Negative consequences for the treatment of depression
By Felipe Fregni
Brazilians are seen as warm and friendly people with large social networks. Although these factors often protect against major depression, local studies show that Brazilians get depressed as much as those in other countries.
Indeed, sometimes the rate of depression is higher. Researcher C. M. Vorcaro and colleagues, for instance, tell us about a study of 15,000 people in a community in Brazil that yielded some surprising results. These Brazilians showed a higher rate of depression than that observed in similar studies in developed and developing countries: one out of every ten people were depressed over the course of a year, and 15.6 percent of the people in this community were depressed over the course of their lives. That is far from the stereotype of the happy, go-lucky Brazilian.
Socio-economic status explains much about why Brazilians are experiencing so much depression. When people don’t have enough to eat or can’t provide for their family, they tend to get depressed. Low socio-economic status (SES) is associated with an increased prevalence of psychiatric disorders, such as major depression, V. Lorant and other researchers have found. Poor people often don’t know how to cope and have frequent tragedies known in the field as ongoing life events. They are constantly stressed and often have weaker social support. All these factors might explain their increased risk of depression. In addition, a recent study showed that patients from low-income neighborhoods are less likely to respond to antidepressant treatment (Cohen, A., et al., "Social inequalities in response to antidepressant treatment in older adults."Arch Gen Psychiatry, 2006).
In a population-based 2004 study conducted in Brazil with 2302 individuals; the scientist Almeida-Filho and colleagues observed a relationship between major depression and social class. Upper and middle class people were depressed less often than the working class and poor. Although Brazil is the eighth largest economy in the world, it has one of the worst income distributions. These statistics help to explain why Brazilians get depressed. A recent study from IPEA (Instituto de Pesquisa Econômica Aplicada—Institute of Applied Economic Research) showed that the Gini index in Brazil is 0.60. The Gini index measures equality: a Gini index of 0 represents perfect economic equality, and 1 perfect inequality. Brazil ranks 148 in a list of 150 countries, only ahead of Swaziland (0.61) and Sierra Leone (0.63).
In this scenario, mental health care is critical in Brazil. However, at the present time, lower income populations that suffer the most from depression receive less mental health care, compared to the more privileged population. This phenomenon has been described as “inverse care law.” Although globalization has improved mental health care in several aspects, it might, at the same time, be worsening mental health care for the poor. There are four main reasons: (1) inadequate psychiatric training – not suitable for local conditions; (2) increase in global health care expenditures that takes resources from mental health care; (3) lack of clinical research in mental health care in Brazil and (4) lack of drug development in Brazil.
THE PHENOMENON OF GLOBALIZATION
Globalization is the global movement characterized by an increase in the movement of commodities, money, information, and people. Since the end of World War II, this spiralling movement has been catalyzed by technological developments and new economic theories. Indeed, the development of technology, organizations, legal systems and infrastructure is responsible for sustaining this movement.
The consequences of this phenomenon in medicine are significant. With globalization, medical practices moved fast across borders creating a change in the practices of several countries, including developing countries. This phenomenon of medical knowledge transference is particularly accentuated in the direction from the developed to developing world because of the intensive volume of medical research, scientific production and also the entrepreneurship of several institutions in developed countries.
While globalization is a new trend that has intensified in the last half century, this transfer of information from developed to developing world is not new and indeed has improved public health in developing countries. For instance, most vaccines were initially developed in industrial countries and then taken to developing countries. Thus, common infectious diseases like smallpox were wiped out or, like polio, dramatically reduced. However, globalization has brought not only beneficial, but also collateral, effects.
INADEQUATE PSYCHIATRIC TRAINING
One important concern is that psychiatrists in Brazil are being trained to treat patients in Europe and United States as most of information—from textbooks to journal papers—comes from these countries. But what is the problem of training psychiatrists using the U.S. and European mental health care standards as these are highly efficient medical systems? The main issue here is not having this training but not having an alternative training tailored to the socio-economic conditions of Brazil. Young psychiatrists want to learn how to treat depression using newer antidepressants such as venlafaxine and reboxetine that cost 30 times more than the old antidepressants, such as amytriptline and imipramine. This issue is aggravated in large urban areas as these young psychiatrists aim to work in the private system, therefore, treating wealthier patients.
If newer antidepressants were better than old antidepressants, then there would be no reason in training psychiatrists to use old drugs. However, this is not the case. In a study of 116 patients published in the Journal of Psychopharmachology, the clinical scientist E. Benedictis showed that venlafaxine and amytripline have similar efficacy in reducing depressive symptoms. In a 1997 study conducted by a researcher of University of Vienna (S. Kasper) also found that old antidepressants (tricyclics antidepressants) are as effective as newer drugs.
