Scholarly article on topic 'Social determinants of depression and suicidal behaviour in the Caribbean: a systematic review'

Social determinants of depression and suicidal behaviour in the Caribbean: a systematic review Academic research paper on "Health sciences"

Share paper
Academic journal
BMC Public Health
OECD Field of science

Academic research paper on topic "Social determinants of depression and suicidal behaviour in the Caribbean: a systematic review"

Brown et al. BMC Public Health (2017) 17:577 DOI 10.1186/s12889-017-4371-z

BMC Public Health

Social determinants of depression and suicidal behaviour in the Caribbean: a systematic review


Catherine R Brown1*, Ian R Hambleton1, Natasha Sobers-Grannum2, Shawn M Hercules1,5, Nigel Unwin1, E Nigel Harris3, Rainford Wilks3, Marlene MacLeish4, Louis Sullivan4, Madhuvanti M Murphy2 and The U.S. Caribbean Alliance for Health Disparities Research Group (USCAHDR)

Background: Depressive disorder is the largest contributor to years lived with disability in the Caribbean, adding 948 per 100,000 in 2013. Depression is also a major risk factor for suicidal behaviour. Social inequalities influence the occurrence of depression, yet little is known about the social inequalities of this condition in the Caribbean. In support of the 2011 Rio Political Declaration on addressing health inequities, this article presents a systematic review of the role of social determinants on depression and its suicidal behaviours in the Caribbean.

Methods: Eight databases were searched for observational studies reporting associations between social determinants and depression frequency, severity, or outcomes. Based on the PROGRESS-plus checklist, we considered 9 social determinant groups (of 15 endpoints) for 6 depression endpoints, totalling 90 possible ways ('relationship groups') to explore the role of social determinants on depression. Studies with >50 participants conducted in Caribbean territories between 2004 and 2014 were eligible. The review was conducted according to STROBE and PRISMA guidelines. Results were planned as a narrative synthesis, with meta-analysis if possible.

Results: From 3951 citations, 55 articles from 45 studies were included. Most were classified as serious risk of bias. Fifty-seven relationship groups were reported by the 55 included articles, leaving 33 relationship groups (37%) without an evidence base. Most associations were reported for gender, age, residence, marital status, and education. Depression, its severity, and its outcomes were more common among females (except suicide which was more common among males), early and middle adolescents (among youth), and those with lower levels of education. Marriage emerged as both a risk and protective factor for depression score and prevalence, while several inequality relationships in Haiti were in contrast to typical trends.

Conclusion: The risk of bias and few numbers of studies within relationship groups restricted the synthesis of Caribbean evidence on social inequalities of depression. Along with more research focusing on regional social inequalities, attempts at standardizing reporting guidelines for observational studies of inequality and studies examining depression is necessitated. This review offers as a benchmark to prioritize future research into the social determinants of depression frequency and outcomes in the Caribbean.

* Correspondence:

1George Alleyne Chronic Disease Research Centre, Bridgetown, Barbados

Full list of author information is available at the end of the article


(3 BioMed Central

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.C International License (, which permits unrestricted use, distribution, anc reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to

the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.


The Global Burden of Disease study has ranked depressive disorders as the largest contributor to years lived with disability (YLD) in the Caribbean since 1990, with these conditions adding 948 YLD per 100,000 in 2013 [1, 2]. Among 15-49 year olds, this represents 10% of all YLD [1, 2]. Suicide, a last-resort outcome of depression, occurs at a global rate of 11.4 per 100,000, though stigma-associated underreporting underestimates the true value [3]. While suicide represents the second leading cause of death among 15-29 year olds globally, an important risk factor such as depression often goes un-diagnosed or untreated [3]. Even more, undiagnosed or untreated depression is a risk factor for increased adverse outcomes of many chronic and acute illnesses [4-8].

Social experiences throughout the life course influence the occurrence of depressive disorders and subsequent adverse outcomes [9]. For instance, income inequality, particularly in wealthy countries, is associated with a higher prevalence of mental disorders, and the degree of socioeconomic disadvantage is proportionate to the risk of developing such a disorder [10]. Moreover, when socioeconomic inequalities are perpetuated through generations, inequalities are further entrenched in depressive disorders over time [10]. Examining whether there are differences among particular groups, and determining their basis, can guide policy towards improving outcomes. The World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) has highlighted the role of health research in understanding health inequalities and inequities, and through the 2011 Rio Political Declaration, countries have committed to monitoring, understanding and addressing health inequities [11,12].

Globally, research on social determinants of depression and its outcomes is limited mostly to primary studies. Observational studies from India, USA, UK, and Europe report that older age, female gender, lower education, and poor economic status are associated with depression [13-17]. However, systematic reviews are limited in scope as they tend to focus narrowly on economic disadvantage, showing that the poor and disad-vantaged suffer disproportionately from common mental disorders and their adverse consequences [9, 18-20]. Other social determinants as well as other regions warrant exploration to illustrate whether regional or country-level contexts have a role to play [9]. To date, there has been no published systematic assessment of evidence on the social determinants of depression among Caribbean populations. This systematic review is guided by the analytical framework used to examine the social determinants of specific conditions by the WHO CSDH [21]. This review uses a simplified version of the framework to answer the primary research question: what is the distribution, by known social determinants

of health, of the frequency, severity, and adverse outcomes of depression among populations living in the Caribbean?


