Introduction
Depression is a significant public health concern globally, and particularly in Colombia, where it contributes substantially to the burden of disease. In low- and middle-income countries (LMICs), depression is a leading cause of neuropsychiatric disability, impacting individuals and society profoundly.1 Colombia reflects this trend, ranking depressive disorders as the seventh leading cause of disability with a lifetime prevalence of 5.4%.2,3 Despite the prevalence, access to mental healthcare remains a challenge for many Colombians. National data from 2015 indicates that less than half of those with mental health disorders received any care in the preceding year.3 A key factor contributing to this gap is the limited mental health workforce in Colombia, with only 1.84 psychiatrists per 100,000 population in 2017.4 Furthermore, the accurate identification of depression is often lacking, especially within primary care, where less than half of patients with major depressive disorder are correctly diagnosed.5 These challenges underscore the critical need for improved integration of depression care into primary healthcare settings within Colombia.
The Colombian government has demonstrated a growing commitment to mental health through legislative actions. Law 1616 of 2013 granted all Colombians the right to mental healthcare,6 and this was further strengthened in 2018 with a resolution prioritizing the integration of mental health services into primary care.7 In support of these national initiatives, researchers from Javeriana University and Dartmouth College collaborated on the DIADA project (Detection and Integrated Care for Depression and Alcohol Use in Primary Care). This project aims to leverage digital technology to enhance the accessibility and quality of mental health services (as detailed in Torrey et al.).8 As part of this project, qualitative research was conducted through focus groups and in-depth interviews to identify specific barriers and facilitators to integrating depression screening into Colombian primary care. While research globally has explored factors such as stigma, provider confidence, financial constraints, and limited training for primary care providers in mental health,9–11 context-specific understanding within Colombia’s primary care setting is crucial. To address this gap, our study investigates stakeholder experiences to elucidate the barriers to effective depression diagnosis and management in Colombian primary care.
Methods
Study Design and Participants
Participants were recruited from five primary healthcare sites across Colombia, selected as scale-up sites for the DIADA project. These sites represented diverse settings: an urban ambulatory center in Bogotá (Site 1), an urban regional hospital in Boyacá (Site 2), a rural primary care center (Site 3), a rural clinic serving both urban and rural populations (Site 4), and a rural clinic coordinating mental health services across 47 municipalities (Site 5). Ethical approval was obtained from the Institutional Review Boards of both Dartmouth College and Javeriana University.
The study employed focus groups and in-depth interviews with four key stakeholder groups: healthcare professionals, healthcare administrators, patients, and community organization representatives. Inclusion criteria included being at least 18 years old. Healthcare workers needed a minimum of nine months of employment at their institution, patients must have used the institution’s services within the past year, and community representatives required over five years of community experience. Participants received compensation equivalent to US $16 and provided informed consent.
Focus groups, facilitated by an experienced anthropologist, were organized by participant type. Semi-structured in-depth interviews, lasting approximately one hour, were conducted by two researchers trained in qualitative methods with participants from the focus groups to further explore emergent themes. Example guiding questions for focus groups can be found in Table 1.
Data Analysis
Focus groups and interviews were audio-recorded, transcribed verbatim in Spanish, and de-identified. Three qualitative research experts independently reviewed the transcripts. Data analysis began with a deductive approach using a preliminary matrix of categories developed by the research team, followed by thematic analysis guided by this matrix. This methodology allowed for the identification of recurring patterns in stakeholder perceptions.12,13 NVivo 11 software was used for coding and analysis.14 All analyses were conducted in Spanish. An iterative process was used to develop the codebook, and consistency was ensured through open coding of a transcript and inter-coder reliability testing to resolve coding discrepancies.
