Attitudes towards Depression among Primary Healthcare Providers in Contrasting Fragility Contexts in Lebanon: A Cross Sectional Study [Working paper]

Abstract

Background: Depression is a leading contributor to global disability, yet significant treatment gaps persist—particularly in fragile and low-resource settings. In Lebanon, efforts such as the WHO’s Mental Health Gap Action Programme (mhGAP) and the National Mental Health Program (NMHP) aim to improve mental health integration within primary care. This study investigates the attitudes of primary healthcare providers (HCPs) toward depression in two contrasting Lebanese contexts—urban Beirut and rural Bekaa—and examines how mhGAP training influences these attitudes.

Methods: A cross-sectional survey was conducted in 2020 using the 22-item Revised Depression Attitude Questionnaire (R-DAQ) was administered to 237 HCPs across 11 Ministry of Public Health (MoPH) Primary Healthcare Centers (PHCCs) in Beirut and Bekaa. Data collection included socio-demographics, mental health training background, and clinical experience. Quantitative analysis involved descriptive statistics, t-tests, ANOVA, multiple regression, and exploratory factor analysis.

Results: Most participants were female (60.3%) and based in Beirut (59.9%), with nearly half being medical doctors. While 94.4% reported frequent encounters with patients experiencing mental health issues, only 40.7% had received mental health training, and less than half of those were trained on mhGAP. Overall, HCPs held neutral-to-positive attitudes toward depression (mean R-DAQ score = 79 ± 8.08), with the strongest agreement around the need for a generalist approach. Professional confidence was moderate, and therapeutic optimism was mixed, with some respondents endorsing stigmatizing beliefs.

Attitudes were significantly more positive among HCPs trained in mhGAP, working in Beirut, having postgraduate education, or regularly encountering mental health patients. Multivariable analysis confirmed that mhGAP training and practice setting were key predictors of more favorable attitudes. Exploratory factor analysis validated the original three-factor structure of the R-DAQ.

Conclusion: While primary care providers in Lebanon generally support integrating mental health into routine care, gaps remain in training and confidence—especially in more fragile rural settings. Scaling up evidence-based training such as mhGAP may enhance provider preparedness and reduce stigma toward depression, supporting broader mental health reform efforts in fragile health systems.