Full details of the review methodology are available in the study protocol (see Additional file 1). The protocol was guided by an initial scoping review of depression, a previous systematic review of social determinants of diabetes [22], and concurrent systematic reviews of breast and prostate cancer.

Eligibility criteria

Observational studies of any design were sought that reported relationships between a social determinant and depression frequency (incidence, prevalence), depression severity (score on any depression scale) or depression outcomes (suicide ideation, parasuicide, suicide). These particular outcomes were selected based on an initial scoping review of depression which showed a majority of research to examine these variables. Articles published between January 2004 and December 2014 in the dominant Caribbean languages (English, Spanish, French, and Dutch) were sought from 32 Caribbean territories. This 10-year period was selected as the study is taking place within the context of a major review of regional and national policy responses in the Caribbean to chronic non-communicable diseases [23]; therefore the findings have relevance to the current situation and could inform policy response.

Included studies drew upon samples from either the general population or healthcare facility catchments. Age restrictions were not used, but sample sizes <50 were excluded as unlikely to be fully representative of underlying populations. The selection of social determinants was guided by the extension of the PRISMA statement for the transparent reporting of systematic reviews and meta-analyses with a focus on health equity, which recommends the "PROGRESS-Plus" checklist [24]. This acronym checklist refers to a core list of social determinants, namely: place of residence, race or ethnicity (alternatively culture or language), occupation, gender, religion, education, socio-economic position (SEP), social capital, plus other social determinants that might be of interest [24]. For this study, 'age' was included a 'Plus' to this listing.

Search strategy, study selection, data extraction

The databases searched were: MEDLINE (via Pubmed); EMBASE (via Ovid); SciELO; PsycInfo (via EBSCO); CINAHL (via EBSCO); CUMED, LILACS, and IBECS (via WHO Virtual Health Library) [25-30]. The final search was conducted in February 2015. The search strategies are detailed in a supplementary file (see

Additional file 2). Search results were maintained in Endnote reference manager software [31].

Study selection and data abstraction were undertaken in duplicate by two independent reviewers (CRB, SMH); any inconsistencies were resolved by a third reviewer (MMM). Study selection was conducted in two stages. First, titles and abstracts were screened to identify potentially relevant articles; second, full-text screening of potentially relevant articles was conducted to identify articles for inclusion in the review. If inadequate information was available for decision-making in the first stage, the article automatically progressed to full-text review. In addition to those excluded, 8 articles were either inaccessible or awaiting publication [32-39]. With guidance by the STROBE statement on strengthening the reporting of observational studies in epidemiology and the PRISMA-Equity statement [40, 41], an electronic data abstraction form was created in REDCap database [42] (see Additional file 1).

Risk of bias assessment

Risk of bias was assessed according a tool adapted from STROBE and Cochrane ACROBAT-NRSi guidelines (see Additional file 1) [40, 43]. Bias was assessed in 5 domains at the relationship level: confounding (was control for known and potential confounders adequate?), participant selection (is the sample representative of the target population?), missing data (is the data reasonably complete?), outcome measurement (is a social determinant or disease endpoint appropriately measured?), selective reporting (is a relationship selectively reported?). Studies were classified as having serious, moderate, low, or unclear risk of bias. To accommodate the different tools and methods used to identify depressive disorders, the use of a validated tool and the involvement of clinical expertise were considered to be necessary features of the screening process. If a measurement tool was not validated or if a clinician was not involved in the screening, the relationship was classified as "high-risk" under the outcome measurement domain. Two reviewers (CRB, MMM) made an independent judgement on the overall risk of bias of each included article, considering equal importance of each domain and the likely direction and magnitude of the bias from each domain. Discrepancies were discussed by the two reviewers to achieve consensus.

Synthesis of results

The review was planned as a narrative synthesis with supplementary meta-analysis if possible. Key study details are presented, followed by a description of each association between a social determinant and either a measure of depression frequency, severity, or outcome. The number and type of inequality relationships were summarized in an

'evidence gap map' - a visual tool to highlight the current evidence on the social determinants of depressive disorders in the Caribbean and as a guide for focusing future research [44] Given the methodological heterogeneity of the study settings and their measurement tools, meta-analysis was not conducted.


Summary of included studies

Figure 1 presents a flowchart of articles identified, excluded, and included. Additional file 3: Table S1 describes characteristics of the 55 included articles, from 45 unique studies which examined one or more inequality relationships. Of these 55 articles, 29 reported on depression frequency, 15 reported on depression severity, and 18 reported on depression outcomes (12 articles overlapped examining measures from two endpoint groups). A total of 15 social determinants were examined. Depression frequency was reported as a prevalence in all articles. Studies were conducted in English-speaking (Bahamas, Barbados, Grenada, Guyana, Jamaica, St. Kitts & Nevis, St. Lucia, St. Vincent, Trinidad and Tobago); French-speaking (Haiti, Martinique); Spanish-speaking (Cuba, Dominican Republic, Puerto Rico); and Dutch-speaking (Suriname) Caribbean territories. Majority of articles originated from Cuba (n = 15) and Jamaica (n = 15).

