In a rural population of adults in Haiti’s Central Plateau, over 6% of the population endorsed current suicidal ideation, and the mean level of depression symptomatology was a score of 20.4 on the BDI. Factors significantly associated with depression symptom burden were: age, female gender, SES, recent life stressors such as life-threatening illness or death in the family, daily life stressors such as lack of food or traveling long distances to work, explanatory models of distress, endorsing current suicidal ideation, marital status, and education level. Current suicidal ideation was most strongly associated with scores on our culturally-adapted KreyÃÂ²l BDI, followed by alcohol use, having been to a Vodou priest, and lacking care if sick.
The observed associations of depression symptom burden with age, female gender, distance from healthcare, and exposure to stressful life events, including disaster-related stressors, are consistent with literature in other LMICs and post-disaster settings [79–81]. Additionally, the associations of depressive symptomatology with SES and psychological symptoms of household members are consistent with previous findings among medically-ill samples in Haiti [29, 30]. Social exclusion might explain the 7.5 point increase on the BDI for individuals who have been divorced; in high-income countries, divorce is one of the major life events precipitating depression . Furthermore, the rarity of divorce in Haiti may also contribute to its stigma and subsequent social alienation. Factors related to healthcare were also associated with depression symptom burden; traveling more than one hour to see a doctor and suffering from a major illness were both associated with higher BDI scores.
Explanatory models, i.e. the perceived causes of mental distress [83, 84], were also associated with BDI scores. In our sample, over 60% of participants identified disasters as potentially causing sadness or stress, while 10% endorsed that spirits could cause mental distress. Among women, the belief that spirits cause sadness was associated with higher BDI scores. Among men, the belief that disasters cause sadness was associated with higher BDI scores. In some literature, holding an external locus of control, characterized by a belief that factors outside the self primarily drive wellbeing, is associated with greater psychiatric distress [85–88]. In our sample, the nature and cause of the observed gender difference is unclear.
In recent priority setting regarding major mental health research questions in humanitarian settings, such as natural disasters, the top rated issue was the identification of major stressors for populations in complex emergencies . Although the study area did not directly experience damage from the 2010 earthquake, significant associations were found between depression and earthquake-related variables. Among men, having individuals move into one’s house following the earthquake was associated with poorer mental health outcomes. Among women, having a relative die in the earthquake was associated with greater symptoms of depression. Thus, for men, structural and economic consequences of the earthquake were associated with symptoms of depression, whereas for women, emotional consequences may have been more significant. Taken together, these findings suggest that psychosocial and other mental health responses to disasters may be shortsighted if only focused on areas directly affected. Additionally, interventions to reduce mental distress associated with disasters should consider unique needs based on gender.
Two surprising findings were the associations of education among women and employment among both genders with depression symptomatology. Women with more than a primary-level education scored 7.7 points higher on the BDI compared to uneducated women, even when controlling for age and other potential confounders. This may be due to the socioeconomic context of the rural, agriculturally-focused study region from which educated individuals are more likely to migrate to urban areas to escape low-paying agricultural or household work. The expectation may be that educated women will leave the region to gain employment in Port-au-Prince or abroad. Accordingly, women who are educated but do not leave may be seen as failing to reach their potential, and these women may suffer dissonance between the model of life learned about through education and their current circumstances. In Afghanistan, education, hope, and aspirations have negative associations with mental health in some groups, and this has been described as a disconnect between what is expected and what is possible in that environment . A similar disconnect between aspirations and reality may help explain the association between employment and poorer depression outcomes for both genders. Those employed in rural Haiti may primarily be unskilled laborers traveling away from home for low-paying employment. In-depth qualitative research is required to further elucidate these associations in Haiti.
It is not possible to make claims about prevalence of clinical depression in this study because the Kreyol BDI has not been clinically validated. However, it is worth noting that 41.7% of our respondents scored 20 or greater on our adapted BDI, which is the cut-off for moderate depression in American samples . This is comparable to a study in rural Nepal conducted after the ceasefire concluding the decade-long civil war; that study found a depression prevalence of 40.6% using a validated Nepali BDI with a cutoff of 20 or higher for clinical depression . The Haitian and Nepali populations share a history of poverty, lack of medical care, and structural violence, in addition to recent disasters. The putative rate of 41.7% depression in this Haitian sample is also comparable to depression rates observed in war-affected Liberia (prevalence 40%)  and Uganda (prevalence 44.5%) , as well as among Burmese refugees in Thailand (prevalence 40.8%) . This suggests that the combination of man-made or natural disasters against a backdrop of poverty, poor healthcare, and other structural violence factors is associated with widespread prevalence of depression symptomatology.
The association between suicidal ideation and depression has been demonstrated repeatedly in cross-national WHO studies of suicide-related behaviors . However, as pointed out by the WHO studies, suicidal ideation does not consistently predict suicide attempts. The WHO estimates that the lifetime cross-national prevalence rate of suicidal ideation is 9% , which is greater than the 6% current prevalence in rural Haiti. A limitation of this comparison is that the WHO study did not report rates of current suicidal ideation. One concern, based on findings of patients of Black Caribbean ancestry in the United Kingdom, is that this population may have a higher ratio of attempts to ideation compared with White European populations . Future research should investigate whether this is in fact the case in Haiti.
