Introduction

Depression is one of the most common mental health disorders (MHD) worldwide. Globally more than 264 million people of all ages suffer from depression and around 800,000 commit suicides (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators 2018). Mental health disorders is a growing public health issue in the Asia Pacific region, especially in low- and middle-income countries (Samy et al. 2015). Major depression is a serious form of depression prevailing in 1.1% to 19.9% of individuals across Asia Pacific (Chiu et al. 2004).  According to the United Nations Sustainable Development Goal Target 3.4, member countries pledged to reduce premature mortality from noncommunicable diseases (NCDs) by one-third through prevention, treatment and promotion of mental health and well-being by 2030 (WHO 2016). Approximately 22.1% of the world population is affected by MHDs such as depression, anxiety, post-traumatic stress disorder, bipolar disorder and schizophrenia (Charlson et al. 2019). The Malaysian National Health and Morbidity Survey conducted in 2019 revealed that 2.3% of Malaysian citizens had depression. As per the WHO report on preventing suicides, Malaysia reported a suicide rate of 3/100,000 population (WHO 2019).

The involvement of private, corporate, and other stakeholders in mental health services besides the Ministry of Health is minimal. The main barriers to collaboration were lack of autonomy, relatedness, motivation, resources and reciprocation (Shoesmith et al. 2020). 

Stigma regarding mental health adversely affects rates of presentation to psychiatrists or non-psychiatrist healthcare providers in both primary and secondary care settings for screening, diagnosis, referral and treatment of depression, anxiety, and other comorbid MHDs (Ibrahim et al. 2019; Hanafiah et al. 2015a; Rugema et al. 2015). This semi systematic review provides valuable information to form a base for a full systematic review.

The objective of the present study was to review publications related to mental health, quantifying patients in different stages of their journey for depression. The approach adopted for this review was based on the methodology called Mapping the Patient Journey Towards Actionable Beyond the Pill Solutions for Non-communicable Diseases (MAPS) published earlier (Bharatan et al. 2021). The unique feature of the MAPS approach was the consultative engagement with the national subject matter experts, who validated the included articles for local relevance, supplemented additional articles for presenting the current and accurate state of depression management in the country, and substituted data based on local practice scenario where no data was available for any particular patient journey stage.

This approach helped to assess the influence of depression literacy, mental health beliefs and stigma on help-seeking behaviour in the Malaysian context and to find out the barriers and drivers in the care pathway to form the basis for further interventions. The study aimed to focus on an insightful discussion around mental health in Malaysia, so it becomes a health priority for the nation, prompting further actions and steps at a national level. This review focuses on stigma and beliefs, specifically related to depression out of many MHDs. This can help in making interventions more efficient for patients with mental health issues.

Materials and Methods

Depression was defined as the presence of 5 or more symptoms in the last two weeks with at least one of the symptoms being either depressed mood or the loss of interest or pleasure according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 (American Psychiatry Association 2022). Depression literacy implies knowledge about depression in the context of its epidemiology, aetiology, symptomatology, treatment and prognosis (Nguyen Thai & Nguyen 2018). It is a necessary ingredient to make people aware so as they can avail various mental health services. Mental health beliefs stand for the beliefs of the people regarding MHDs. Stigma was described as disapproval of, or discrimination against, a person in the form of and not limited to labelling, rejection, social exclusion and in employment, based on traits that serve to distinguish them from other members of a society (Major & O’brien 2005; Hanafiah et al. 2015b). Stigma adversely affects help-seeking behaviour among people with common MHDs and becomes a barrier in receiving effective care including for other comorbid physical illnesses. Eventually, this affects the quality of life for people with MHDs. Methods of conducting the review and eligibility criteria were documented in advance (Bharatan et al. 2021).