Figure 2 illustrates the distribution of inequality relationships among the included articles. Across the nine categories of social determinants, there were a total of 15 social determinants and 6 review endpoints, totalling 90 inequality relationship groups that could have been reported. Fifty-seven (63%) of these relationship groups were reported by the 55 included articles, leaving 33 relationship groups (37%) without an evidence base. There were 222 inequality relationships reported: 86 on depression frequency, 15 on depression severity, and 121 on depression outcomes. When articles reporting data from same study were considered and removed, the number of inequality relationships fell to 214: 82 reporting depression frequency, 13 reporting depression severity, and 119 reporting depression outcomes. While most relationship groups were explored, the quantity of inequality relationships within each group was limited.

Risk of bias of included studies

A summary of the overall risk of bias classification assigned to each of the 55 articles is presented in Additional file 4: Table S2. Classifications specific to each article in each of the five domains are described in an extended table, Additional file 5: Table S3. Of the 55 articles, 11 were classified as moderate-risk, 31 were classified as serious-risk, 8 were classified as unclear-risk, 3 were classified as serious/moderate-risk, and 2 were classified as serious/unclear-risk. Figure 3 details the proportion of

Fig. 1 Flowchart of search strategy and article selectior

relationship classifications within each of the risk of bias domains. Overall, lack of adjustment for potential confounding was the main contributor to an increased risk of bias, followed by non-disclosure or inadequate handling of missing data. This collective high risk of bias of the included studies must be taken into consideration when interpreting results.

Results of inequality relationships

The amount of inequality relationships, stratified by social determinant, varied greatly - from 61 examining gender, to 1 examining crowding. The results of the social determinants which contributed the most relationships - gender, age, residence, marital status, and education - are detailed below. Descriptions for the remaining social determinants are located in a supplementary file, Additional file 6.


Gender was examined in 61 inequality relationships (58 unique) across 47 articles: depression prevalence (n = 23), depression score (n = 11), suicidal ideation (n = 7), parasuicide (n = 12), suicide (n = 8). Among these, 12 were classified as having moderate risk of bias, 38 as having serious risk of bias, and 11 as having

unclear risk of bias. Across depression prevalence, depression score, suicidal ideation and parasuicide, females outnumbered males with only minor exceptions: one study from Haiti found a slightly higher prevalence (92% vs 86.5%) and depression scores (x = 23.4 vs x = 21.1) among males [45]; and three studies showed slightly more parasuicide in males in Martinique and Puerto Rico [46, 47, 48]. Suicide, however, unanimously occurred more frequently by males across several countries [49-56].

Age was examined in 32 inequality relationships across 26 articles: depression prevalence (n = 11), depression score (n = 3), suicidal ideation (n = 5), parasuicide (n = 8), suicide (n = 5). Among these, 10 were classified as having moderate risk of bias, 17 as having serious risk of bias, and 5 as having unclear risk of bias. Of those studies examining depression in adolescents specifically, most found the highest prevalence and depression scores among 16 and 17 year olds [57-60]. However, suicidal ideation and parasuicide were more prevalent among younger adolescents aged <16 years than those older [46, 48, 61, 62]. Adult studies examining depression prevalence reported varied results, but the single adult

Social Determinant Frequency Severity Outcome

Incidence Prevalence Depression score Suicide ideation Parasuicide Suicide

p Residence 6 NIL 3MIX 1URB 3 RUR 5 RUR

Crowding IPOS

Physical Infrastructure 1 NEG 1 NEG

R Ethnicity 4 NIL 2 MIX UND 2 NIL 2 IND

O Occupation 6 MIX 1 NEG 1 NEG 4 NEG IPOS

G Gender 21 F 11 F 7 F 12 F 7 M

R Religion 2 NEG 1 NEG 2 NEG 2 NEG

E Education 6 NEG 4 NEG 2 NEG 3MIX

Income 6 NEG 3 NEG 2 NIL 3 NIL 1 NEG

s Social capital 3 NEG 2 NEG 3 NEG 2 NEG

Household structure (youth/adults) 4 BLEND/ 3 MIX 1 BLEND/ 1 SMALL 1 BLEND /- 2 BLEND/ 2 SMALL

Marital status 7 MIX 4 MIX 1 NIL 2 UNMAR 1 NIL

Social support 1 NIL 1 NEG 1 NIL

+ Age (youth/adults/elderly) 4 MA / 5 MIX/2 MIX 2 MA/1 POS/- 4 EA /1 NEG/- 2EA/6 Ml X/- 5 MIX (all ages)

