Abstract
ABSTRACT BACKGROUND: Chronic non-communicable diseases (NCDs) are a major global health problem of the 21 stcentury. They are now the world's leading cause of disease burden and high mortality. An even more alarming health problem is when depression coexists with chronic NCDs, as is frequently the case. Management of this co-morbidity with collaborative care has become a global topic of interest, with the World Health Organization (WHO) recommending implementation of collaborative care for this purpose. The study investigated existing protocols and/or interventions for managing this co-morbidity in Rwandan district hospitals. METHODS: The study used an action research design involving a research team of 14 health care professionals to collaboratively identify existing protocols or interventions for managing comorbidity of depression and NCDs in Rwanda. Focus group discussion using a structured interview guide was used to collect qualitative data, followed by qualitative content analysis using inductive approach. RESULTS: We found no particular protocols or interventions in place to manage the co-morbidity of depression and chronic NCDs. Depression and chronic NCDs were found to be treated separately, in separate health care settings and by different health professionals. CONCLUSION:The findings revealed a gap in management of comorbid depression and chronic NCDs in Rwanda district hospitals. We recommend that health care providers follow the WHO collaborative care advisory for better quality care and better patient improvement in management of this co-morbidity.
INTRODUCTION
Chronic NCDs are a major global health problem, causing morbidity and mortality in all countries (1) (2) (3) . More alarming still is when depression coexists with chronic NCDs (as is frequently the case),which is associated with major health consequences including high morbidity and mortality (4) (5) (6) (7) (8) (9) . Chronic NCDs that are frequently linked with depression include cardiovascular diseases, diabetes, cancer and chronic respiratory diseases (10) (11) (12) . This co-morbidity has become a major concern worldwide, and optimal management of the problem is increasingly a topic of interest. A number of studies that have reviewed the management of this co-morbidity in various settings confirm that collaborative care is cost-effective in management of the co-morbidity (13) (14) (15) . Collaborative care for management of comorbid depression and NCDs in primary care settings is also recommended by the WHO (16) . In low-income countries, it is, however, still frequently the case that mental health care is separate from physical care (17) . This separation of treatment is associated with significant negative health effects such as complex medication regimens with high risk of drug interactions and poor medication adherence, duplicative medical tests, unnecessary hospitalizations and increased mortality (13) (14) (15) .
INTRODUCTION
The co-morbidity of depression and chronic NCDs in Rwanda is an ongoing concern for health care providers,with estimated prevalence of depression among diabetic and hypertensive patients,for example, being 27% and 29% respectively (18) . Patients with chronic NCDs in Rwanda also face numerous difficulties in addition to the daily burden of managing their illnesses and their complications-difficulties common to patients from a developing country such as shortage of health care professionals, long distances to the health care settings and socioeconomic problems. Likewise, some of these patients have also been victims of the 1994 genocide in Rwanda: orphans, widows, the unemployed, or simply those who have no one to care for them. All these difficulties make patients from Rwanda with chronic NCDs vulnerable to stress, anxiety and depression.
INTRODUCTION
The focus of this study was to investigate the current situation regarding management of comorbidity of depression and chromic NCDs in Rwanda district hospitals. It therefore aimed to indicate potential solutions to deficiencies that emerge.
METHODS
This article is part of a larger study focussed on adapting the collaborative care model to the Rwandan context for management of co-morbid of depression and chronic NCDs. The study was ethically approved by the University of KwaZuluNatal Ethics Committee, the University of Rwanda Institutional Review Board and the Rwanda Ministry of Health.
METHODS
Action research sequential-explanatory design with mixed methods was used for the larger study. The study was conducted in three cycles adapted from action research procedures (19) . In the first cycle which was exploratory, the researcher identified the problem by exploring the prevalence of depression among diabetic and hypertensive patients and also the availability of protocol/interventions to manage this co morbidity. For this first cycle, mixed methods approach (Quantitative and qualitative) was used where quantitative approach was used to determine the prevalence of depression among participants with chronic NCDs represented by diabetes and hypertension in our study. While qualitative approach was used to identify existing protocol/interventions to manage this co morbidity. Therefore, this article presents the findings from the qualitative aspect which explored the current situation regarding management of the co-morbidity of depression and chronic NCDs in Rwanda district hospitals.
METHODS
The research areas were three selected district hospitals in Rwanda. The two first hospitals were district hospitals from urban area with endocrinology and mental health services, and the third hospital was a district hospital from a rural area with endocrinology and mental health services. The selection of hospitals from urban area and one from rural area increased the chance of sample representation from both urban and rural settings.
METHODS
In action research, researchers and health care practitioners come together to identify a problem and propose solutions (20) . Accordingly, a research team of 14 health professionals (two psychiatrists, three medical doctors, three registered nurses, three chief nurses and three mental health nurses) participated in our study. Simple random sampling was used to choose the team members. They were all working in three participating hospitals except for two psychiatrists who were working in other settings (in Rwanda there are no psychiatrists based in district hospitals). The inclusion criteria for the medical doctors and registered nurses was that they were already working with patients with chronic NCDs.