The association of alcohol use and suicidal ideation is not surprising; this association has been identified in numerous studies [96–100]. Substance abuse not only predicts suicidal ideation, but is a strong predictor of suicide attempts and completions, in part because it can increase impulsivity . Lack of someone to care for the respondent when sick also predicted suicidal ideation. Loneliness and lack of social support, as with substance abuse, are common risk factors in most studies of suicidality [102–105]. The association with prior visits to a Vodou priest is consistent with the finding that persons in low-income countries who have attempted suicide may have visited a non-psychiatric health worker, such as a traditional healer, prior to attempting suicide .
There is a paucity of accurate demographic data for the Central Plateau. Despite this, if we assume our sample is generally representative, we would expect 17,460 individuals to endorse current suicidal ideation in rural areas of the Haitian Central Plateau given 2009 population estimates for persons over 18 years of age (284,948) and our estimated population rate of current suicidal ideation [106, 107].
Implications for referral, treatment, and prevention
The goal of this study was to elucidate patterns of burden for depression symptomatology and suicidal ideation in rural Haiti in order to identify potential actions for referral, treatment, and prevention. Regarding referral, having visited a Vodou priest was associated with suicidal ideation, whereas having visited a biomedical provider was not. This suggests that persons with suicidal ideation are likely to have visited a Vodou practitioner. Therefore, referrals from Vodou priests and other community and mental health resources may be ideal to support those with current thoughts of ending their life. That said, partnerships with traditional healers can have negative outcomes as well, such as being more expensive than biomedical treatment . Religious and traditional healers may also worsen stigma based on the explanatory models they invoke [109, 110]. These risks should be taken into account when developing referral systems in Haiti.
Our research indicates that natural disasters, such as earthquakes, can have far reaching psychological effects, including on individuals not directly in the earthquake-affected region. Therefore, depression screening programs should attempt to reach those who are indirectly affected, such as those accepting displaced persons and those with relatives who died in the disaster. For example, individuals within households that hosted displaced persons could all undergo screening, as hosts are also at risk of increased symptoms of depression. An additional screening group could be those who have suffered recent losses such as widows and those with a death in the family. Individuals who deal with these groups, such as religious leaders who assist in funerary rites, could be a source of referrals. Rather than medical professionals, religious leaders may be better positioned and able to distinguish between culturally-appropriate grief expressions versus more pathological and impairing psychiatric sequelae.
For treatment, while psychiatric services need to be improved in general, there are specific populations who would particularly benefit from improved mental healthcare. One such group is substance abusers who are at risk of suicidal ideation and likely suicide attempts. Packages of care for substance abuse are available, and trials have been conducted in a range of LMICs . These could be piloted and optimized for Haiti’s Central Plateau. Cross-cultural studies of substance abuse treatment have shown that involvement of the family is extremely important, and this should be emphasized in Haiti. Another important treatment group is the medically ill. In our study, persons with medical problems were at increased risk for depression symptoms, a finding that is consistent with global literature on medical illness and mental health . Therefore, interventions that target depression, anxiety, and demoralization among the medically ill could significantly lower the burden of mental illness [113–115], while also improving medical outcomes .
The finding that depression symptom burden was higher among women may be associated with reproductive life events . In Pakistan, community-based psychotherapeutic programs have successfully reduced the burden of maternal depression . Similar interventions would be feasible in Haiti given the low level of technical psychiatric knowledge needed for implementing such a program . Further research is needed to elucidate gender-specific causes and effects of depression in Haiti.
For prevention of mental illness, structural interventions to reduce poverty are likely indispensible. Poverty and mental disorders easily become vicious cycles; therefore, reducing poverty will help prevent mental disorders and reduce barriers to recovery among those who already suffer from psychological distress [118, 119]. Food security is one component of poverty reduction that has shown a strong association in this population and thus should be targeted. In addition, improving the quality and availability of medical care also will likely prevent some of the current burden of depression. This medical care should include not only clinical services, but also community outreach for persons with current medical conditions who may need home health assistance. The observed relationship between reported lack of a caregiver when sick and suicidal ideation points toward the need for community-based psychosocial support to reach out to ill persons lacking family support.
Ultimately, there are a number of current models for improving mental healthcare in low-income settings [21, 120, 121]. An additional key will be to address the policy barriers to implementing these evidence-based practices in Haiti.
Strengths and limitations
Our study has several limitations. First, compared to the 13 zones sampled, the four zones excluded due to inaccessibility could have higher depression symptomatology and suicidal ideation due to further isolation from biomedical, mental health, and psychosocial services. Second, due to lack of an up-to-date census or list of households, we had to rely on the WHO’s “random walk” protocol. Nevertheless, the “random walk” protocol has been shown to give accurate and precise results even when compared to a randomized probability sample based on a household census . Third, since our BDI instrument has not been clinically validated, we cannot establish specific cut-offs to determine the absolute prevalence of major depression. Regardless, the use of a culturally-adapted BDI is a major strength of our study and aids in ensuring valid determination of risk factors, even if absolute prevalence cannot be estimated . An additional strength is that all reported cases of active suicidal ideation were confirmed through follow up by a licensed clinical social worker.