A narrative review of factors influencing detection and treatment of depression in Vietnam

Depression is among the most common psychiatric conditions in primary health care, and constitutes an important part of the global disease burden. However, it is difficult to obtain comparable data on depression worldwide and models for treatment and intervention need to be locally adapted. We conducted a narrative review of research literature on factors that influence depression screening, diagnosis and treatment among the Vietnamese population. This explorative approach included studies describing: a) culturally or contextually specific risk-factors for depression; b) any depression treatment seeking or treatment acceptability/adherence aspects or; c) depression screening among Vietnamese patients. We searched the PubMed and Cinahl databases, as well as relevant Vietnamese peer-reviewed journals and this produced 20 articles that were included in the review. Our findings indicate the importance of considering somatic symptoms when screening for depression in Vietnam as well as the use of culturally adapted and dimensional screening instruments. Our study confirms that depression reflects chronic social adversity, and thus an approach to mental health management that focuses solely on individual pathology will fail to address its important social causes. Further studies should elucidate whether neurasthenia is a commonly used illness label among Vietnamese patients that coincides with depression. The tendency among Vietnamese to seek traditional Vietnamese medicine and meditation practice when experiencing emotional distress was supported by our findings.


Introduction
Depression is among the most common psychiatric conditions in primary health care, and constitutes an important part of the global disease burden. Depressive disorder is increasingly recognized as a major global problem and was estimated to account for 2,5% of total DALY's in the year 2010 [1]. Increased attention has been paid to this, and Crisholm et al. [2] used data from 14 regions in the world to analyse cost-effective ways of reducing the burden. They found that it is difficult to obtain comparable data on depression worldwide and that models for treatment and intervention need to be locally adapted.
In this paper we will review existing literature to study what needs to be taken into consideration regarding depression diagnosis and treatment in Vietnam. The study is part of a project aiming to implement locally appropriate mental health intervention models at the community level.

Cultural background and mental health system in Vietnam
In Vietnam, Confucianism, Buddhism and Taoism have carried major impacts in creating a holistic thinking where clear distinctions between physical and psychological symptoms are not made [3]. The Cartesian mind/body dualistic framework that underlies Western psychiatric nosology does thus not necessarily concur with this holistic view [3]. The persistence of a traditional model of health, illness and the body among lay people has been described as the perhaps most salient fact in Vietnamese medical history [4]. The Vietnamese are found to often seek care from traditional approaches, including Traditional Vietnamese Medicine (TVM), Traditional Chinese Medicine, witchcraft, spiritual blessing and sorcery [3].
There are 64 provinces in Vietnam and in 27 of these there is a separate psychiatric hospital, while in the rest of the provinces psychiatric problems are handled at the district hospital. There are three mental hospitals that operate under the Ministry of Health (MoH) [5]. Two provinces do not have a mental hospital or department [6]. The medical management of mental illness in Vietnam only involves medication, and there is no family education or psychotherapy. Those psychologists who work in hospitals are mainly engaged in clinical testing [5]. Twenty percent of the physician-based primary health care services include complementary/alternative/ traditional practitioners. TVM is used for neurasthenia, and dissociative disorders and treatment consists mainly of acupuncture, massage and herbal medicines. Patients with schizophrenia, personality disorders, paranoia, or suicidal thoughts appear not to be treated by TVM [5].
In the past, medical care in Vietnam was free at all levels. However, after the adoption of the economic renovation policy in 1986, only a part of patients' medical costs have been covered by public funding, while private clinics have opened. Mental hospitals are entirely subsidized by the government [5]. The government only pays for control and medication of epilepsy and schizophrenia, while medication and treatment for other mental illnesses is paid out-of-pocket. The supply and pricing of psychiatric medicines is regulated by the government, and the cost of one day's antipsychotic medication is 33% of one day's minimum wage [6].
Vietnam's mental health plan was last revised in 2010. The eaqrlier version consisted of a national plan of action on treatment of schizophrenia and epilepsy in hospitals [7] but the revised plan also comprises the integration of mental health services into primary care [8], as well as the treatment of depression [9]. The human resources for mental health are scarce in Vietnam. In 2011, there were 1.01 psychiatrists per 100 000 population, 67,39 medical doctors not specialised in psychiatry, 75.34 nurses and 0.03 psychologists working in the mental health sector [8]. Researchers and policy makers have jointly identified the main gaps in the Vietnam mental health system to be the lack of knowledge about the feasibility and cost of any intervention [7].