Results
The study comprised 16 focus groups and 4 in-depth interviews across the five sites, involving 108 participants (36 patients, 30 health professionals, 26 health administrators, and 16 community organization representatives). Interviews included one participant from each stakeholder group. Findings are presented using Chaudoir et al.’s multi-level framework, categorizing barriers and facilitators at patient, provider, organizational, and structural levels (Table 2). 15,16 A significant overarching barrier identified was stigma, analyzed using Ahmedani’s stigma model, encompassing prejudice, self-stigma, and provider stigma (Table 3).17 Understanding and addressing depression stigma is crucial, as highlighted by cross-national studies indicating a persistent global “backbone of stigma”.18
Stigma as a Barrier to Depression Diagnosis
Prejudice: Societal Stigma
Prejudice, as a societal belief system that devalues individuals with stigmatized conditions,17 significantly impacts depression care. Mental health prejudice can lead to discrimination and reinforce negative stereotypes.18,19 In our study, a key manifestation of prejudice was patients’ fear of social repercussions upon disclosing depression. Healthcare administrators noted patient reluctance to discuss symptoms due to concerns about family tension and societal judgment. One patient described mental illness diagnosis as the “worst possible,” highlighting the intense social stigma. This prejudice compels individuals to conceal their condition to avoid social isolation and discrimination.
Self-Stigma: Internalized Shame
Self-stigma, the internalization of societal prejudice leading to feelings of guilt and inadequacy,17 emerged as a significant barrier. Modified labeling theory suggests that fear of being labeled mentally ill can induce stigma, impacting self-esteem, opportunities, and care-seeking behavior.20–22 Providers and administrators reported patients associating mental illness with being “crazy” and avoiding care for fear of this label. This self-stigmatization led individuals to prefer self-management of depression to avoid the perceived stigma of mental illness.
Provider Stigma: Unintentional Bias in Healthcare
Provider stigma, similar to prejudice, involves healthcare professionals creating social distance from or unintentionally marginalizing individuals with mental health disorders.17 This can result in reduced early detection and inadequate follow-up.23 While most providers in our study supported primary care depression treatment, some patients reported feeling that their concerns were not taken seriously. Some patients reported receiving minimal support beyond initial identification, such as being told to “manage it” without further treatment or referrals, indicating a potential gap in provider engagement and follow-through.
Patient Level Barriers
Beliefs and Attitudes Towards Depression Treatment
Patient beliefs and attitudes significantly impede depression diagnosis and treatment-seeking. A prominent barrier was fear of medication, including addiction and skepticism about medication effectiveness. Providers observed that these fears led to treatment refusal and appointment no-shows. Another negative attitude was annoyance at receiving a depression diagnosis. Administrators noted that some patients, especially older adults, perceived a depression diagnosis as undermining their other health concerns, indicating a lack of understanding or acceptance of mental health as a valid health issue.
Financial Constraints
Financial barriers, particularly in rural areas, represent a major impediment to accessing depression care. Despite Colombia’s universal healthcare system (Law 100) and relatively low out-of-pocket health expenses,24 indirect costs remain substantial. Rural patients, after primary care diagnosis, often face referrals to distant specialists, incurring costs for transportation and lodging. This financial burden forces difficult choices between basic needs and healthcare, leading to loss to follow-up or relapse and return to primary care in crisis.
Limited Mental Health Literacy
A significant patient-level barrier is the lack of mental health literacy. Health administrators emphasized the societal need for education to destigmatize mental illness. They highlighted the necessity to educate the public that depression is a treatable medical condition, like any physical illness. This lack of understanding means many individuals with depression symptoms are not equipped to seek help. Furthermore, without adequate mental health literacy, families may overlook symptoms, especially in older adults, attributing depression to aging rather than a treatable condition.
Provider Level Barriers
Insufficient Training in Depression Management
The primary provider-level barrier is inadequate training in mental health care. Primary care providers, especially those trained outside major urban centers like Bogotá, reported insufficient or absent medical school training in depression diagnosis and management. This lack of training leads to missed diagnoses or detection only during crises. Even when diagnosed, providers often lack confidence in management strategies or awareness of depression treatment guidelines. Providers also noted that existing guidelines are not sufficiently adapted for rural Colombian contexts, further complicating care delivery in these settings. This training gap hinders providers’ ability to educate patients effectively. As one focus group participant noted, providers may lack time, patience, or training to educate patients adequately about medication and treatment plans, leading to patient confusion and non-adherence.
This lack of training contributes to delayed detection in primary care, with many cases remaining untreated until crisis points, often presenting in emergency departments. Providers and administrators reported that follow-up care is sometimes lacking until a severe event like a suicide attempt occurs.
