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Depression Research and Treatment
Volume 2018, Article ID 1592596, 11 pages
https://doi.org/10.1155/2018/1592596
Review Article

Depression and Its Help Seeking Behaviors: A Systematic Review and Meta-Analysis of Community Survey in Ethiopia

1University of Gondar College of Medicine and Health Science, School of Nursing, Gondar, Ethiopia
2Bahir Dar University college of Medicine and Health Science College Department of Psychiatry, Ethiopia

Correspondence should be addressed to Berhanu Boru Bifftu; moc.liamg@urobunahreb

Received 29 September 2018; Accepted 5 December 2018; Published 18 December 2018

Academic Editor: Axel Steiger

Copyright © 2018 Berhanu Boru Bifftu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background. Depression is one of the most common mental illnesses affecting around 322 million individual in the world. Although the prevalence of depression is high and its treatment is effective, little is known about its pooled prevalence and help seeking behaviors in the community settings of Ethiopia. Thus, this study aimed to determine the pooled prevalence of depression and its help seeking behaviors in Ethiopia. Methods. A systematic literature search in the databases of Pub-Med, Cochrane, and Google Scholar was performed. The quality of studies was assessed using the Newcastle-Ottawa quality assessment tool adapted for cross-sectional studies. Heterogeneity test and evidence of publication bias were assessed. Moreover, sensitivity test was also performed. Pooled prevalence of depression and its help seeking behavior were calculated using random effects model. Results. A total 13 studies for depression, 4 studies for help seeking intention, and 5 studies for help seeking behaviour were included in this review. The pooled prevalence of depression and help seeking intention and behaviour was found to be 20.5% (95% CI; 16.5% -24.4%), 42% (95% CI; 23%-60%), and 38% (95% CI; 23%-52%), respectively. There is no significant heterogeneity for depression (I2 = 0%, p =0.620), help seeking intention (I2 = 0%, p =0.996), and behaviour (I2 = 0%, p =0.896). There is no publication bias for depression egger’s test (p =0.689). Conclusion. More than one in every five individuals were experiencing depression. Less than one-third of individuals with depression seek help from modern treatment. Authors suggest community based mental health screening and treatment.

1. Background

Mental illness is a growing concern of public health that affects more than 340 million people worldwide. Out of the top 10 leading causes of disability, five are mental illnesses [13]. Depression is one of the most common mental illnesses with an estimated prevalence of 4.4% globally [2]. The prevalence of depression is on rising by 18.4% from 2005 to 2015 [3]. Depression increased the mortality, morbidity, disability, family, and the country as whole [1, 2, 4, 5]. Depression also affects occupational and interpersonal functioning of the individual [68], particularly the cost associated with loss of working days [6]. Moreover, depression increases the risk of cardiac illness, diabetes, and hypertension [6, 9]. In Ethiopia, depression is the third leading cause of burden of diseases [7]. The magnitude and the adverse impact of depression are unbearable [1012] with an estimated prevalence ranging from 2.4% [13] to 60% [10, 1427]. It contributed as a third leading cause of burden of diseases [7]. It also contributes for the comorbid medical [2834] and surgical illness and affect the treatment adherence [3538]. Moreover, depression contributes for substance use [17, 39] and suicide [8, 40, 41]. Factors such as low socioeconomic status, residence, sex, substance use, previous history of mental illness, family history of mental illness, and chronic illness were associated with depression [15, 17, 24, 30, 31, 42].

Depression is a treatable mental illness [1, 2, 12, 43]. Despite its huge impact and availability of effective treatment [1, 4347], vast majority of individuals who suffer from mental illness do not access treatment for their problems. In general, epidemiological evidence revealed the prevalence of professional help seeking behavior for mental illness is ranging from 35% to 50% in developed countries [43, 48] and from 10% to 15% in developing countries [12, 42, 44, 4951]. In regard to depression, the professional help seeking behavior was ranging from 33% in Africa to 55.6% in Europe [52] with a regional variation [20, 53, 54]. Factors such as fear of stigma and embarrassment, lack of time, comorbid substance use, demographic and geographical variation [50], co-morbid chronic illness [49, 55], psychosocial factors [5, 43, 5658], perceived cause, accessibility, and effectiveness of the treatment [59, 60] were associated with the treatment gap. In Ethiopia, the treatment gap for mental illness reached 90% [12, 27, 6164], and specifically for depression, it ranged from 12% to 82% [18, 20, 27]. Communities’ knowledge, attitude, substance use, socioeconomic and geographic factors [12, 65, 66], lack of resource, and the dominance of traditional healer were barrier for the treatment seeking behaviors [67, 68]. Untreated depression is a potential for symptoms of severe treatment resistant and increased burden and complexity of the disorders [7, 41, 69, 70]. Therefore, studying the help-seeking behavior enables us to understand and discover people’s dynamics in their decisions of help seeking behavior from trained health care professional. Moreover, it gives vital information on communities’ attitude and practice toward their preference treatment place for depression. This information helps the planning and provision of training to strengthen the referral mechanisms and health policy of the country to address the choice of the communities’ treatment place. In Ethiopia, there is inconsistent epidemiological evidence about depression and its help seeking behavior [18, 20, 27], which need comprehensive evidence for decision making and, yet, there are no a single systematic review and meta-analysis using community survey. Thus, the purpose of this systematic review and meta-analysis was to assess the magnitude of depression and its help seeking behaviors in Ethiopia.