Methods
We utilized a modified version of the procedure described by Green and co-workers [10] to conduct a narrative review of factors that influence depression screening, diagnosis and treatment among the Vietnamese population. The aim was to find published research that describes factors of importance for developing appropriate depression screening and treatment methods. This explorative approach included studies describing: a) culturally or contextually specific risk-factors for depression (of relevance for treatment strategies); b) any depression treatment seeking or treatment acceptability/adherence aspects (of relevance for treatment or screening strategies) or; c) depression screening among Vietnamese patients (of relevance for screening strategies). The inclusion criteria were thus purposefully relatively loosely defined. The search terms used included depression, Vietnam*, and excluded veteran (due to the large number of studies found on Vietnam veterans in the USA), in title or abstract, in PubMed and CINAHL (See Table 1). The searches were conducted on December 14 th , 2012. We also separately searched six relevant Vietnamese peer-reviewed research journals to see if any work had been published in Vietnamese. These searches were conducted between April 17 th and 19 th . We only included studies among specific groups, such as elders, perinatal women/men, or youth when the results were deemed generalizable beyond that group. Also, we included studies with refugees/immigrants in other countries, when the studies were in particular about the cultural expression of depression, or conducted with newly arrived immigrants/refugees. However, studies with Vietnamese patients in other countries that studied health system factors were not included, as they were not deemed relevant for the Vietnamese health care system.

Results
Two searches were conducted in the two databases, as well as six separate searches in the six Vietnamese journals, and this yielded 157 hits. All the hits were screened through reading the title, abstract or full text article in order to decide whether they fit the search criteria. This screening process left 20 studies. The main study characteristics including study title, authors, setting, sample and methodology are shown in Table 2. The results relevant for the study aim are presented below, reference numbers are annotated in the text as listed in Table 2.

Screening
We found studies reporting the development, assessment and use of two Vietnamese psychiatric scales, the Vietnamese Depression Scale (VDS) and the Phan Vietnamese Psychiatric Scale. The VDS was developed in the USA to be used among newly arrived refugees, and includes some psychophysiological symptoms derived from DSM-III-R, as well as some specific Vietnamese descriptions of cognitive, affective, and somatic indications of depression (12). The scale contains 15 items with a maximum score of 34 (12). When comparing the Indochinese Hopkins Symptom Checklist Depression Subscale (HSCL-D) with the VDS, they were found to have similar areas under ROC curve (0.91 and 0.93 respectively), when measured at the optimal cutoffs of 26 and 11 respectively. These cut-offs gave Se 96%, Sp 86% and ppv 60% for the HSCL-D and Se 98%, Sp 79% and ppv 79% for the VDS (12).
In the development of the Phan Vietnamese Psychiatric Scale (PVPS), some ethnographic and qualitative research was undertaken. Through interviews with 180 Vietnamese community residents in Sydney and review of Vietnamese literature, the scale was derived from Vietnamese idioms, expressions and understandings of mental illness. Many of the symptoms were derived from Vietnamese health beliefs regarding energy flow and the location of emotional states in physical parts of the body (3). When comparing two diagnostic instruments for mental disorder among Mekong Delta Vietnamese and Vietnamese living in Australia, it was found that the PVPS detected four times more cases of mental illness among Mekong Delta Vietnamese than the internationally used CIDI (2). A validation of three screening instruments, the EPDS, the Zung-SAS and the GHQ-12 for the detection of common mental disorders (depression, anxiety and panic) among perinatal women and men in northern Vietnam discovered that the valid cut-off points in that setting are much lower than in most other countries (10). The validated cut-off scores for women were 3/4 (Se 69.7%; Sp 72.9%), 37/38 (Se 67.9%; Sp 75.3%) and 0/1 (Se 77.1%; Sp 56.6%) (10) and for men were 4/5 (Se 68.3%, Sp 77.4%, ppv 75.8%), 35/36 (Se 70.7%, Sp 79%, ppv 77.5%) and 0/1 (75.6%, Sp 74.7%, ppv 74.9%) (14). The authors discussed that this is probably due to differences in emotional literacy, nonfamiliarity with test-taking and the effects of chronic social adversity (10,14). Two Vietnamese language studies presented the validation (19,20) and internal consistency (20) of the Center for Epidemiological Studies-Depression Scale (CES-D) among adolescents and young adults. The scale was validated with good results, and the internal consistency (cronbach's alpha) was found to be 0.82 (20) and 0.87 respectively (19).

