at two-year follow-up.
At the two-year follow up, doctors in the SERUMS program will assess current rates of
depression in the same villages as the second stage of the intervention. Researchers will use
qualitative methods to assess how many patients diagnosed with depression sought treatment and
remaining reasons for not seeking treatment.

Accomplishing these aims will begin to reduce the burden of depression and health disparities in
rural areas, as well as assessing what future steps still need to be taken to improve mental health
care in rural areas.
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PETERMAN: Burden of Depression in Peru: A Review

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