I am not proposing that psychiatrists in Brazil should be trained using inferior standards; on the contrary, the goal is to use the most efficacious and adequate treatments for the conditions in Brazil. As shown by the studies above, old antidepressants can be as effective as newer antidepressants; therefore, these old drugs need to be included and mandatory in the psychiatric training. This is especially important as physicians are more likely to prescribe and use drugs with which they have experience.
Another example is the use of cognitive behavior therapy for the treatment of depression. A review article published in the renowned journal American Journal of Psychiatry by a group of Canadians researcher led by Dr. Casacalenda showed that the percentages of symptoms remission for patients that received medication, psychotherapy and control treatments were 46.4%, 46.3% and 24.4% respectively. Because cognitive behavior therapy only depends on the training of psychotherapists and cost of labor in Brazil is less expensive than in developed countries, this might be a more cost-effective alternative to be used in Brazil. Therefore, further policies in mental health care should give incentives to the training of mental health workers in these alternative therapeutic approaches.
INCREASE IN HEALTH CARE EXPENDITURES
Health care costs have been rising globally for several years. In the United States, for instance, expenditures in health care more than doubled between 1990 and 2003 (from $696 billion in 1990 to $1.7 trillion in 2003). This increase was less pronounced in Brazil. Nevertheless, in 10 years, this increase was almost 50 percent. In part, the development of new technologies and new treatments accounts for increased health care expenditures. . Therefore, politicians—confronted with higher health care expenditures without greater resources—end up cutting the budget in some areas such as mental health care.
The cost of new drugs is a major factor for the sharp and constant increase in health care expenditures. Pharmaceutical companies, confronted with the expiration of drug patents, create new compounds similar to old ones in order to get a new patent and charge more for the new drug. In an editorial in the Canadian Medical Association Journal, Marcia Angell, the former editor in chief of New England Journal of Medicine (the most influential journal in clinical medicine), states that “the main output of the big drug companies is ‘me-too’ drugs”—minor variations of highly profitable drugs already on the market. This problem is frequently observed with antidepressants as they represent one of the largest markets for the pharmaceutical industry.
LACK OF CLINICAL RESEARCH IN BRAZIL
One of the consequences of globalization of medicine is that standard medical care might not be adequate for certain areas. In the case of Brazil, as I discussed above, use of old antidepressants and other treatments such as cognitive behavior therapy should be intensified. But in order to change current practices and policy, clinical research is necessary.
As in other areas, there is a chronic lack of research in mental health in Brazil. Although some progress has been made in the past years, much remains to be done. One problem is the lack of a health research agenda in Brazil. Research conducted in Brazil does not necessarily address national health priorities because research grants are based only on scientific merits. Researchers usually choose topics likely to be published internationally, such as clinical trials involving newer and more expensive drugs. Information generated from this research does not benefit the poor in Brazil.
Therefore, there is a critical need for more data on mental health in Brazil. Although the number of epidemiological studies has increased in the last years, the number of randomized clinical trials investigating new alternatives of treatment and interventions is extremely low. Finally, few Brazilian journals are indexed in international and national databases, thus, decreasing the proliferation of this information within Brazil.
LACK OF DRUG DEVELOPMENT IN BRAZIL
Drug development is also underdeveloped in Brazil, an increasing trend due to international expansion of the big pharmaceutical companies. The companies invest large amounts of money in marketing; therefore it is extremely difficult to compete with them. In addition, in order to a company to be successful in the drug development business, it needs to aim at international markets; hindering drug development in Brazil.
Thus, drugs more adequate to the conditions in Brazil are not developed. In addition, this deficiency has a direct negative impact on clinical research in Brazil. Therefore governmental incentives and new policies in this area are necessary to develop this sector.
Globalization in medicine is responsible for several advances in medicine in developing nations as well as in fostering the development of novel therapeutic approaches. However, it is also responsible in increasing inequalities in health care in developing countries. New policies in mental health care in Brazil are critical to improve mental health care in Brazil. Hopefully, in the future, the stereotype of the happy Brazilian might become a reality, and depression in Brazil, for the most part, the memory of a less equitable past.
Felipe Fregni is an Instructor in Neurology at Harvard Medical School; Director of the Center for Noninvasive Brain Stimulation at Beth Israel Deaconess Medical Center and a Lemann Fellow in Public Health of the David Rockefeller Center for Latin America Studies. A version of this article with references can be found athttp:/drclas.fas.harvard.edu/publications