Symptomatic presentation and risk-factors
Seven of the retrieved studies gave support to the notion that Vietnamese patients with depression experience and present their distress mainly through somatic symptoms. The PVPS includes a somatic scale, which accounted for a large percentage of the increase in number of detected cases of depression compared to the CIDI (2). Nguyen et al. (1) found that the most common reasons for seeking treatment among patients later diagnosed with depression were somatic complaints, namely insomnia and headaches (1). Also a study which examined the factorial structure of the Vietnamese Depression Scale among Vietnamese refugees in the USA found that there was significant overlap between the affective and somatic experiences (7). Newly arrived refugees in the USA, who were screened as depressed with the VDS had increased frequency of somatic symptoms including headaches, backaches and limb aches (11). A study assessing depression with the EPDS among postnatal women in Ho Chi Minh City (17) found that specific questions about common symptoms of depression (difficulty going to sleep, waking in the night, worrying and severe fatigue) appeared to be more meaningful to participants and were more prevalent than most non-specific somatic symptoms (e.g. difficulty swallowing, heart palpitations, breathing difficulties or heavy heart). Women with elevated EPDS scores were more likely to report gastrointestinal disturbances (17).
A Vietnamese term usually translated to neurasthenia seems to be a label that is used by Vietnamese patients and health workers to describe depression symptoms, and may be a more common reason for care-seeking than depression. This assumption is supported by a qualitative study among mothers and health workers in semi-rural Vietnam (9) and by a case study of a Vietnamese immigrant in the USA (8). In the development and use of the VDS, culture-specific symptoms were found to be frequent (12). In particular, feelings of anger, shame, and being dishonored and in despair, as well as the feeling of going crazy were important items for distinguishing those with depression, but do not fit within its Western definition (13).
A study among Vietnamese and French individuals compared the rates of depression in a community sample as obtained through International Classification of Diseases, 10 th revision (ICD-10) and self-rated depression in response to anchoring vignettes as none, mild, moderate, severe and extreme. The study found that being female increases the probability of self-reporting moderate, severe or extreme depression by 1.8%. This   To elicit illness explanatory models of depression and postnatal depression from mothers and health workers who meet mothers during their pregnancy and/or postpartum period.
Nine mothers and nine health workers from a semi-rural community in north Vietnam.
Illness explanatory model interviews using a case vignette of depression and postnatal depression. To establish the validity of three widely used psychometric screening instruments in detecting CMDs in women in northern Viet Nam.
A community-based representative cohort of 364 Vietnamese women in the perinatal period, in the north of Vietnam.  A population-based sample of 497 women, recruited from all pregnant women in randomly selected communes in Ha Nam province, were surveyed in early and late pregnancy.   The CES-D was translated and adapted for the Chi Linh district context. The revised scale was then tested among 12,447 youths and adolescents (age 10-24 years) The scales internal consistency (cronbach's alpha) was 0.82. All tested socio demographic variables (gender, marital status, age, education level and urban or rural residence) were significantly associated with the total mean score of depression. increased rate of self-rated depression among females can be explained by reporting biasfemales either "over-report" or males "under-report" depression. A study among relatively socially advantaged pregnant women in Hanoi found that lack of salaried work, or a secure source of income and living in crowded conditions were associated with higher scores in the EPDS (16). Also, higher scores in the coercion subscale of the Intimate Bonds Measure (IBM) were associated with higher EPDS scores, in particular women who felt criticized over small things and who felt controlled by their partners had significantly lower mood (18). In a study among postnatal women in Ho Chi Minh City (17) women who had assistance to rest and someone to prepare special foods were less likely to be distressed. However, the avoidance of traditionally prescribed foods was associated with higher rates of distress, perhaps because it may reflect a response to critical scrutiny or active enforcement from others, in particular a mother-in-law. This study also found that having no permanent job to return to, and being unable to confide in their husbands were associated with clinically significant depressive symptomatology (17). A study among adolescents and young adults in the Chi Linh district of Hai Duong province, aged 10-24 years, found that higher depression scores in acordance with the CES-D were significantly associated with being female, unmarried, of age group 15-19 years, living in an urban area and having a higher education level (20). Finally, in a study among pregnant women in Ha Nam province, in addition to from pregnancy specific factors, experience of childhood abuse, non-economic life adversity, intimate partner violence and economic difficulties were determinants of persistent antenatal common mental disorders. The most common sources of non-economic life adversity were hostile behaviors from the in-law family, husbands having extramarital affairs or abusing alcohol, and worrying about the health, well-being and development of ones children.