No relationship reported One or more relationships reported

Number of relationships reported (articles reporting data from same study are classified as 1 relationship) Overall direction of effect of relationships NIL - no directionality; POS - positive relationship; NEG - negative relationship; MIX - mix of positive, negative, and nil relationships; URB - higher outcome variable among urban-dwellers; RUR - higher outcome variable among rural-dwellers; IND - higher outcome variable among persons of Indian ethnicity; F - higher outcome variable among females; M - higher outcome variable among males; BLEND - higher outcome variable among blended/reconstituted families; SMALL - higher outcome variable among smaller households; UNMAR - higher outcome variable among unmarried persons; EA - higher outcome variable among early adolescents (11-14); MA - higher outcome variable among middle adolescents (15-17)

Fig. 2 Summary of 214 unique inequality relationships among 55 included articles [45-86, 99, 100-111]

study examining depression score found older age to be associated with increased scores for both genders in Haiti [63]. The sole adult study examining suicidal ideation in adults found Puerto Ricans aged <50 years to be more likely to perform this than those aged >64 years (OR 1.71, 95%CI 1.39-2.65) [48]. Lower rates of parasui-cide and suicide were also reported among elderly, but without a definitive peak among the younger age groups [47-51, 53, 54, 64, 65]. An exception is one registry-based study which reported a peak suicide rate of 28.7 per 100,000 in Cubans aged >74 years, with rates decreasing with age [50].


Residence was examined in 22 inequality relationships (18 unique) across 20 articles: depression prevalence (n = 7), depression score (n = 5), suicidal ideation (n = 1), parasuicide (n = 3), suicide (n = 6). Among these, 6 were classified as having moderate risk of bias, 14 as having serious risk of bias, and 2 as having unclear risk of bias. No associations were found between residence and depression prevalence [66-72]. Depression score was examined on a country-level. Two studies examining elderly in three countries found depression

scores to be higher in the Dominican Republic, followed by Cuba, then Barbados [73, 74]. One study reported higher depression scores among Jamaican adolescents than adolescents in St. Vincent, St. Kitts and The Bahamas [75-77]. Jamaican adolescents living in urban areas reported a higher prevalence of suicidal ideation among than those living in rural areas [78]. This is to contrast what is seen for parasuicide and suicide, which occurred more often in rural areas [46-53]. One study examined suicide in a country-level; highest rates were found in in Guyana (22.4 per 100,000) and Suriname (15.3), followed by Trinidad (7.0), Cuba (4.0) and Puerto Rico (3.6) [54].

Marital status

Marital status was examined in 16 inequality relationships (15 unique) across 12 articles: depression prevalence (n = 8), depression score (n = 4), suicidal ideation (n = 1), parasuicide (n = 2), suicide (n = 1). Among these, 3 were classified as having moderate risk of bias, 12 as having serious risk of bias, and 1 as having unclear risk of bias. Overall findings across these variables were inconclusive. While a higher depression prevalence was found among persons not in a relationship in Cuba,

Selective reporting

Measurement of outcomes

Missing data

Participant selection


0% 10% 2096 30% 40% 50% 60% 70% 80% 90% 100% Low Moderate ■ Serious Unclear

Fig. 3 The proportion of risk of bias classifications of the 222 relationships among each of the risk of bias domains

Barbados, and Trinidad [73, 79, 80], studies from Jamaica found higher prevalence among persons who are married versus unmarried [81, 82]. The same applies for depression score: higher scores were reported among unmarried persons in Haiti and Jamaica [63, 81], but also among married persons in another two studies from Jamaica and Puerto Rico [82, 83]. Two studies examining parasuicide reported married persons to be less likely to report parasuicide [47, 48].


Education was examined in 15 inequality relationships across 13 articles: depression prevalence (n = 6), depression score (n = 4), suicidal ideation (n = 2), parasuicide (n = 3). Among these, 1 was classified as having moderate risk of bias, 13 as having serious risk of bias, and 1 as having unclear risk of bias. Most studies examining the frequency and score of depression and suicide ideation demonstrated a higher prevalence/score among persons with less education or maternal education [48, 58, 70, 79, 81, 82, 84-86]. In Trinidad, persons with primary education only are nearly three times as likely to have depression than those with secondary or higher education (OR 2.7, 95%CI 1.4-5.1) [84]. Suicidal ideation was twice as common among Puerto Ricans with <12 years of overall education when compared to those with >3 years of college education (OR 2.21, 95%CI 1.313.74) [48]. The single Haitian study examining education contrasted these trends, which found higher depression scores among more educated females [63].


Summary of evidence

This systematic review has examined the extent of evidence on the influence of social determinants of health on depression frequency, severity, and adverse outcomes

in the Caribbean. Fifty-five articles from 45 separate studies were included. With 90 possible ways (relationship groups) of exploring the role of social determinants on depression, 222 relationships were reported looking at 57 distinct relationship groups, leaving 33 relationship groups (37%) without an evidence base.