2. Methods

We conducted a systematic review and random effects meta-analysis to identify the magnitude of depression and its help seeking behaviors using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) [71].

2.1. Search Strategies

We searched databases: PubMed, Cochrane, and Google Scholar. PubMed electronic database was searched until September, 15, 2018, using the search term ((depression [MeSH Terms]) OR (depression) OR (depressive symptoms [MeSH Terms]) OR (depressive symptoms) OR (depressive disorders [MeSH Terms]) OR (depressive disorders) OR (dysthymia [MeSH Terms]) OR (dysthymia) OR (mood disorder [MeSH Terms]) OR (mood disorder)) AND ((disclosure [MeSH Terms]) OR (disclosure) OR (coping mechanism [MeSH Terms]) OR (coping mechanism) OR (defense mechanism [MeSH Terms]) OR (defense mechanism) OR (resilience [MeSH Terms]) OR (resilience) OR (health care utilization [MeSH Terms]) OR (health care utilization) OR (health service utilization [MeSH Terms]) OR (health service utilization) OR (help seeking behavior [MeSH Terms]) OR (help seeking behavior) OR (help seeking intention [MeSH Terms]) OR (help seeking intention OR (treatment seeking [MeSH Terms]) OR (treatment seeking) OR (health care seeking behavior [MeSH Terms]) OR (health care seeking behavior) OR (healer [MeSH Terms]) OR (healer) OR (pathway [MeSH Terms]) OR (pathways) OR (services contact [MeSH Terms]) OR (service contact) OR (first contact [MeSH Terms]) OR (first contact) OR (help seeking [MeSH Terms]) OR (help seeking)) AND Ethiopia. There was no restriction on language and year of publication. The reference lists of included studies were manually searched. Likewise, Cochrane review databases were searched using similar search terms tailored to it. Google Scholar was also searched for gray literature and published paper in unindexed journals. For the required information not clear/not avail, authors were contacted via email.

2.2. Selections of the Studies

Figure 1 showed the study selection process. All citations (N = 1458) identified through our search strategy were imported into EndNote version X7 reference management software and used automated “Find Duplicates” function to exclude any duplicates. The title and abstracts of the 1458 articles were assessed by two reviewers (BBB and YDG).

Figure 1: Flow diagram of the included studies.
2.3. Definition of the Variables

In this systematic review and meta-analysis, depression refers to the occurrence of either depression (major or minor), depressive symptom, dysthymia, or their combinations. Help seeking behavior is an individual’s willingness/intention to seek help or actual help seeking behavior from at least one of modern health facilities such as: hospital, health center, clinic, health post and/or from health care professional (psychiatrist, nurse, psychologist, sociologist and other) and coded as “Yes”/“No.”

2.4. Inclusion and Exclusion Criteria
2.4.1. Participants

They include any population based study including those on behalf of another individual (e.g., family members).

They exclude homeless, livening abroad, specific group (e.g., women, people with disability), and refugee.

2.4.2. Outcomes

Studies presenting quantitative data on (i) depression and (ii) help seeking behavior for depression or depressive symptom from modern treatment place (hospital, health center, clinic, and health post) and or health care professionals (psychiatrist, psychologist nurse, and others) and coded as “Yes”/“No” for analysis.

Depression with comorbid medical or surgical illness, substance use, and other psychiatric illnesses are excluded.

Help seeking for other mental illness (psychosis, suicide and substance use disorder, and others).

2.4.3. Study Designs

Community based quantitative cross-sectional studies design is included.

Institution based qualitative study design that did not estimate the prevalence of depression and help seeking behavior is excluded. Moreover, studies that focus on case reports, paper, and conference abstracts that did not provide enough information were excluded.

Data Extraction. A standardized and prepiloted checklist was used to extract the required information. Data were extracted on study characteristics and outcomes by two independent reviewers (BBB and YDG) and stored in a Microsoft Excel Spread Sheet. The extracted data include details of author’s name, year of publication, study area, sample size, assessment tool, prevalence of depression, and help seeking behaviors (intention and actual help seeking behavior).

2.5. Quality Assessment

Two review authors’ independently assessed the quality of included studies using the Newcastle-Ottawa quality assessment tool adapted for cross-sectional studies. This tool had seven items in three domains (selection, comparability, and outcome). Individual paper was grade with score ranged from zero to nine. Quality of each paper was determined using the overall sum of each item score and defined as good for score ≥5 and fair for score ranged from 3 to 4 and poor for score <3. This quality appraisal score was assessed by two investigators (BBB and YDG) and disagreements were solved by discussion.

2.6. Data Synthesis and Statistical Analysis

The extracted data were entered into a Microsoft Excel Database and then imported into STATA 14 that we installed packages for Meta-analyses online. Meta-analyses were performed separately for each outcome: depression, help seeking behavior (help seeking intention and actual help seeking behavior). The estimated pooled prevalence and weighted mean differences of depression and help seeking behavior were calculated using random-effects model at 95% confidence interval [72]. Test for Heterogeneity between the studies was performed using Cochran’s Q statistic and the I2 statistics [73]. I2 values greater than 50% were considered as indicative of substantial heterogeneity. Evidence of publication bias was assessed using visual inspection of the symmetry in funnel plot [74] and egger test [75]. Sensitivity analysis was also conducted to examine influential study [76].