METHODS
Focus group discussion was used as a method of data collection. The focus group was held at the University of Rwanda, precisely at the College of Medicine and Health Sciences. Before the discussion took place, the researcher provided more information about the purpose of the study and asked the team members who agreed to participate in the study to sign the informed consents . Interviews conducted by the researcher followed the key questions on the structured interview guide, with a range of answers from the various team members on each question. The researcher played a facilitating role, making sure that the group focused on the problem being explored and encouraging participation by every team member. Audio tape and note-taking were used, and the research assistant (a registered nurse working in the Department of Nursing at the University of Rwanda) helped in the note-taking. The focus group meeting lasted for two hours.
METHODS
Content analysis of qualitative data was done using inductive approach. Data analysis by was conducted in three phases, as outlined by Elo and Kyngäs(21): a preparation phase, an organizing phase and a reporting phase. In the preparation phase, data was read and reread, and units of analysis were chosen. In the organizing phase, categories and sub-categories were developed, while in the reporting phase, results were reported.
METHODS
Research ethics was respected as the study involved human beings. Care was taken at each stage on permission to conduct the study and respondents' right to self-determination, privacy, anonymity, confidentiality, fair treatment and protection from harm and discomfort were observed. All participants signed the informed consent form. 
RESULTS

Categories and sub-categories emerging from questions exploring the current management of co-morbidity
Categories emerged from our analysis of data:
Categories and sub-categories emerging from questions exploring the current management of co-morbidity
 meaning of co-morbidity;  common co-morbidities;  awareness of co-morbid depression with chronic NCDs;  common NCDs associated with depression  screening tools of depression in patients with NCDs;  particular protocol or interventions to the management of co-morbidity of depression and NCDs.
Categories and sub-categories emerging from questions exploring the current management of co-morbidity
Meaning of co-morbidity: Participants offered various definitions which nonetheless which correlated with one another; all were in agreement that co-morbidity of illnesses is the occurrence of more than one disease in the same person.
Categories and sub-categories emerging from questions exploring the current management of co-morbidity
Common co-morbidities in the district hospitals: When asked about common comorbidities that they had to deal with in their respective hospitals, most participants cited diabetes and hypertension. Also, frequently cited by the participants were co-morbidities not just of two diseases but also of three diseases (e.g. diabetes, hypertension and gastritis; diabetes, hypertension and asthma; diabetes, hypertension and depression). Awareness about co-morbid depression with chronic NCDs: Participants' responses when asked if they were aware of this co-morbidity were grouped, following analysis, into five subcategories:  awareness of occurrence of the comorbidity;  non-focus on depression;  suspected by some signs and symptoms;  referral of the patient if suspected to the mental unit;  no follow up of the patient.
Awareness of occurrence of the co-morbidity
All respondents revealed that they knew very well that depression can occur any time in a patient with one or more chronic NCDs. A psychiatric explained that if a patient with both depression and one or more than one chronic NCDs happens to visit the hospital or be hospitalized, he will in that case be referred to the general hospital to get treatment for the medical problem and then come back for the mental problem.
Awareness of occurrence of the co-morbidity
Participants also explained that patients may not even recognize signs and symptoms of depression, and this may cause that most of them Don't consult for depression, since they are unware that they may have it.
Awareness of occurrence of the co-morbidity
Suspected from signs and symptoms: Participants explained that although depression is mostly unrecognized in patients with NCDs, with its signs and symptoms often being confused with those of the medical problem, there are some signs and symptoms which trigger suspicion of depression in a patient. 
Screening tools of depression in patients with
NCDs: Tools to screen for depression such as Patient Health Questionnaire-9 (PHQ-9) and Beck Depression Inventory (BDI) exist in district hospitals, and mental nurses use them every day to screen for depression. The surprise, however, was that mental nurses were not aware that these tools are also highly recommended for screening for depression among patients with chronic NCDs, PHQ-9 in particular (15) .
Particular protocols orinterventions to manage co-morbidity of depression and NCDs
No particular protocols or specific interventions: All participants confirmed that no particular protocols or interventions existed to manage this co-morbidity. 
No Follow up:
It was clear from the discussion that no follow-up was done by medical professionals once they had asked the patient to see the mental professionals. 
DISCUSSION

Awareness of co-morbid depression and chronic NCDs among health professionals (research team), and frequent NCDs associated with depression
The study found that the health care professionals were aware that depression can occur at any time in a patient with one or more chronic illnesses because of stress, fear or anger resulting from chronic illnesses. However, almost all the health professionals agreed that depression is mostly unrecognized in patients with chronic illnesses, either because the focus is on the medical condition or simply because of confusion between medical signs and depression signs. These findings correspond with those confirmed by other authors. According to Simon (22) , the presence of a chronic medical illness may reduce the possibility that physicians or other health care providers recognize or treat depression. Studies have also confirmed that depression is under-diagnosed and under-treated close to 50% to 65% of the time in primary health care settings (23) (24) (25) (26) .