Overall, most of our findings mirror global trends [87]. Depression frequency, depression severity, and suicidal behaviour were higher among females (with the exception of suicide being more common in males); persons with lower education, income, and occupation levels; those participating in less religious activity; and those with less social capital and support. The connection between depression and social inequity is not a new phenomenon as disadvantaged groups have been shown to place individuals at a higher risk of developing and dying from this condition [9, 18, 87]. For instance, the occurrence of common mental disorders is shown to be associated with low educational attainment, material disadvantage, unemployment, and social isolation [19, 87]. This social class gradient is more marked among females than males [9], perhaps partly explaining the heavy female burden of mental disorder.

Important to note, however, are the geographic and cultural idiosyncrasies that can affect mental health trends, making the examination of depression highly context-specific [9, 87, 88]. For instance, evidence from Haiti contrasted typical global trends. The two Haitian studies in this review found a higher depression prevalence and scores in males than females, higher depression scores among those with more education than less, and higher depression scores with increasing age than decreasing age [45, 63]. Haiti's poor economic situation, exacerbated by recent natural disasters, could be an explanatory factor for increases in scores in these groups as violence and childhood neglect, both associated with

current and later-life depression, increase with decreasing economies [45, 88]. Specifically, increased depression scores in more highly educated Haitian women could result from a cognitive dissonance between an optimistic aspiration of professional employment and the stark reality of the country's limited employment opportunities [63, 89].

Interestingly, there is a paucity of research (n = 3) from Suriname and Guyana, two countries which not only have predominant portions of East Indians making up their ethnography, but also some of the highest rates of suicide worldwide [90-92]. Suicide has permeated the East Indian culture, often glorified as courageous and a means to avoid shame and disgrace [93]. Whether the impact of ethnicity on depression/suicidal behaviour is grounded in deep cultural customs or perhaps social disparities woven into ethnic status of these countries is an area which needs further investigation.

Social factors act as buffers throughout stressful circumstances (such as living in a low SEP) by offering emotional, informational, or instrumental resources [9, 94] This is evidenced in the negative associations found with social capital, social support and social household structure. For this reason, our overall inconclusive finding for marital status is unexpected as marriage is generally thought to offer improved social capital and support [87, 95, 96]. Furthermore, marital status in Jamaica was a risk factor for depression prevalence and severity, while studies in other Caribbean territories found it to be protective or have no association. This begs to consider the quality and context of marriages in Caribbean countries, as particular factors such as relationship quality, extended family support, and ability to cope with marital stress and child rearing likely confound relationships between marital status and depression occurence [88, 95]. The interaction between social determinants themselves is an important consideration. As in this example, the relationship between marital status and depression may be moderated by the level of social support outside of the marriage. More specifically, the inverse relationship between education and depression is certainly moderated by the setting, as can be seen in evidence in Haiti versus other Caribbean countries.

Contradictory reports might also be due to differing methodology. Assessing risk of bias of depression studies was challenging due to lack of detail and explicitness of the measurement of depression and suicidal behaviour. For example, some studies failed to state the depression scale used (was it evidence-based?) or who delivered the scale (was this individual trained?). In attempts at accommodating these elements, risk of bias methodology considered 'validation of measurement tools' and 'clinician involvement' in the measurements of variables.

These added caveats emphasize the significance of and need for a standardised tool for assessing risk of bias of subjective measures such as depression, as a gold standard does not currently exist. It is recommended that researchers in this field give sufficient detail on the methods of assessment to allow for more objectivity in reporting.

The relationship between depression and social factors can be bidirectional; while depression perpetuates reduced education, employment and income by interfering with ones capacity to function in productive roles, this social decline can itself increase the development of depression and exacerbate its outcomes [9]. Regardless, the median rate for treated depression is only 50%, of which only a small proportion of this treatment is considered adequate [87]. Treatment deficiencies could be improved more efficiently by considering the social inequities that put certain groups at higher risk.

How best to fill this evident research gap is an important consideration [97]. While improving the quality of studies is a recommendation across the board, it is less obvious whether research should be prioritized to focus on areas with no research (Fig. 2, red boxes) or to work towards improving the existing low-level evidence base (Fig. 2, green boxes). Currently, regional focus on mental health is weak, and many mental health systems are behind in their efforts at decentralization and prevention services [98]. Examining the social inequalities help, at the very least, to justify prioritization of addressing mental deprivation and inequality in the Caribbean.


There is an unavoidable limitation in social determinant studies: interrelationships among the social determinants themselves which act as confounders. Caribbean evidence is limited in its quality and distribution across social determinants. The majority of articles were classified as having high risk of bias, mostly because of failure to adjust for important potential confounders, but also due to the variation in sampling and screening instruments. Additionally, inconclusive findings within many relationship groups could at least be partially due to a small number of studies available within each group. There is also the potential for missing data from individual studies, possibly due to the sensitivity of the disease and its outcomes and associated non-reporting. The Caribbean has been considered as one region in this review, masking what is likely to be important country-level variation in the relative importance of social determinants. Country-level information on depression screening and access to treatment are important potential confounders that were not assessed. No explicit searching was conducted for grey literature due to limited resources.