3. Results

The literature search resulted in 1458 recorded papers. Of these records, 1014 were excluded just by reading their titles. Of the remaining 273 studies, 156 were excluded by reading their abstract and found to have a different outcome variable. Finally, 18 papers were excluded because of their different methods and prevalence/results were not clearly reported. Thus, the remained 18 studies were included in the systematic review and meta-analysis (Figure 1).

3.1. Study Characteristics

A total of 13 studies for depression, 4 studies for help seeking intention, and 5 studies for help seeking behaviour were included in this meta-analysis. All studies were community based and utilized cross-sectional study design. Of these included studies, two studies were from Amhara, three studies were from Oromia, two studies were from Southern Nation and Nationalities of People, and one study was national data. For the assessment of depression PHQ-9 (n=4), ICD-10 (n=2), DSM-IV (n=3), BDI-21 (n=1), HSCL-15 (n=1), and SCAN (n=1) were utilized. One study also reported use of the WHO STEPS instruments. For the assessment of help-seeking behavior case vignette (n=7) and GHSQ (n=2) were used (Table 1).

Table 1: Characteristics of included studies.
3.2. Quality of Included Studies

The overall quality score of included studies ranged from 3 to 8. Of these, 14 studies had good quality and the remaining 4 studies had poor quality (Table 2).

Table 2: Quality of included studies in the analysis.
3.3. Depression

A total of 13 studies, including data from 20067 participants, were included in the study. The pooled prevalence of depression was found to be 20.5% (95% CI; 16.5% -24.4%) (Figure 2). There is no evidence of significant heterogeneity (I2 = 0%, p =0.620) and publication bias egger’s test (p =0.637). The sensitivity analysis showed that none of the point estimates was outside of the overall 95% confidence interval confirming that there was no influential study. Thus, pooled estimates based on all the 13 studies could be important.

Figure 2: Forest plot presenting the pooled prevalence of depression using random effect models with 95% CI.
3.4. Help Seeking for Depression

In this systematic review and meta-analysis, the pooled prevalence of help seeking intention and behaviour was found to be 42% (95% CI; 23%-60%) and 38% (95% CI; 23%-52%), respectively (Figure 3). No evidence of significant heterogeneity help seeking intention (I2 = 0%, p =0.996) and behaviour (I2 = 0%, p =0.896). The overall sensitivity analysis showed that none of the point estimates was outside of the overall 95% confidence interval confirming that there was no influential study. Although evidence from visual inspection of the funnel plot and the Egger’s test (P =0.025) showed publication bias, there is no change in the trim and fill analysis.

Figure 3: Forest plot presenting the help seeking intention and behaviour using random effect models with 95% CI.

4. Discussion

The current review is the only community based epidemiological review of depression and its help seeking behaviors in Ethiopia. More than one in five of the community reside were found to have depression in Ethiopia [20.5% (95% CI; 16.5% -24.4%)]. This study confirmed the existence of high magnitude of depression in Ethiopia. Compared to other studies carried out by World Mental Health Survey Initiative at different time [(4.1/9.8% to 19.1% for the last 12 months) and (18.1% to 36.1% for the lifetime prevalence)] [7779], we found higher prevalence of depression. This study also higher than a recently published community based samples of meta-analysis over one year (12.9%) [80]. This variation may be due to the difference in study period. This is supported by the results of subgroup analysis that showed the prevalence of depression in studies published from 2004 to 2014 was higher than those published from 1994 to 2003 [80]. The other possible explanation may be due to the regional variation [78, 79]. As supported by the WMHS epidemiological variation of depression across country that may attributed to the variation in the concept of the illness, socio-economic status and psychosocial norm.

Regarding the help seeking behaviors, the pooled prevalence of help seeking intention was found to be 48% (95% CI; 38%-57%). This may be an indication for mental health treatment gap in Ethiopia. Even though, similar studies are scarce for comparison this study, there are little supportive studies from developed and developing countries. This result is within the range of (49% to 84%) of other review on perceived need for treatment [81]. Other review of public study also found the treatment recommendation for depression was 49% (48%-50%) for medication and 76% (76%-77%) for psychotherapy [82]. The public’s beliefs about the helpfulness of interventions actually influence their service use for mental health problems is important. On the other hand, even though 42% (95% CI; 23%-60%) of our study showed help seeking intention, the pooled actual help seeking behaviour was found to be low [38% (95% CI; 23%-52%)]. This suggests the needs of assessment that interfered with the actual use of the preferred treatment. This showed all individuals who willing may not perform the actual behaviours. This is supported by a study which showed that, out of 80% adults who agreed (slightly or strongly) that treatment can help people living with mental illness lead normal lives, 35% to 67% adults agreed that other people are caring and sympathetic to people living with mental illness. People’s beliefs toward individual with mental illness usually affect interacting with, providing opportunities, and supporting a person with mental illness and frame whether they disclose the symptoms and seek care [83]. Compared to other systematically reviews, this result is consistent with the WHO African region study which showed 33% of treatment seeking behavior for depression [52]. Another systematic review also revealed a treatment-seeking behavior ranging from 17.0% and 77.8% of treatment [84]. A recently published WHO survey showed overall 29.0% of treatment [50]. This is also supported by a review from Africa using a pathways to care [50, 85] with an estimated pooled proportion ranging from 38% to 60.4% first treated by professionals [86]. Thus, the results of this finding implies though limited studies are avail: (i) the need of more study and (ii) high magnitude of depression among the Ethiopia community, (iii) with low help seeking behavior. This may suggest the needs of more information and evaluate the effectiveness of the current mental health care system on the screening of depression and its help seeking behavior from modern treatment place/professionals.