Awareness of co-morbid depression and chronic NCDs among health professionals (research team), and frequent NCDs associated with depression
The study found that diabetes, hypertension and asthma were the conditions most reported by health professionals as associated with depression. They explained that these diseases are regarded by most patients as portending imminent death. These qualitative findings were confirmed by quantitative findings of this study that found out tha tdepression was higher in patients with diabetes and hypertension (83.8%). These findings confirm those from a systematic review of 31 studies in which higher numbers for depression were found in certain chronic illnesses thatincluded diabetes, asthma and cardiovascular diseases (27) . Polsky et al.(28) also reported that lung diseases and heart diseases are among those most associated with depressive patients. Other diseases reported by Kang et al. (29) as particularly associated with depression included cancer, stroke and acute coronary syndrome.
Screening tools to diagnose depression among patients with chronic NCDs
The findings revealed that in medical units at the district level, there were no specific screening tools to diagnose depression among patients with NCDs. Although the PHQ-9 questionnaire was available in mental health units of these hospitals, mental nurses had been trained by the Ministry of Health to use this tool to screen for depression only in patients with HIV/AIDS. Unfotenately the same nurses were not aware that the tool can be also used to screen for depression among patients with NCDs. Its use is in fact recommended by the WHO for this specific purpose (15) . We also found that the BDI was available at the psychiatric referral hospital for screening for depression in general. The tools most recommended by researchers for use in screening for depression among patients with NCDs are PHQ-9 and BDI (15, (30) (31) (32) .
Screening tools to diagnose depression among patients with chronic NCDs
Our findings suggested non-availability for medical staff at district level of depression screening tools for use among patients with NCDs. Screening tools should made available to medical doctors who should also receive training on how to use these tools to screen for depression among patients with NCDs. Early diagnosis of depression in patients with chronic illnesses is widely supported and recommended (15, 33, 34) .
Protocols or interventions to manage comorbidity of depression and NCDs
The study found that no specific protocols or interventions were in place for managing comorbidity of depression and chronic NCDs in the participating district hospitals. When comorbidity was present, it was handled through separate treatments by separate medical health and mental health professionals. There was no collaboration between these health care providers in treating this co-morbidity, and there was no follow-up from medical doctors who may have advised the patient to consult in the mental unit. This separated treatment of comorbid depression and chronic NCDs is not unique to Rwanda and is encountered in most developing countries, as has been shown by Clarke and Currie (17) .
Protocols or interventions to manage comorbidity of depression and NCDs
Despite WHO's recommendation of collaborative management of this co-morbidity between mental and medical professionals (13) , separated treatment persists (17) .
Protocols or interventions to manage comorbidity of depression and NCDs
This separate treatment continues to be associated with health complications such as complex medication regimens with high risk of drug interactions and poor medication adherence, duplicative medical tests, unnecessary hospitalizations, and worsening mortality (13) (14) (15) ).
Protocols or interventions to manage comorbidity of depression and NCDs
An important point here is that in Rwanda there is decentralized care of chronic NCDs at the primary level (district level) in a program known as "Integration of human resources for chronic care" in which a group of health professionals (4-10 generalist physicians, 2-3 chronic NCD nurses, 4-5 HIV and TB nurses and 2-3 neuropsychiatric nurses) are assigned to the district hospitals to care for chronic illnesses. Based on our findings, however, despite this integration of human resources, there is no evident collaborative strategy between these professionals and cases are seen and treated separately.
Protocols or interventions to manage comorbidity of depression and NCDs
In most developed countries, collaborative care is used in various settings, including the primary health care level, to manage the comorbidity of depression and chronic NCDs such diabetes, hypertension and certaint ypes of cancers, and has been proven cost effective for this purpose (13) (14) (15) . A randomised controlled trial in 14 primary care clinics in Washington State studied patients with depression and poorly controlled diabetes, or coronary heart disease, or both, and concluded that, compared with care as usual, collaborative care led to significant improvement in the management of depression and chronic diseases (32).
Protocols or interventions to manage comorbidity of depression and NCDs
Ali et al. (35) and Carney & Freedland (36) argued that management of chronic noncommunicable disorders based solely on the treatment of a single diagnosis is flawed from the public health perspective. This is because these chronic diseases are usually accompanied by variousco-morbidities such as hypertension, cardiovascular disease and, most commonly, depression, resulting in competing demands when patients seek care from different clinicians.
Protocols or interventions to manage comorbidity of depression and NCDs
In conclusion, our finding on absence of protocols or interventions to manage the comorbidity of depression and chronic NCDs means that patients with this co-morbidity continue to receive separated treatments that can have serious health consequences for them. We therefore suggest that there should be a shift from separate treatment of this co-morbidity to collaborative treatment in line with WHO's recommendations. This could be achieved by forming the collaborative care team constituted by a medical doctor, a mental health nurse and a registered nurse based at the district hospital.

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