Of 15 social determinants examined, gender, age, residence, marital status, and education contributed the most inequality relationships, with gender accounting for 27% of all relationships. The WHO CSDH has emphasised the importance in understanding health inequalities, and the Caribbean has pledged to address these [11, 12]. Along with more research focusing on regional social disparities in the Caribbean, attempts at standardizing observational reporting guidelines for observational studies of inequality is necessitated. This review offers as a benchmark to prioritize future research into the social determinants of depression frequency, severity, and outcomes in the Caribbean.

Additional files

Additional file 1: Study Protocol, which details the study protocol for the systematic review. (PDF 2252 kb)

Additional file 2: Search Strategy, which details the search strategies of the database. (PDF 472 kb)

Additional file 3: Table S1. Characteristics of 55 articles from the Caribbean region describing the socialdistribution of depression [45-86, 99, 100-120]. (XLSX 41 kb)

Additional file 4: Table S2. Risk of bias among 222 inequality relationships from 55 included articles [45-86, 99, 100-111]. (XLSX 14 kb)

Additional file 5: Table S3. Extended risk of bias classification table of 55 included articles, to supplement Table S2, which depicts the risk of bias classification of each of the five domains for individualrelationships of each article. (XLSX 21 kb)

Additional file 6: Supplementary Narrative of Results of Inequality Relationships, which describes additionalresults for remaining social determinants not discussed narratively in the main paper. (DOCX 54 kb)


CINAHL: Cumulative Index of Nursing and Allied Health Literature; CSDH: Commission on the SocialDeterminants of Health; CUMED: Cuba Medicina; EMBASE: Excerpta Medica Database; IBECS: Índice Bibliográfico Españolen Ciencias de la Salud; LILACS: Latin American and Caribbean Health Sciences; MEDLINE: MedicalLiterature Analysis and RetrievalSystem Online, or MEDLARS Online; NCD: Non-communicable disease; SciELO: Scientific Electronic Library Online; STROBE: Strengthening the Reporting of Observational studies in EpidemiologySEPSocioeconomic Position; USCAHDR: United States Caribbean Alliance for Health Disparities Research Group; WHO: World Health Organization


Members of the U.S. Caribbean Alliance for Health Disparities Research Group outside of the writing group are acknowledged for their support in this research: Nadia Bennett, Aurelian Bidulescu, Trevor Ferguson, Damian Francis, Christopher Hassell, Anselm JM Hennis, Lynda Williams, and Novie Younger-Coleman.

Members of the USCAHDR Group with affiliations (in alphabetical order) are: Alvarado M, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Bennett N, The University of the West Indies, Kingston, Jamaica, West Indies. Bidulescu A, Indiana University, Bloomington, IN, USA. Brown CR, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Ferguson T, The University of the West Indies, Kingston, Jamaica, West Indies. Francis D, The University of the West Indies, Kingston, Jamaica, West Indies. Hambleton IR, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Harris EN, The University of the West Indies, Kingston, Jamaica, West Indies. Hassell C, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Hennis AJM, Chronic Disease Research Centre, Bridgetown,

Barbados, West Indies. Hercules SM, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Howitt C, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. MacLeish M, The Sullivan Alliance, Alexandria, VA, USA. Murphy MM, The University of the West Indies, Cave Hill, Barbados, West Indies. Samuels TA, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Sobers-Grannum N, The University of the West Indies, Cave Hill, Barbados, West Indies. Sullivan L, The Sullivan Alliance, Alexandria, VA, USA. Unwin N, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Wilks R, The University of the West Indies, Kingston, Jamaica, West Indies. Williams L, Chronic Disease Research Centre, Bridgetown, Barbados, West Indies. Younger-Coleman N, The University of the West Indies, Kingston, Jamaica, West Indies.

Availability of data and material

The data that support the findings of this study are available from the databases used in the study but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the originalstudy author.

Authors' contributions

CRB- design of the work, acquisition, analysis, and interpretation of data, drafting the work, finalapprovalof the version to be published. IRH-conception and design of the work, analysis and interpretation of data, drafting the work, revising it critically for important intellectualcontent, final approvalof the version to be published. NS-G- conception and design of the work, acquisition, analysis and interpretation of data, drafting the work, final approvalof the version to be published. SMH- design of the work, acquisition and interpretation of data, finalapprovalof the version to be published. NU - conception and design of the work, interpretation of data, revising it critically for important intellectualcontent, finalapprovalof the version to be published. ENH- conception and design of the work, revising it critically for important intellectualcontent, finalapprovalof the version to be published. RW- conception and design of the work, revising it critically for important intellectual content, finalapprovalof the version to be published. MM- conception and design of the work, revising it critically for important intellectual content, finalapproval of the version to be published. LS- conception and design of the work, revising it critically for important intellectualcontent, finalapprovalof the version to be published. MMM- conception and design of the work, analysis and interpretation of data, drafting the work, revising it critically for important intellectualcontent, finalapprovalof the version to be published.


This study was fully supported by grant number U24MD006959 from the NationalInstitute on Minority Health and Health Disparities. The funding body was not involved in the design of the study, collection, analysis, and interpretation of data, nor the writing the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the officialviews of the NationalInstitute on Minority Health and Health Disparities or the National Institutes of Health.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Publisher's Note

Springer Nature remains neutralwith regard to jurisdictionalclaims in published maps and institutionalaffiliations.