Search Strategy

Articles related to awareness, screening, diagnosis, treatment, adherence, control, health literacy and prevalence in Malaysia in the context of depression were primarily sought through a structured systematic search using MeSH terms on Embase, MEDLINE, and BIOSIS databases through the OVID platform, to ensure maximum retrieval for published literature for the topic at hand. An unstructured search was conducted on Google, Incidence and Prevalence Database (IPD), World Health Organisation and Malaysian Ministry of Health's websites, to collect evidence from non-peer-reviewed sources. The last search was run on the  24th July 2021. To address any gap in the availability of data, anecdotal data was provided by the national subject matter experts based on their clinical practice experiences.

Search Terms

We searched the following subject matter terms in our search strategy which included “Depression, Major depressive disorder, Persistent depressive disorder, Depressive disorder, Major depression, Mental health, Mental disorder, Mood disorder, MDD". The factors  related to the study analysis were knowledge, *diagnos* adheren*, complian*, *control* and Malay*.

Selection Criteria

Studies quantifying patients in different stages of their journey for depression were selected for the review. Studies related to mental health conducted in Malaysia were reviewed. All articles published in English were included except thesis abstracts, letters to the editor and editorials. Any study design including cohort, case-control, cross-sectional, observational studies, randomised controlled trials, systematic review, and meta-analysis, except case studies was included. Among the structured search results, studies published between 1st January 2005 and 24th July 2021 were selected to provide a balance between availability, currency, and relevance of data, whereas, in the unstructured search, articles were selected irrespective of the year of publication. Thesis abstracts, letters to the editor, editorials, case studies or articles representing smaller population subgroups were excluded in the analysis. Studies not focusing on depression and related only as an outcome, risk factor, context or comparator were also excluded. Duplicate records retrieved due to multiple keyword searches were excluded from the review. Data gaps were identified and supplemented with studies published in local languages and/or anecdotal data provided by local experts, who were the leading national health specialists from Malaysia.

Study Selection 

Eligibility assessment of titles and abstracts based on inclusion/exclusion criteria was done by an independent reviewer. Full papers were screened by another independent reviewer for  articles that fulfilled these criteria but could not be screened due to limited information available in the title and abstract. Disagreements were resolved by a discussion between the two reviewers. If an agreement was not achieved between two reviewers, a third reviewer recommended the final decision. The recommendation of the third reviewer was further discussed between all 3 reviewers to finalise the paper selection. The inclusion of the study was influenced by the outcome of the discussion. 

Data Extraction 

The first independent reviewer extracted data from the studies and validated it by the national subject matter experts to ensure consistency with real-world insights and expert opinion. Criteria of the selected publications for the semi-systematic review include availability of abstract, author name, year of publication, language, and type of article and study characteristics related to the population studied. Following this step, the stage of the patient journey, design of the study, outcomes measured, barriers identified, factors associated with negative help-seeking, and interventions suggested if any, were extracted from the included studies.

Statistical Analysis and Quality Assessment

Data from the included studies were pooled. Patient journey stages were estimated from the pooled data using weighted means. Joanna Briggs Institute’s critical appraisal tool for prevalence studies was used to assess the quality of the included articles (Munn et al. 2015; Joanna Briggs Institute 2020) (Table 1). 

Results 

Eligibility of Studies for Inclusion in the Review

There was a paucity of data on patient journey stages in the published studies. After screening 979 articles out of 1062 retrievals from the structured search and four articles from the unstructured search, five articles were eligible for inclusion in the review and final synthesis, including three articles from the structured search and two from the unstructured search (NHMS 2020; Khan et al. 2010; Jammy Suzana et al. 2005; Mathialagan et al. 2012; Zainal et al. 2019). The flow of studies through the review is depicted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram (Figure 1). The selection of the papers included in the analysis was accepted by all the reviewers. 

The year of publication of the included studies ranged from 2005 to 24th July 2021. Four research articles and one report were included in the final synthesis. Two studies depicted quantitative data for the prevalence of depression, one for awareness, two for treatment, and one for control. No study depicted quantification of screening, diagnosis, and adherence. Findings extracted from individual studies and the results of the quality assessment are tabulated in Table 1. 