4.1. Strengths and Limitations of the Study

To our knowledge, this is the first systematic review and meta-analysis about the epidemiology of depression and its help seeking behavior in Ethiopia. Moreover, there are inclusions of all studies without the restrictions of year of publication and language. In addition to this, we conducted heterogeneity test and sensitivity analysis for possible sources of heterogeneity and identified influential paper across the studies. However, some limitations are considered during the interpretation of the results. First, although the focus of this study was on quantitative studies, the exclusion of qualitative studies and institution based studies minimize the number of included studies. Second, although we used reference lists and Google Scholar to include all the available studies, there may be possibility of having some overlooked articles. Finally, the use of case vignettes in the studies that may have different concept in the community recognitions of the disorder and help seeking behavior minimize the true figure. Despite these, this systematic review and meta-analysis revealed the recently available evidence that help to narrow the scant studies in the area, particularly in Ethiopia for the development of and/or strengthening the mental health care needs of the community.

4.2. Conclusion and Recommendations

More than one among five individuals were experiencing depression and less than one-third of individuals with depression seek help from modern treatment. Thus, authors suggest the need of community based mental health care for early identification and provisions of accessible, affordable, and cost effective treatment.

Data Availability

All data are included in this paper.

Conflicts of Interest

Authors declare that they have no conflicts of interest.

Authors’ Contributions

Berhanu Boru Bifftu was responsible for conceptualization, project administration, software, supervision, and original drafting. Berhanu Boru Bifftu, Wubet Worku Takele, Yonas Deressa Guracho, and Fekadu Ambaw Yehualashet conducted data curation, investigation, methodology, validation, and review writing and editing of the manuscript. Berhanu Boru Bifftu and Yonas Deressa Guracho made formal analysis and visualization. All authors contributed with data analysis, critically revised of the paper, and agreed to be accountable for their individual contributions.

Acknowledgments

Authors would like to thank all the primary authors of this study, especially those who agreed to share the findings of their studies for those studies that need more clarification.

Supplementary Materials

PRISM CHECK LIST for the systematic review and meta-analysis of CMDs among women with obstetric fistula. (Supplementary Materials)