Author details

1George Alleyne Chronic Disease Research Centre, Bridgetown, Barbados. 2The University of the West Indies, Cave Hill, Barbados. 3The University of the West Indies, Kingston, Jamaica. 4Sullivan Alliance, Alexandria, VA, USA. 5McMaster University, Hamilton, Canada.

Received: 5 August 2016 Accepted: 7 May 2017 Published online: 15 June 2017


1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380(9859):2095-128.

2. Institute for Health Metrics and Evaluation. GBD Compare 2013. http:// Accessed 13 Mar 2016.

3. World Health Organization. Preventing suicide: A global imperative. 2014. pdf?ua=1&ua=1. Accessed 12 Jul 2016.

4. Lin EHB, Heckbert SR, Rutter CM, Katon WJ, Ciechanowski P, Ludman EJ, et al. Depression and increased mortality in diabetes: unexpected causes of death. Ann Fam Med. 2009;7(5):414-21.

5. Freedland KE, Carney RM. Depression as a risk factor for adverse outcomes in coronary heart disease. BMC Med. 2013;11:131.

6. Coughlin SS. Anxiety and depression: linkages with viral diseases. Public Health Rev. 2012;34(2):92.

7. Pan A, Sun Q, Okereke OI, Rexrode KM, Hu FB. Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review. JAMA. 2011; 306(11):1241-9.

8. Zivin K, Ilgen MA, Pfeiffer PN, Welsh DE, McCarthy J, Valenstein M, et al. Early mortality and years of potential life lost among veterans affairs patients with depression. Psychiatr Serv. 2012;63(8):823-6.

9. World Health Organization. Social determinants of mental health. 2014. pdf?ua=1. Accessed 29 Mar 2016.

10. Campion J, Bhugra D, Bailey S, Marmot M. Inequality and mental disorders: opportunities for action. Lancet Lond Engl. 2013;382(9888):183-4.

11. Commission on Social Determinants of Health. Closing the gap in a generation: health inequity through action on the social determinants of health. 2008. finalreport_2008.pdf?ua=1. Accessed 20 July 2015.

12. World Health Organization. Rio political declaration on social determinants of health. declaration.pdf?ua=1. Accessed 20 Jul 2015.

13. Shidhaye R, Gangale S, Patel V. Prevalence and treatment coverage for depression: a population-based survey in Vidarbhan, India. Soc Psychiatry Psychiatr Epidemiol. 2016;51:993-1003.

14. Pabayo R, Dunn EC, Gilman SE, Kawachi I, Molnar BE. Income inequality within urban settings and depressive symptoms among adolescents. J Epidemiol Community Health. 2016;70:997-1003.

15. De Oliveira G, Cianelli R, Gattamorta K, Kowalski N, Peragallo N. Social Determinants of Depression Among Hispanic Women. J Am Psychiatr Nurses Assoc. 2016 Sep 13;[Epub ahead of print].

16. Lee BX, Marotta PL, Blay-Tofey M, Wang W, de Bourmont S. Economic correlates of violent death rates in forty countries, 1962-2008: a cross-typological analysis. Aggress Violent Behav. 2014;19:729-37.

17. Niedhammer I, Lesuffleur T, Coutrot T, Chastang J-F. Contribution of working conditions to occupational inequalities in depressive symptoms: results from the national French SUMER survey. Int Arch Occup Environ Health. 2016;89:1025-37.

18. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: a systematic review. Soc Sci Med. 2010;71:517-28.

19. Fryers T, Melzer D, Jenkins R, Brugha T. The distribution of the common mental disorders: social inequalities in Europe. Clin Pract Epidemiol Ment Health CP EMH. 2005;1:14.

20. Thomson H, Thomas S, Sellstrom E, Petticrew M. The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007. Am J Public Health. 2009;99(Suppl 3):S681-92.

21. Blas E, Kurup AS, editors. Equity, social determinants, and public health programmes. 2010. 9789241563970_eng.pdf. Accessed 27 Oct 2015.

22. Sobers-Grannum N, Murphy MM, Nielsen A, Guell C, Samuels TA, Bishop L, et al. Female gender is a social determinant of diabetes in the Caribbean: a systematic review and meta-analysis. PLoS One. 2015;10(5): e0126799.

23. International Development Research Council. Evaluating CARICOM's political commitments for non-communicable disease prevention and control. 2015; Accessed 10 Nov 2015

24. O'Neill J, Tabish H, Welch V, Petticrew M, Pottie K, Clarke M, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol. 2014;67(1):56—64.

25. U.S. National Library of Medicine. Fact Sheet MEDLINE, PubMed, and PMC (PubMed Central): How are they different? 2015. pubs/factsheets/dif_med_pub.html. Accessed 13 Aug 2015.

26. Elsevier R&D Solutions. Embase Fact Sheet. 2015. https://www.elsevier.


Sheet-Web.pdf. Accessed 13 Aug 2015.