Pooled Estimates of Patient Journey Stages

The prevalence of the major depressive disease is estimated by the review to be 2.3%. Initial screening, diagnosis and adherence were low despite high awareness (76.9%) and high initiation of treatment (75.3%). Overall control (82.7%) was good for depression. The summary estimation of the patient journey stages is provided in Table 2.

Barriers, Factors and Drivers of Positive Help-Seeking Behavior for Depression in Malaysia and Role of Primary Care Physicians (PCPs) in Mental Health Services

It was reported in the studies that stigma due to social and educational issues were the major obstacle in mental health help-seeking (Khan et al. 2010). Negative attitudes and bad perceptions of a community towards MHDs increased stigma and severely affected the help-seeking behaviour of the patients. Poor health literacy led to poor decision making regarding mental health (Khan et al 2010). The major cause of depression, as reported in the studies was a failure in achieving a personal goal (Khan et al. 2010). Most believed in availing alternative, religious and traditional healing instead of evidence-based mental healthcare (Hanafiah et al. 2015a; Rugema et al. 2015). Those who were willing to seek help for mental health preferred PCPs over psychiatrists (Khan et al. 2010). 

Similar opportunistic screenings are not done for common MHDs, especially depression (Carbonell et al. 2020; Norman & Fitter 1991).  In a larger perspective, mental health screening has not been given sufficient priority in the country. Under-diagnosis by PCPs led to ineffective mental health care and made specialised care further inaccessible (Jammy Suzana et al. 2005). Moreover, PCPs prescribed older drugs with greater adverse effects, which led to tolerability issues, increased health expenditure burden, and eventually resulted in poor adherence (Mathialagan et al. 2012). A perceived need was identified for training PCPs in specialised mental healthcare to improve their clinical skills and attitudes towards patients with MHDs, especially depressive disorders (Jammy Suzana et al. 2005). A trained healthcare provider can also educate the patients to improve adherence to the treatment.

Discussion

Recent years have seen a rise in awareness towards mental health in Malaysia due to activities conducted across the country through television programmes or radio interviews. Yet there is a lack of awareness regarding the availability of services and many people delay accessing mental health services and treatment, which leads to a poor prognosis of MHDs. Once a person becomes aware of the information related to mental health, he or she could progress towards MHD literacy. Low depression literacy and misbeliefs in MHDs can lead to stigma and act as a barrier in seeking help and getting effective care, which leaves patients deprived of specialised mental health services, resulting in poor quality of life and unemployment (Ibrahim et al. 2019).

Limited data were available to synthesise evidence despite a comprehensive search. The opinion was sought from the national subject matter experts to fill in the gaps in data availability. As per the opinion of the authors based on the local practice scenario, although the published studies show high awareness, treatment, and control of depression in Malaysia, a more accurate estimation of patient journey stages may be at 20% for screening, 50% to 60% for diagnosis, and 30% to 40% for adherence.

Out of the 31.9 million population, around 40.7% has sufficient health literacy (NHMS 2020). Awareness of depression among Malaysian adults is high due to various awareness activities organised on television, radio, and other forms of media. The data reflect that despite the efforts made to raise awareness, not many patients seek help for screening for their mental health. Furthermore, despite a high proportion of diagnosed patients initiated on treatment, low adherence reduced the effectiveness of measures taken to curb depression among the population.

Stigma regarding mental health leads to obstacles in generating awareness, screening and diagnosing MHDs, treating patients effectively, and ensuring adherence and control. It arises out of disapproval and discrimination by the community due to misbeliefs and lack of awareness. This hinders help-seeking and leads to devastating outcomes of MHDs (Corrigan et al. 2002). 