References

  1. V. Patel, D. Chisholm, R. Parikh, F. J. Charlson, L. Degenhardt, T. Dua et al., “Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders,” in Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, V. Patel, D. Chisholm, T. Dua, R. Laxminarayan, and M. L. Medina-Mora, Eds., The International Bank for Reconstruction and Development/The World Bank (c) 2016 International Bank for Reconstruction and Development/The World Bank, Washington, 3rd edition, 2016. View at Google Scholar
  2. WHO, Depression and Other Common Mental Disorders, Global Health Estimates, Geneva, 2017.
  3. H. Keshavarz, D. Fitzpatrick-Lewis, D. L. Streiner et al., “Screening for depression: a systematic review and meta-analysis,” CMAJ Open, vol. 1, no. 4, pp. E159–E167, 2013. View at Publisher · View at Google Scholar
  4. M. Jordans, S. Rathod, A. Fekadu et al., “Suicidal ideation and behaviour among community and health care seeking populations in five low- and middle-income countries: a cross-sectional study,” Epidemiology and Psychiatric Sciences, pp. 1–10, 2017. View at Google Scholar · View at Scopus
  5. B. Kohrt, L. Asher, A. Bhardwaj et al., “The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies,” International Journal of Environmental Research and Public Health, vol. 15, no. 6, p. 1279, 2018. View at Publisher · View at Google Scholar
  6. M. Reddy, “Depression: the disorder and the burden,” Indian Journal of Psychological Medicine, vol. 32, no. 1, pp. 1-2, 2010. View at Publisher · View at Google Scholar
  7. A. Misganaw, Y. A. Melaku, G. A. Tessema et al., “National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990–2015: findings from the global burden of disease study 2015,” Population Health Metrics, vol. 15, no. 1, 2017. View at Publisher · View at Google Scholar
  8. B. Duko and G. Ayano, “Suicidal ideation and attempts among people with severe mental disorder, Addis Ababa, Ethiopia, comparative cross-sectional study,” Annals of General Psychiatry, vol. 17, no. 1, 2018. View at Publisher · View at Google Scholar
  9. K. Srinivasan, A. N. Isaacs, E. Villanueva, A. Lucas, and D. Raghunath, “Medical attribution of common mental disorders in a rural Indian population,” Asian Journal of Psychiatry, vol. 3, no. 3, pp. 142–144, 2010. View at Publisher · View at Google Scholar · View at Scopus
  10. M. Awas, D. Kebede, and A. Alem, “Major mental disorders in Butajira, Southern Ethiopia,” Acta Psychiatrica Scandinavica, vol. 100, no. 397, pp. 56–64, 1999. View at Publisher · View at Google Scholar · View at Scopus
  11. A. Alem, L. Jacobsson, D. Kebede, and G. Kullgren, “Awareness and attitudes of a rural Ethiopian community toward suicidal behaviour a key informant study in Butajira, Ethiopia,” Acta Psychiatrica Scandinavica, vol. 100, no. 397, pp. 65–69, 1999. View at Publisher · View at Google Scholar · View at Scopus
  12. K. A. D. Haile, A. Chaka, G. Ayano, and D. Abebaw, “Model of Decentralization and Integration of Mental Health into Primary Health Care a Supplement to the mhGAP Program,” Austin Medical Sciences, vol. 2, no. 1, 2017. View at Google Scholar
  13. B. Simon, “The place of physical medicine in the treatment of patients with mental conditions,” New York State journal of medicine, vol. 47, no. 8, pp. 854–857, 1947. View at Google Scholar · View at Scopus
  14. M. Menberu, T. Mekonen, T. Azale et al., “Health care seeking behavior for depression in Northeast Ethiopia: depression is not considered as illness by more than half of the participants,” Annals of General Psychiatry, vol. 17, no. 1, 2018. View at Publisher · View at Google Scholar
  15. T. Bitew, “Prevalence and risk factors of depression in Ethiopia: a review,” Ethiopian Journal of Health Sciences, vol. 24, no. 2, pp. 161–169, 2014. View at Publisher · View at Google Scholar · View at Scopus
  16. A. Fekadu, G. Medhin, M. Selamu et al., “Population level mental distress in rural Ethiopia,” BMC Psychiatry, vol. 14, no. 1, 2014. View at Google Scholar · View at Scopus
  17. G. Hussien, M. Tesfaye, D. Hiko, and H. Fekadu, “Assessment of Prevalence and Risk Factors of Depression among Adults in Gilgel Gibe Field Research Center, South West Ethiopia,” Journal of Depression and Anxiety, vol. 06, no. 01, 2017. View at Publisher · View at Google Scholar
  18. A. Fekadu, A. Alem, G. Medhin et al., “Utility of the concept of minor depressive disorder: Evidence from a large rural community sample in a developing country setting,” Journal of Affective Disorders, vol. 104, no. 1-3, pp. 111–118, 2007. View at Publisher · View at Google Scholar · View at Scopus
  19. S. Hailemariam, F. Tessema, M. Asefa, H. Tadesse, and G. Tenkolu, “The prevalence of depression and associated factors in Ethiopia: findings from the National Health Survey,” International Journal of Mental Health Systems, vol. 6, article 23, 2012. View at Publisher · View at Google Scholar · View at Scopus
  20. S. D. Rathod, M. J. De Silva, J. Ssebunnya et al., “Treatment contact coverage for probable depressive and probable alcohol use disorders in four low- and middle-income country districts: The prime cross-sectional community surveys,” PLoS ONE, vol. 11, no. 9, 2016. View at Google Scholar · View at Scopus
  21. M. Benti, J. Ebrahim, T. Awoke, Z. Yohannis, and A. Bedaso, “Community Perception towards Mental Illness among Residents of Gimbi Town, Western Ethiopia,” Psychiatry Journal, vol. 2016, Article ID 6740346, 8 pages, 2016. View at Publisher · View at Google Scholar
  22. Shegeye Sumet DTAaGA, “Intention to Seek Help for Depression and Associated Factors among Residents of Aykel Town, Northwest Ethiopia,” in Proceedings of the EPHA 28th Annual Conference, North America, Northwest Ethiopia, 2015, http://etphaorg/conference/indexphp/28thConference/28thConference/paper/view/579.
