Discussion
We found only a limited number of published studies on the prevalence of psychiatric disorders in Bangladesh. Overall prevalence varied from 6.5 to 31% among adults and from 13.4 to 22.9% among children. Despite wide ranges in prevalence estimates reported, these figures strongly suggest that mental disorders constitute a big public health problem in Bangladesh.
It is worthwhile to mention some of the limitations of the review. Data from the selected articles are not comparable due to differences in settings (clinic- vs. community-based), different assessment tools and the different thresholds used to determine the psychiatric disorders. Therefore the various prevalence estimates available could not be used properly to assess the trend over time. Our review may have been subject to publication and selection bias as we were unable to contact the experts and collect unpublished materials or access any grey literature.
In general, the prevalence estimates of psychiatric disorders are prone to underestimation as majority of patients and their families deny due to strong stigma attached to mental disorders. This limits the number of affected patients seeking health care actively [
43].
The prevalence reported by Islam et al. [
16] might have underestimated due to focusing on only the major types of psychiatric disorders. There is wide variation between rural communities and also between rural and urban settings [
15],[
18]. The prevalence reported in an urban overcrowded community was much higher as the study included older people who are more prone to mental disorders [
16]. This review suggests both rural [
15] and urban [
13] settings a higher vulnerability of mental disorders among females as compared to males. There is a significantly higher prevalence of mental disorders among economically poor respondents, and specifically among women from large families as reported by Hosain et al. [
18]. These findings are consistent with another rural study [
19] which reported that social stigma inhibits women from seeking medical treatment for their mental problems. Despite considerable variations in the design of studies, prevalence of psychiatric disorders in adult population is more or less similar to socio-culturally similar settings in neighboring India [
46] and Pakistan [
47].
The only national survey conducted between 2003 and 2005 illustrated the high burden of mental disorders in Bangladesh [
12]. As there is no similar nationally representative mental health survey carried out in recent time, it is not possible to assess the change and to estimate overall need for resources to address the mental health burden. In general, tools for screening and cut-off values used in the reported studies contributed to the variation in the prevalence reported in different articles. However, the problems of underreporting and under-diagnosis of mental disorders are major challenges for the future of psychiatric epidemiology in Bangladesh.
As evident from this review, data on mental disorders among children in Bangladesh are quite scanty. Moreover, the comparison of prevalence studies of childhood psychiatric disorders is challenging due to the heterogeneous nature of samples, screening and diagnostic tools used, and methods of combining information in addition to differences in age distributions which requires standardization for fair comparison. The overall prevalence of psychiatric disorders in a community study by Mullick & Goodman [
23] did not differ much with the findings of study by Rabbani et al. [
11]. As there are only a handful of child mental health professionals with specialized training in Bangladesh, the vast gap between actual need and available services requires special and immediate attention [
23]. Research in socially disadvantaged and underprivileged groups is also needed to improve the diagnosis, treatment and outcomes in those vulnerable groups [
21]. Childhood psychiatric disorders were significantly associated with malnutrition [
24], rural residence, low education of fathers, and positive family history [
11] which all need a multi-sectorial approach to address these neglected areas. The children mental health survey [
11] results provided a baseline measure and resources which can be a basis for taking initiatives for further prevalence study as well as creating provision for effective service delivery models.
The interaction between mental disorder and chronic diseases is complex, yet risks and causalities are well-established [
48]. Mental disorder may increase the risk for chronic disorders and many chronic disorders can increase an individual’s risk for developing mental disorders, thereby complicating help-seeking, diagnosis, management and prognosis [
49].
Current epidemiological evidence suggested at least one third of people with diabetes are suffering from depressive disorders [
50],[
51]. Although in this review we found four articles [
26],[
30],[
32],[
33] which reported similarly high prevalence of depression among diabetics. It is reported that more than half of the cancer patients suffer from depression [
27],[
28] which is conceivable given the severity and progressive nature of the disease, high cost and lack of adequate care facilities available. Limited data from South Asian settings reported two- to fivefold increase in the prevalence rates of depression in people with diabetes compared to people without diabetes [
52]–[
54]. Depressions intensify symptom presentation and interfere with the physical treatment [
27]. Psychiatric morbidity is considerable among the cancer patients that need to be addressed with additional treatment and support [
28]. These findings suggest a need for further rigorous study of chronic diseases and mental health for optimizing treatment of both conditions using sound methodologies as well as validated screening and diagnostic tools.
This review confirms inadequate care seeking as well as poor service delivery for mental health disorders. Referrals of patient with mental disorders to mental health specialists by the general practitioners or other health care providers are almost non-existent. The referral is also hampered due to superstitious beliefs related to psychiatric disorders. These are seen as triggered by evil influences while this leads to seeking remedies from traditional healers. These potentially harmful practices can be minimized through mass awareness [
34],[
39] and development and implementation of mental health guidelines. This also can be influenced through raising individual level awareness and social mobilization [
55]. Denial mental health problems is common among the general population as they perceive these conditions as untreatable. Additional constraint is imposed by lack adequately trained general practitioners and health workers at primary care level. There are no structured and organized mental health services available at primary and even at secondary health care level. Although women are more often sufferers and also more vulnerable to develop psychiatric disorders, they are more neglected than males in receiving care. This is more likely the result of a male-dominated culture in Bangladesh [
38]. Therefore, the access to mental health services need to be made more accessible by the women at all levels of mental health care service delivery [
42]. Although Bangladesh has formally a well-structured three tier health care delivery system [
56], due to dearth of mental health professionals and poor logistic support, this existing system is not functioning well for mental health conditions [
57].
Management of psychotic depression requires treatment from psychiatrists who are mainly available in the tertiary care hospitals in major cities [
40]. Primary care services lack adequately trained personnel to identify and treat depression as a single condition or in association with particular chronic disorders. Although training and services to address psychiatric conditions are gradually increasing, vast majority of mental health patients yet to get the benefit of such initiatives as they have limited access [
45],[
57]. Most of the psychotropic medications are available in Bangladesh yet psychotherapy is hardly available. Bangladesh lacks a mental health act although a draft bill is in the final stage but is yet to be approved by the authorities.
Acknowledgements
We gratefully acknowledge the contribution of Muhammad Ashique H. Chowdhury, Ali Tanweer Siddiquee, Shyfuddin Ahmed, Sonia Pervin, Sholeh Rahman and Mohammad Tauhidul Islam on behalf of the Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) for their comments and valuable suggestions on the initial draft. We thank Avra Das Bhowmik and Faruk Alam from National Institute of Mental Health (NIMH), Dhaka, Bangladesh for their insightful comments. This work did not require any additional funding. DA and MH are supported by icddr,b which acknowledges with gratitude the commitment of the Centre’s donors for their generous support to its research efforts.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MH participated in the conception, design, coordination, acquisition of literature, analysis and interpretation of data, and drafting/revising the manuscript. HA participated in the acquisition of data and manuscript drafting and revisions. WC and LN participated in the conception, design and drafting. DA conceived the study, guided drafting, and substantially contributed to the design, acquisition of literature, analysis and interpretation of data, and revised the draft critically for important intellectual contents. All authors read and approved the final manuscript.