Explanatory models of depression in sub-Saharan Africa: Synthesis of qualitative evidence.

Debate about the cross-cultural relevance of depression has been central to cross-cultural psychiatry and global mental health. Although there is now a wealth of evidence pertaining to symptoms across different cultural settings, the role of the health system in addressing these problems remains contentious. Depression is undetected among people attending health facilities. We carried out a thematic synthesis of qualitative evidence published in the scientific literature from sub-Saharan Africa to understand how depression is debated, deployed and described. No date limits were set for inclusion of articles. Our results included 23 studies carried out in communities, among people living with HIV, attendees of primary healthcare and with healthcare workers and traditional healers. Included studies were carried out between 1995 and 2018. In most cases, depression was differentiated from 'madness' and seen to have its roots in social adversity, predominantly economic and relationship problems, sometimes entangled with HIV. Participants described the alienation that resulted from depression and a range of self-help and community resources utilised to combat this isolation. Both spiritual and biomedical causes, and treatment, were considered when symptoms were very severe and/or other possibilities had been considered and discarded. Context shaped narratives: people already engaged with the health system for another illness such as HIV were more likely to describe their depression in biomedical terms. Resolution of depression focussed upon remaking the life world, bringing the individual back to familiar rhythms, whether this was through the mechanism of encouraging socialisation, prayer, spiritual healing or biomedical treatment. Our findings suggest that it is essential that practitioners and researchers are fluent in local conceptualisations and aware of local resources to address depression. Design of interventions offered within the health system that are attuned to this are likely to be welcomed as an option among other resources available to people living with depression.

"When someone becomes old then every part of the body too becomes old": Experiences of living with dementia in Kintampo, rural Ghana.

Studies have suggested that in African countries, symptoms of cognitive decline are commonly seen as part of "normal ageing" or attributed to supernatural causes. The impact of folk beliefs about causality upon help-seeking is unclear. Likewise, there is a lack of evidence relating to how families cope with living with an older resident with dementia. Our study's aim was to explore the sociocultural beliefs, understandings, perceptions and behaviours relating to living with dementia in Kintampo, Ghana. We conducted in-depth interviews with a total of 28 people, using a series of case studies among 10 older people living with dementia and their families. Results revealed that symptoms of cognitive impairment were generally linked to inexorable bodily decline understood to be characteristic of "normal" ageing. Stigma was therefore perceived to be non-existent. Whilst managing the costs of care was often a challenge, care-giving was largely accepted as a filial duty, commonly shared among female residents of large compound households. Families experimented with biomedical and traditional medicine for chronic conditions they perceived to be treatable. Our findings suggest that whilst families offer a holistic approach to the needs of older people living with chronic conditions including dementia, health and social policies offer inadequate scaffolding to support this work. In the future, it will be important to develop policy frameworks that acknowledge the continued social and economic potential of older people and strengthen the existing approach of families, optimising the management of non-communicable diseases within primary care.