We found heightened awareness and treatment for depression; this is usually found in study settings where the population of interest has known underlying mental illness.  Unfortunately, in a clinical setting and daily practice, this may not be the true representation as the majority of patients with underlying mental health issues are not aware of their conditions. Efforts to increase awareness can be made by normalising the discussions around depression and anxiety through influential persons related to religion, entertainment, politics, or local society. A mere increase in awareness may not improve help-seeking behaviour, as patients may seek online assessments and advice without physically visiting any care provider,  or may lead to help-seeking by those who do not need the services and will overburden health services. Failure to provide mental health services after increasing awareness may lead to a negative experience for patients and further, affect their chances of seeking help causing a further rise in stigma regarding health services (Wang et al. 2007). 

Access to mental health services, resource availability, cultural and religious factors, and socio-economic factors determine the extent and type of stigma associated with mental health. Besides patients, the stigma surrounding mental health is also observed in family, friends, caregivers, employers, healthcare providers, and social service volunteers (Knaak et al. 2017). Involving various non-traditional stakeholders like community, family, friends, and colleagues, in the care of mental health patients is vital for improving help-seeking and ensuring adherence to treatment (Kohrt et al. 2018; Leggatt et al. 2002).

The barriers in mental health help-seeking as presented by this review can inform further coping strategies and focused interventions for depression. As a riposte to the current state of mental health care in the country, PCPs need to perform opportunistic screening for depression during their numerous contacts with patients. This can be done even when the patient comes with physical symptoms and chronic conditions like other NCDs, by asking simple questions about the patient’s mood and appetite and referring patients to psychiatrists as required. This will enhance access to basic as well as specialised mental health services. 

The hospital-based community psychiatry care and mental health services should be integrated with primary healthcare and community-based groups. The focus of mental health services needs to shift from a mental institution-based care model to a comprehensive community-oriented mental health care model. Recently, many hospitals in Malaysia have started community mental health centres to improve access to services for MHDs (Marhani 2018)

Focusing on mental health literacy, especially related to depression, can raise awareness, and help in coping up with stressors. A similar approach has been evaluated and practised in the past by implementing a web-based psychoeducational intervention for depression and anxiety (Yeap & Low 2009). 

The review reflects that patients with low education levels and belonging to vulnerable ethnicity are at greater risk of depression and other MHDs (Mathialagan et al. 2012; Jammy Suzana et al. 2005). This reflects that mental health literacy should be given importance from childhood. The review also emphasises the need to focus on mental health besides physical health during schooling. Interventions focused on health promotion and treatment targeting youth, university students, and working adults may improve the overall status of mental health in the country. Integrating mental health services as part of care for other NCDs will reduce the stigma. Technologies could also be used to increase awareness, accessibility, and services availability.

Conclusion

Primary care providers play a vital

role in screening patients for NCDs. For hypertension, they measure the blood pressure of patients at every contact, and similar importance is given to diabetes during health system contacts. This semi systematic review had few limitations. Since this is a semi-systematic review where local experts (who are also the authors) validated the screened studies for congruence with the local scenario and added local language articles or locally relevant articles in the pool of the included studies, this could have introduced publication bias. The authors also recognize the variation in definitions used in different studies and the lack of a standardized questionnaire for data verification as other limitations. Moreover, the denominators of various stages of the patient journey were independent of one another. Curbing social stigma is a key to mental health help-seeking behaviour, especially in Malaysia. PCPs should be empowered for delivering effective mental health care. Interventions involving community, family, friends, and colleagues are important in improving help-seeking behaviour. The data generated by the review can help in resource allocation, developing healthcare workforce capability, and enhancing efficiencies. The interventions should consider the impact of social, cultural, and religious aspects on mental health.

Acknowledgement

The author acknowledge the experts who provided insights for bridging the data gaps. The support provided by the independent reviewer Aditi Karmarkar from Upjohn – A Pfizer Division, is deeply acknowledged. The medical writing support was provided by the Medical Writer/Reviewer at Indegene and was funded by Viatris.