Barriers to care-seeking and perceived causation
A lack of recognition of depression among Vietnamese was demonstrated by a study comparing depression concepts between Australian nursing students in Australia, and Vietnamese nursing students from Ho Chi Minh City (4). They were asked to respond to a vignette describing a young woman with depression symptoms, either in a family context, or merely depression symptoms listed without a context. The Australians were found to perceive the depression symptoms as much more severe than the Vietnamese, thus demonstrating differences in the recognition of symptoms as a mental health problem. The Vietnamese tended to interpret the overt expression of depression symptoms (negative emotions) as a sign of immaturity or weakness of character, and in general were less accepting of the expression of emotions (4). The tendency to not openly speak of depressive symptoms in Vietnamese society was further supported by findings from a qualitative study in a semi-rural area in the north of Vietnam (9). A study among Vietnamese immigrants in Canada aimed to identify the barriers to care-seeking by interviewing people who were experiencing distress but not currently using clinical services (5). All the narratives of distress found here made reference to notions of 'vital energy' and 'hot/cold' and 'wind principles' derived from traditional Vietnamese medicine. The distress described which was most like depression was uâ't u'ć, which was caused by an unacceptable social situation that one could not denounce because it was seen as socially inacceptable to express negative emotion related to social hierarchies. The symptoms were mainly handled through traditional herbal remedies, and through acceptance of the social situation through for instance spiritual means such as Buddhist meditation (5). A case study of a Vietnamese immigrant in the USA showed that depression was perceived to be caused by difficult social situations and somatic factors, rather than psychological factors (8) -a finding supported by Niemi et al. (9). A study which tested a culturally adapted form of CBT among Vietnamese refugees with PTSD and panic attacks, found it to be efficacious and acceptable. The therapy consisted of 11 individual sessions, where cultural adaptation included culturally appropriate visualization, and a form of mindfulness meditation (6).

Discussion
We have conducted a thorough search of the existing literature concerning relevant factors for depression screening and treatment in Vietnam. We believe that we have captured a considerable part of the relevant aspects in the published scientific literature. We are, however aware of several limitations of this narrative review. For example, the versatile form of studies included does not allow quantification or pooling of the results. However, we believe that useful information was obtained and will be beneficial in guiding depression management in Vietnam.

Implications for depression screening
Our findings implicate the importance of considering somatic symptoms when screening for depression in Vietnam. Common somatic complaints include insomnia, headache, dizziness, epigastric complaints and general aches and pains. Also, culturally adapted and dimensional screening instruments may be more sensitive in the Vietnamese setting than international, categorical diagnostic instruments. Valid cut-off scores may be lower than in most other settings [11], including neighbouring China and Thailand [12][13][14]. However, the Vietnamese Depression Scale, though it has been validated among refugees in the USA, has to our knowledge not yet been validated in Vietnam.
Given that it appears to be a good and brief screening instrument among the refugee population, The VDS may prove useful even in the Vietnamese health care system.
The illness label 'neurasthenia' may be a common idiom by which depression is expressed in a Vietnamese clinical setting. The medical term neurasthenia is translated as Vietnamese suy nhược thần kinh, Chinese shenjing shuairuo or Japanese shinkei-suijaku, all of which also translate to the common term nervous breakdown. Though neurasthenia was omitted from the DSM in 1980, it is listed in an appendix as the culture-bound syndrome shenjing shuairuo and appears in the ICD-10. The condition is thought to persist in Asia as a culturally acceptable diagnosis, due to being less stigmatising than depression, as subjects are by definition not deranged in mind or dangerous to others [15,16]. Arthur Kleinman described Chinese neurasthenia as a culturally sanctioned idiom of distress related to depression [17], and this may be the case even in Vietnam.