Complexity of Mental Health Conditions
Providers also cited the inherent complexity of mental illness as a barrier to diagnosis. Many felt mental health conditions are harder to identify than physical illnesses due to co-morbidities and less quantifiable symptoms. They described often treating symptoms rather than the underlying illness. This complexity, combined with inadequate training, lowers primary care providers’ confidence (self-efficacy) in managing depression effectively.
Organizational Level Barriers
Poor Coordination Between Care Levels
A major organizational barrier is the weak referral system between primary and secondary care and insufficient specialist resources. Providers and administrators reported a scarcity of nearby psychiatrists and psychologists for referrals. This shortage results in long wait times for specialist appointments, often leading to medication-only treatment. Patients often drop off waitlists due to the delays, returning to primary care without specialized support. Providers also noted frequent loss to follow-up due to lack of specialist access. As one hospital administrator articulated, early identification of depression is futile without adequate resources for care, including medications, personnel, and infrastructure. The administrator questioned the value of identifying depression if specialist care is inaccessible, suggesting a sense of futility and potential discouragement of proactive diagnosis.
Time Constraints and Provider Overburden
Primary care providers reported feeling overburdened by time constraints during appointments. Especially with patients having multiple health issues (co-morbidities), physical complaints often take priority, making it challenging to address depression within limited appointment times. High provider turnover in primary care settings further exacerbates this burden and disrupts continuity of care. These organizational factors hinder consistent and comprehensive depression care.
Structural Level Barriers
Insurance Authorization Processes
At the structural level, insurance authorizations, particularly for specialist referrals or specific medications, create significant barriers. Patients and administrators described lengthy and unsystematic authorization processes within the public insurance system, sometimes taking months, which is detrimental for depression patients needing frequent and continuous care. Patients also reported logistical challenges, such as obtaining authorizations in one location but needing to travel to another to fill prescriptions, making medication access arduous.
Need for Greater Prioritization of Mental Health
Despite governmental progress in prioritizing mental health, some providers perceived a continued need for stronger action from both government and medical education institutions to fully integrate mental health into primary care. Some providers felt that political priorities were skewed by a perception that mental health investments are not immediately cost-effective, leading to delayed prioritization and resource allocation.
Poverty and Social Determinants of Health
Poverty is a significant structural barrier. Providers and administrators noted that poverty and daily struggles contribute to or worsen depression in many patients. One provider expressed uncertainty about effectively treating depression without addressing patients’ challenging social environments, finding it nearly impossible to adhere to international depression care guidelines in such contexts.
Patient Level Facilitators
Support Networks
Strong support networks emerged as a key patient-level facilitator. Patients who sought help for depression often had strong support systems, having already accepted their diagnosis with family and friend support and seeking tools for management. Patients expressed interest in peer support groups as a way to enhance their support networks. One patient stated a preference for peer support groups over medication and psychiatrist visits, highlighting the value of community and shared experience in managing depression.
Provider Level Facilitators
Patient-Provider Relationship
A strong, trusting patient-provider relationship is a crucial facilitator. Patients emphasized the importance of provider communication in understanding their condition and medications. Providers noted that rapport-building is essential for depression identification, as some patients find it easier to disclose their struggles when they feel understood and supported. Given the strong stigma surrounding mental health, a positive patient-provider relationship is paramount for encouraging help-seeking and adherence to treatment. One doctor emphasized that understanding their problem is key for patients to accept treatment, requiring a shift from viewing depression as a stigma to seeing treatment as an opportunity for improvement, cultivated through a strong patient-provider relationship.
Targeting Depression Screening at Key Life Stages and Comorbidities
Providers identified specific life stages as opportune times for depression screening. They noted depression prevalence across life cycles, from childhood to old age, triggered by diverse factors. Specifically, pregnancy and postpartum periods were highlighted. Gynecologists in Colombia routinely use psychosocial risk scales during prenatal care, leading to more frequent depression diagnoses and referrals for pregnant and postpartum women. Older adulthood was also identified as a key stage due to increased risk of isolation-related depression and higher likelihood of seeking care for social interaction. Providers suggested educating older adults about depression symptoms to encourage early consultation. Adolescence was another critical period due to stressors like family issues, academic pressures, and social relationships. Community and school-based depression education were seen as opportunities for early identification in this age group. Furthermore, diagnosing depression alongside co-morbidities was also seen as a facilitator, as physical health visits could provide an entry point for mental health screening and care.