  23. D. Kebede, A. Fekadu, A. Alem, T. Beyero, T. Shibire, and N. Deyessa, “The distribution of mental disorders among an isolated island community in southern Ethiopia,” Ethiopian Medical Journal, vol. 43, no. 2, pp. 71–77, 2005. View at Google Scholar · View at Scopus
  24. D. Kebede, A. Alem, N. Deyassa, T. Shibre, A. Negash, and T. Beyero, “Socio-demographic correlates of depressive disorder in Butajira, rural Ethiopia.,” Central African Journal of Medicine, vol. 49, no. 7-8, pp. 78–83, 2003. View at Google Scholar · View at Scopus
  25. G. L. Molla, H. M. Sebhat, Z. N. Hussen, A. B. Mekonen, W. F. Mersha, and T. M. Yimer, “Depression among Ethiopian Adults: Cross-Sectional Study,” Psychiatry Journal, vol. 2016, Article ID 1468120, 5 pages, 2016. View at Publisher · View at Google Scholar
  26. C. Hadley, A. Tegegn, F. Tessema, J. A. Cowan, M. Asefa, and S. Galea, “Food insecurity, stressful life events and symptoms of anxietry and depression in east Africa: evidence from the Gilgel Gibe growth and development study,” Journal of Epidemiology and Community Health, vol. 62, no. 11, pp. 980–986, 2008. View at Publisher · View at Google Scholar · View at Scopus
  27. A. Deribew, “Awareness and attitude towards common mental health problems, agaro town, south western ethiopia,” Ethiopian Journal of Health Sciences, 2005. View at Google Scholar
  28. G. Tesfaw, G. Ayano, T. Awoke et al., “Prevalence and correlates of depression and anxiety among patients with HIV on-follow up at Alert Hospital, Addis Ababa, Ethiopia,” BMC Psychiatry, vol. 16, no. 1, article no. 368, 2016. View at Publisher · View at Google Scholar · View at Scopus
  29. F. Ambaw, R. Mayston, C. Hanlon, and A. Alem, “Depression among patients with tuberculosis: Determinants, course and impact on pathways to care and treatment outcomes in a primary care setting in southern Ethiopia - A study protocol,” BMJ Open, vol. 5, no. 7, Article ID e007653, 2015. View at Publisher · View at Google Scholar · View at Scopus
  30. B. Duko, A. Gebeyehu, and G. Ayano, “Prevalence and correlates of depression and anxiety among patients with tuberculosis at WolaitaSodo University Hospital and Sodo Health Center, WolaitaSodo, South Ethiopia, Cross sectional study,” BMC Psychiatry, vol. 15, no. 1, article 214, 2015. View at Google Scholar · View at Scopus
  31. T. Dejenie Habtewold, Y. T. Radie, and N. T. Sharew, “Prevalence of depression among type 2 diabetic outpatients in black lion general specialized hospital, addis ababa, ethiopia,” Depression Research and Treatment, vol. 2015, Article ID 184902, 2015. View at Publisher · View at Google Scholar · View at Scopus
  32. B. B. Bifftu, B. A. Dachew, B. T. Tiruneh, and N. Birhan Tebeje, “Depression among people with epilepsy in Northwest Ethiopia: a cross-sectional institution based study,” BMC Research Notes, vol. 8, no. 1, article no. 1515, 2015. View at Publisher · View at Google Scholar · View at Scopus
  33. A. Alem, D. Kebede, T. Shibre, A. Negash, and N. Deyassa, “Comparison of computer assisted scan diagnoses and clinical diagnoses of major mental disorders in Butajira, rural Ethiopia,” Ethiopian Medical Journal, vol. 42, no. 2, pp. 137–143, 2004. View at Google Scholar · View at Scopus
  34. S. Tafari, F. E. Aboud, and C. P. Larson, “Determinants of mental illness in a rural Ethiopian adult population,” Social Science & Medicine, vol. 32, no. 2, pp. 197–201, 1991. View at Publisher · View at Google Scholar · View at Scopus
  35. R. Tsigebrhan, C. Hanlon, G. Medhin, and A. Fekadu, “Help seeking and suicidality among people with epilepsy in a rural low income country setting: Cross-sectional survey,” International Journal of Mental Health Systems, vol. 11, no. 1, 2017. View at Google Scholar · View at Scopus
  36. P. Britteon, N. Cullum, and M. Sutton, “Association between psychological health and wound complications after surgery,” British Journal of Surgery, vol. 104, no. 6, pp. 769–776, 2017. View at Publisher · View at Google Scholar · View at Scopus
  37. M. Endeshaw, J. Walson, S. Rawlins et al., “Stigma in Ethiopia: Association with depressive symptoms in people with HIV,” AIDS Care Psychological and Socio-medical Aspects of AIDS/HIV, vol. 26, no. 8, pp. 935–939, 2014. View at Publisher · View at Google Scholar · View at Scopus
  38. A. Alem, D. Kebede, G. Woldesemiat, L. Jacobsson, and G. Kullgren, “The prevalence and socio-demographic correlates of mental distress in Butajira, Ethiopia,” Acta Psychiatrica Scandinavica, vol. 100, no. 397, pp. 48–55, 1999. View at Publisher · View at Google Scholar · View at Scopus
  39. A. Mossie, D. Kindu, and A. Negash, “Prevalence and Severity of Depression and Its Association with Substance Use in Jimma Town, Southwest Ethiopia,” Depression Research and Treatment, vol. 2016, 2016. View at Google Scholar · View at Scopus
  40. A. Fekadu, G. Medhin, M. Selamu et al., “Non-fatal suicidal behaviour in rural Ethiopia: A cross-sectional facility- and population-based study,” BMC Psychiatry, vol. 16, no. 1, article no. 75, 2016. View at Publisher · View at Google Scholar · View at Scopus
  41. T. Shibre, C. Hanlon, G. Medhin et al., “Suicide and suicide attempts in people with severe mental disorders in Butajira, Ethiopia: 10 year follow-up of a population-based cohort,” BMC Psychiatry, vol. 14, no. 1, 2014. View at Google Scholar · View at Scopus
  42. E. Coppens et al., “Public attitudes toward depression and help-seeking in four European countries baseline survey priort othe OSPI-Europe intervention,” Journal of Affective Disorders, 2013. View at Publisher · View at Google Scholar