Implications for treatment planning
Many psychotherapies developed within Euro-American culture, such as CBT demand the ability and willingness to converse about private experiences and to be outspoken about feelings and relationships [18]. Conversely, a notion of the social context of depression and the inappropriateness of indulging in one's own emotions among Vietnamese was supported by our literature review. Traditional Confucian culture is sociocentric, where relationships with others are included in the definition of the person [19], and the self is primarily expressed through commitment to family or another social group [18]. Thus, helping a person from this cultural background to see herself as an individual caught in oppositions to the will of others could cause her to become alienated from her own family [18]. Such fundamental values that patients hold must be taken into account in order for any psychotherapy to be effective. Central features that we found of importance for treatment planning included the perceived social causation of depression, as well as the importance of accepting social hierarchies and life conditions as they are. Studies in China, where Confucian, socieocentric values are similarly predominant, have shown that individual therapies where families are not allowed to participate may be thought of as strange [20]. This may also be the case for some Vietnamese patients.
Noting that our review brought to light the importance of traditional medical frameworks for the Vietnamese understanding of, and treatment seeking for depression, TVM practitioners may prove a good resource for the management of depression. The World Health Assembly of 2009, and the Beijing Declaration on Traditional Medicine [21] indeed urge member states to consider including traditional medicine into their health systems based on local priorities and capacities as well as on evidence of safety, efficacy and quality [22]. Vietnam is among the only four countries of the world where an integrative model of health care, including traditional medicine has been enacted. This means that TVM is included in the national drug policy; providers and products are registered and regulated; traditional therapies are available at hospitals and clinics; treatment with TVM is reimbursed under health insurance; relevant research is undertaken; and education in traditional medicine is available [23]. However, in the particular area of mental health care provision, this integrative process has not been implemented. Nevertheless, there are certain barriers to the use of traditional medicine -not least the lack of agreement on what constitutes scientific evidence since the epistemologies of traditional medicine differ so vastly from that of biomedicine [24].
Additionally, the mental health care system may be strengthened by including meditation practices in to treatment plans, as such an approach may prove coherent with local understandings of depression. Indeed, mindfulness meditation has in recent years gained a growing evidence-base for depression treatment [25]. The influence of Buddhism on Vietnamese culture is vast, and it is the Pure Land sect of Mahayana Buddhism that is practiced by the majority. This form of Buddhism does not focus on meditation practice, but rather on ritual practices such as prayer and almsgiving [26]. However, in the recent years, meditation halls where lay people go to practice mindfulness meditation have begun to open in conjunction with much visited pagodas [27].
Finally, our review revealed a number of social aspects that are implicated in depression causation. These included problems with the in-law family, and the husband, in terms of coercion and hostile behavior. Also, job insecurity and economic difficulties were found to be determinants of depression. A UNFPA-WHO international meeting on maternal mental health in Hanoi 2007 came to the conclusion that an approach to mental health management should involve multiple sectors including those dealing with development, poverty reduction, human rights, social protection, violence prevention, education, gender, and security [28,29].

Conclusions
Our findings indicate the importance of considering somatic symptoms when screening for depression in Vietnam as well as the use of culturally adapted and dimensional screening instruments. Our study confirms that depression reflects chronic social adversity, and thus an approach to mental health management that focuses solely on individual pathology will fail to address its prevalent social causes [29]. Further studies should elucidate whether neurasthenia is a commonly used illness label among Vietnamese patients, that coincides with depression. The tendency among Vietnamese to seek TVM and meditation practice when experiencing emotional distress was supported by our findings. In other resource scarce settings, traditional medical treatment has been found to be frequently sought by those with mental illness [30], which may be true even for the Vietnam setting, in which case such provision should be explored.