Positive Attitudes Towards Integration
A shared positive attitude towards integrating depression care into primary care among both providers and administrators was a significant facilitator. The recognition of primary care as the frontline for reaching undiagnosed depression cases and the importance of early intervention indicated a strong buy-in for integration efforts within the healthcare system.
Organizational Level Facilitators
Clinical Guidelines and Protocols
Clinical guidelines and protocols for depression treatment serve as an important organizational facilitator, especially in primary care settings with high staff turnover. Systematic use of guidelines provides structure, instructions, and stability within clinics. While providers reported adapting guidelines to specific situations, they generally viewed their integration as greatly facilitating depression management and ensuring a consistent standard of care.
Discussion
This study aimed to identify barriers and facilitators to integrating depression screening and treatment into primary care in Colombia to inform the implementation of a new care model. Several key action items emerge from these findings.
First, enhancing mental health literacy at the patient level is crucial. Low literacy exacerbates stigma (both self and societal), reducing help-seeking behavior. Research links self-stigma, mental health literacy, and openness to professional help.25,26 Interventions to improve mental health literacy can reduce stigma and increase treatment seeking.27,28 Given the importance of social support, literacy efforts should also target patients’ support networks to encourage family and friends to support help-seeking.28
Second, provider-level action is needed to increase training and resources for primary care providers in depression management. Many providers reported insufficient training, leading to missed or poorly managed diagnoses. Addressing this gap is a significant opportunity. Targeting training to improve depression identification and management in primary care can improve patient outcomes in LMICs.1 In Colombia, training healthcare professionals in depression management has shown to significantly increase depression diagnosis rates.29
Third, strengthening linkages between primary and secondary care at the organizational level is essential for continuity of care. Strategies to improve service linkages include partnership activities, shared clinical meetings, information sharing, care managers, and telehealth consultations from specialists to rural clinics.30 Collaborative care models have also demonstrated significant improvements in depression outcomes.31
Fourth, at the structural level, leveraging the Colombian government’s increasing prioritization of mental health is critical. Enhanced collaboration between researchers, policymakers, and healthcare workers can facilitate and encourage continued investment in this area. Peru’s mental health reform, including Community Mental Health Centers and Guiding Principles for Action in Mental Health,32 offers an exemplary model. Cross-regional knowledge sharing is another valuable strategy for improving depression care in primary care settings.
Limitations of this study include participant self-selection, potentially indicating stronger pre-existing views on primary care depression integration. Also, the study sites were pre-selected DIADA project sites, potentially not fully representative of all Colombian primary care settings. However, site selection across diverse urban and rural regions aimed to capture a broader range of perspectives.
Conclusion
While significant barriers to depression treatment exist in Colombia, this study also highlights substantial opportunities and existing facilitators for improving depression diagnosis and management in primary care. The identified factors directly informed the DIADA project’s care model, specifically in areas of provider and patient education, tool development for diagnosis and management, strengthening referral networks, and policy collaboration.8 These findings can guide future depression interventions in Colombia and other LMICs facing similar resource constraints, ultimately improving depression outcomes and empowering patients in their care.
Acknowledgements
Dr. Diana Goretty Oviedo-Manrique played an essential goal in developing the interview guides and conducting the interviews that are reported on in this article.
Funding
Research reported in this publication was funded by the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH) under Award Number 1U19MH109988 (Multiple Principal Investigators: Lisa A. Marsch, Ph.D. and Carlos Gómez-Restrepo, MD). The contents are solely the opinion of the authors and do not necessarily represent the views of the NIH or the United States Government.
Footnotes
Conflict of interest
Dr. Lisa Marsch, one of the principal investigators on this project, is affiliated with the business that developed the mobile intervention platform that is being used in this research. This relationship is extensively managed by Dr. Marsch and her academic institution.
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