  43. J. L. Magaard, T. Seeralan, H. Schulz, A. L. Brütt, and A. Montazeri, “Factors associated with help-seeking behaviour among individuals with major depression: A systematic review,” PLoS ONE, vol. 12, no. 5, p. e0176730, 2017. View at Publisher · View at Google Scholar
  44. R. C. Keynejad, T. Dua, C. Barbui, and G. Thornicroft, “WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries,” Evidence Based Mental Health, vol. 21, no. 1, pp. 30–34, 2018. View at Publisher · View at Google Scholar
  45. A. Gulliver, K. M. Griffiths, H. Christensen, and J. L. Brewer, “A systematic review of help-seeking interventions for depression, anxiety and general psychological distress,” BMC Psychiatry, vol. 12, 2012. View at Google Scholar · View at Scopus
  46. K. A. Collins, H. A. Westra, D. J. A. Dozois, and D. D. Burns, “Gaps in accessing treatment for anxiety and depression: Challenges for the delivery of care,” Clinical Psychology Review, vol. 24, no. 5, pp. 583–616, 2004. View at Publisher · View at Google Scholar · View at Scopus
  47. M. C. Angermeyer, H. Matschinger, and S. G. Riedel-Heller, “What to do about mental disorder help - Seeking recommendations of the lay public,” Acta Psychiatrica Scandinavica, vol. 103, no. 3, pp. 220–225, 2001. View at Publisher · View at Google Scholar · View at Scopus
  48. J. Alonso et al., Treatment gap for anxiety disorders is global: Results of the WorldMental Health Surveys in 21 countries Depress Anxiety, 2018.
  49. T. Roberts, G. Miguel Esponda, D. Krupchanka, R. Shidhaye, V. Patel, and S. Rathod, “Factors associated with health service utilisation for common mental disorders: a systematic review,” BMC Psychiatry, vol. 18, no. 1, 2018. View at Publisher · View at Google Scholar
  50. S. Evans-Lacko, S. Aguilar-Gaxiola, A. Al-Hamzawi et al., “Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys,” Psychological Medicine, vol. 48, no. 09, pp. 1560–1571, 2018. View at Publisher · View at Google Scholar
  51. Anna Wallerblad, Jette Möller, and Yvonne Forsell, “Care-Seeking Pattern among Persons with Depression and Anxiety: A Population-Based Study in Sweden,” Journal of Family Medicine and Primary Care, vol. 2012, Article ID 895425, 9 pages, 2012. View at Publisher · View at Google Scholar
  52. R. Kohn, S. Saxena, I. Levav, and B. Saraceno, “The treatment gap in mental health care,” Bulletin of the World Health Organization, vol. 82, no. 11, pp. 858–866, 2004. View at Google Scholar · View at Scopus
  53. M. U. Pérez-Zepeda, V. E. Arango-Lopera, F. A. Wagner et al., “Factors associated with help-seeking behaviors in Mexican older individuals with depressive symptoms: A cross-sectional study,” International Journal of Geriatric Psychiatry, vol. 28, no. 12, pp. 1260–1269, 2013. View at Publisher · View at Google Scholar · View at Scopus
  54. M. Modabernia, H. Tehrani, M. Fallahi, M. Shirazi, and A. Modabbernia, “Prevalence of depressive disorders in Rasht, Iran: A community based study,” Clinical Practice and Epidemiology in Mental Health, vol. 4, no. 1, p. 20, 2008. View at Publisher · View at Google Scholar
  55. S. Shi, Z. Lu, and S. Zhu, “Seeking behavior of patients with mental disorders and interfering factors,” Zhonghua Yi Xue Za Zhi, vol. 80, no. 1, pp. 75–78, 2000. View at Google Scholar · View at Scopus
  56. J. Fuller, J. Edwards, N. Procter, and J. Moss, “How definition of mental health problems can influence help seeking in rural and remote communities,” Australian Journal of Rural Health, vol. 8, no. 3, pp. 148–153, 2000. View at Publisher · View at Google Scholar · View at Scopus
  57. J. A. Sirey, “The impact of psychosocial factors on experience of illness and mental health service use,” The American Journal of Geriatric Psychiatry, vol. 16, no. 9, pp. 703–705, 2008. View at Publisher · View at Google Scholar · View at Scopus
  58. M. Ten Have, R. De Graaf, J. Ormel, G. Vilagut, V. Kovess, and J. Alonso, “Are attitudes towards mental health help-seeking associated with service use? Results from the European study of epidemiology of mental disorders,” Social Psychiatry and Psychiatric Epidemiology, vol. 45, no. 2, pp. 153–163, 2010. View at Publisher · View at Google Scholar · View at Scopus
  59. S. Teferra and T. Shibre, “Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study,” BMC Psychiatry, vol. 12, article 79, 2012. View at Publisher · View at Google Scholar · View at Scopus
  60. M. S. Mulatu, “Perceptions of mental and physical illnesses in north-western Ethiopia: Causes, treatments, and attitudes,” Journal of Health Psychology, vol. 4, no. 4, pp. 531–549, 1999. View at Publisher · View at Google Scholar · View at Scopus
  61. E. Girma and M. Tesfaye, “Patterns of treatment seeking behavior for mental illnesses in Southwest Ethiopia: a hospital based study,” BMC Psychiatry, vol. 11, no. 1, article 138, 2011. View at Publisher · View at Google Scholar · View at Scopus
  62. Y. Y. Bekele, A. J. Flisher, A. Alem, and Y. Baheretebeb, “Pathways to psychiatric care in Ethiopia,” Psychological Medicine, vol. 39, no. 3, pp. 475–483, 2009. View at Publisher · View at Google Scholar · View at Scopus
  63. A. Alem, L. Jacobsson, M. Araya, D. Kebede, and G. Kullgren, “How are mental disorders seen and where is help sought in a rural ethiopian community? A key informant study in Butajira, Ethiopia,” Acta Psychiatrica Scandinavica, Supplement, vol. 99, no. 397, pp. 40–47, 1999. View at Publisher · View at Google Scholar · View at Scopus
  64. M.-B. Dagnew, “Pattern of health care utilisation in a small rural Ethiopian town,” Ethiopian Medical Journal, vol. 22, no. 4, pp. 173–177, 1984. View at Google Scholar · View at Scopus
  65. A. Sathiyasusuman, “Mental health services in Ethiopia: Emerging public health issue,” Public Health, vol. 125, no. 10, pp. 714–716, 2011. View at Publisher · View at Google Scholar · View at Scopus
  66. Singhe LGSaMS, “Mental Illness: Global African and Ethiopian Perspectives,” EC Psychology and Psychiatry, vol. 3, no. 4, pp. 107–110.
  67. T. Shibre, A. Spångéus, L. Henriksson, A. Negash, and L. Jacobsson, “Traditional treatment of mental disorders in rural Ethiopia.,” Ethiopian Medical Journal, vol. 46, no. 1, pp. 87–91, 2008. View at Google Scholar · View at Scopus
  68. M. Hailemariam, A. Fekadu, M. Prince, and C. Hanlon, “Engaging and staying engaged: a phenomenological study of barriers to equitable access to mental healthcare for people with severe mental disorders in a rural African setting,” International Journal for Equity in Health, vol. 16, no. 1, 2017. View at Publisher · View at Google Scholar
  69. F. Addisu, M. Wondafrash, Z. Chemali, T. Dejene, and M. Tesfaye, “Length of stay of psychiatric admissions in a general hospital in Ethiopia: A retrospective study,” International Journal of Mental Health Systems, vol. 9, no. 1, 2015. View at Google Scholar · View at Scopus
  70. K. A. Johansson, K. B. Strand, A. Fekadu, and D. Chisholm, “Health Gains and Financial Protection Provided by the Ethiopian Mental Health Strategy: An Extended Cost-Effectiveness Analysis,” Health Policy and Planning, vol. 32, no. 3, pp. 376–383, 2017. View at Publisher · View at Google Scholar · View at Scopus
  71. D. Moher, L. Shamseer, and M. Clarke, “Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement,” Systematic Reviews, vol. 4, no. 1, article 1, 2015. View at Publisher · View at Google Scholar
  72. C. S. Berkey, D. C. Hoaglin, F. Mosteller, and G. A. Colditz, “A random-effects regression model for meta-analysis,” Statistics in Medicine, vol. 14, no. 4, pp. 395–411, 1995. View at Publisher · View at Google Scholar · View at Scopus
  73. J. P. T. Higgins and S. G. Thompson, “Quantifying heterogeneity in a meta-analysis,” Statistics in Medicine, vol. 21, no. 11, pp. 1539–1558, 2002. View at Publisher · View at Google Scholar · View at Scopus
  74. J. L. Y. Liu, “The role of the funnel plot in detecting publication and related biases in meta-analysis,” Evidence-based dentistry, vol. 12, no. 4, pp. 121-122, 2011. View at Publisher · View at Google Scholar · View at Scopus
  75. M. Egger, G. D. Smith, M. Schneider, and C. Minder, “Bias in meta-analysis detected by a simple, graphical test,” British Medical Journal, vol. 315, pp. 629–634, 1997. View at Publisher · View at Google Scholar · View at Scopus
  76. S. Duval and R. Tweedie, “Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis,” Biometrics, vol. 56, no. 2, pp. 455–463, 2000. View at Publisher · View at Google Scholar · View at Scopus
  77. R. C. Kessler, S. Aguilar-Gaxiola, J. Alonso et al., “The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys,” Epidemiologia e Psichiatria Sociale, vol. 18, no. 1, pp. 23–33, 2009. View at Publisher · View at Google Scholar · View at Scopus
  78. A. Al-Krenawi and J. R. Graham, “Tackling mental illness: Roles for old and new disciplines,” World Health Forum, vol. 17, no. 3, pp. 246–248, 1996. View at Google Scholar · View at Scopus
  79. A. J. Ferrari, A. J. Somerville, A. J. Baxter et al., “Global variation in the prevalence and incidence of major depressive disorder: A systematic review of the epidemiological literature,” Psychological Medicine, vol. 43, no. 3, pp. 471–481, 2013. View at Publisher · View at Google Scholar · View at Scopus
  80. Y. Grace, W. W. T. Lim1, Y. Lu, S. Cyrus, W. Melvyn et al., “Prevalence of Depression in the Community from 30 Countries between 1994 and 2014,” Scientific Reports, vol. 8, p. 2861, 2018. View at Google Scholar
  81. M. A. Prins, P. F. M. Verhaak, J. M. Bensing, and K. van der Meer, “Health beliefs and perceived need for mental health care of anxiety and depression-The patients' perspective explored,” Clinical Psychology Review, vol. 28, no. 6, pp. 1038–1058, 2008. View at Publisher · View at Google Scholar · View at Scopus
  82. M. C. Angermeyer, S. van der Auwera, M. G. Carta, and G. Schomerus, “Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta-analysis of population surveys,” World Psychiatry, vol. 16, no. 1, pp. 50–61, 2017. View at Publisher · View at Google Scholar · View at Scopus
  83. R. Kobau, Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration, National Association of County Behavioral Health & Developmental Disability Directors, National Institute of Mental Health, The Carter Center Mental Health Program, Attitudes Toward Mental Illness: Results from the Behavioral Risk Factor Surveillance System. Atlanta (GA); Centers for Disease Control and Prevention, 2012.
  84. K. Bristow and S. Patten, “Treatment-seeking rates and associated mediating factors among individuals with depression,” The Canadian Journal of Psychiatry, vol. 47, no. 7, pp. 660–665, 2002. View at Publisher · View at Google Scholar · View at Scopus
  85. O. Atilola, “Level of community mental health literacy in sub-Saharan Africa: current studies are limited in number, scope, spread, and cognizance of cultural nuances,” Nordic Journal of Psychiatry, vol. 69, no. 2, pp. 93–101, 2015. View at Publisher · View at Google Scholar · View at Scopus
  86. J. K. Burns and A. Tomita, “Traditional and religious healers in the pathway to care for people with mental disorders in Africa: a systematic review and meta-analysis,” Social Psychiatry and Psychiatric Epidemiology, vol. 50, no. 6, pp. 867–877, 2015. View at Publisher · View at Google Scholar · View at Scopus