27. SciELO FAPESP, BIRME. SciELO. SciELO. n.d.; Accessed 13 Aug 2015

28. EBSCO. CINAHL Database. 2015. Accessed 13 Aug 2015.

29. Centro Nacional de Información de Ciencias Médicas, Infomed. Bibliographic Databases. n.d. en&component=30&item=3. Accessed 13 Aug 2015.

30. EBSCO. PsycINFO. 2015. Accessed 9 Mar 2015.

31. EndNote. Philadephia: Thomson Reuters;2014. Accessed

10 Nov 2015.

32. Colderbank A. Social support and behavioral outcomes among Haitian orphans. Alder School of Professional Psychology 2009. http://gradworks. Accessed 12 Jul 2015.

33. Rivera S. Suicide attempt and characteristics of religiously affiliated Puerto Rican adolescents and young adults. Andrews University. 2005;https://www. characteristics_of_religiously_affiliated_Puerto_Rican_adolescents_and_ young_adults. Accessed 12 Jul 2016

34. Etheridge W. Association between west Indian adolescent depression and family environment among male juvenile delinquents. Walden University. 2004; Accessed 12 Jul 2015

35. Vazquez-Garcia HA. Actividad en la comunidad: Puerto Rican adolescents' participation in community activities and psychological wellbeing. [USA]. 2004.

36. González-Cortés D, Reyes-Ortiz SSV, Reyes-Robles M. A variation by gender of suicidal behaviors and substance use associations in a sample of adolescents of Caribbean state island, Saint Lucia: a secondary analysis using who 2007 global school-based student health survey. In: Child Mental Health Interventions. Turkey: Blackwell Publishing; 2011. http://www. Accessed 12 Jul 2016.

37. Mangon E, Grabot D, Charles-Nicholas A. Données descriptives d'usagers de crack en Martinique. Alcoologie Addictologie. 2006;28(4):327-35.

38. Martínez GL, Herrero R, Fabelo C, Diaz D, McCarthy V. A socio-demographic, psychiatric and medical profile of inpatient suicide attempters in a psychiatric hospital of Puerto Rico. Bol Asoc Médica P R. 2009;101(1):23-30.

39. Reid SD, Ramcharan C, Ghany K. Substance abuse among first admissions to the psychiatric unit of a general hospital in Trinidad. West Indian Med J. 2004;53(2):95-9.

40. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9.

41. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E, et al. PRISMA-equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. PLoS Med. 2012;9(10):e1001333.

42. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.

43. A Cochrane risk of bias assessment tool: for non-randomized studies of interventions (ACROBAT-NRSI), version 1.0.0 The Cochrane Collaboration. 2014. Accessed

11 Nov 2015.

44. Snilstveit B, Vojtkova M, Bhavsar A, Gaarder M. Evidence gap maps: A tool for promoting evidence-informed policy and prioritizing future research. Report No.: WPS6725. The World Bank. 2013. https://openknowledge. Accessed 3' May 2016.

45. Martsolf DS. Childhood maltreatment and mental and physical health in Haitian adults. J Nurs Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs Sigma Theta Tau. 2004;36(4):293-9.

46. Bandiera FC, Ramirez R, Arheart KL, Canino G, Goodwin RD. Asthma and suicidal ideation and behavior among Puerto Rican older children and adolescents. J Nerv Ment Dis. 2013;201(7):587-91.

47. Slama F, Dehurtevent B, Even J-D, Charles-Nicolas A, Ballon N, Slama R. Characteristics of a French African Caribbean epidemiological psychiatric sample with a history of suicide attempt. Suicide Life Threat Behav. 2008; 38(6):720-7.

48. Vera M, Reyes-Rabanillo ML, Huertas S, Juarbe D, Pérez-Pedrogo C, Huertas A, et al. Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico. Int J Gen Med. 2011; 4:197-205.

49. Abel WD, James K, Bridgelal-Nagassar R, Holder-Nevins D, Eldemire H, Thompson E, et al. The epidemiology of suicide in Jamaica 2002-2010: rates and patterns. West Indian Med J. 2012;61(5):509-15.

50. Campa CM, Cantún D, Luis C, Santana RS, Cisnero MB, García C, et al. Caracterización epidemiológica de la conducta suicida en la provincia de Santiago de Cuba. MEDISAN. 2012;16(2):205-11.

51. Graafsma T, Kerkhof A, Gibson D, Badloe R, van de Beek LM. High rates of suicide and attempted suicide using pesticides in Nickerie, Suriname, South America. Crisis. 2006;27(2):77-81.

52. Holder-Nevins D, James K, Bridgelal-Nagassar R, Bailey A, Thompson E, Eldemire H, et al. Suicide among adolescents in Jamaica: what do we know? West Indian Med J. 2012 Aug;61(5):516-20.

53. Hutchinson G. Variation of homicidal and suicidal behaviour within Trinidad and Tobago and the associated ecological risk factors. West Indian Med J. 2005;54(5):319-24.

54. Quinlan-Davidson M, Sanhueza A, Espinosa I, Escamilla-Cejudo JA, Maddaleno M. Suicide among young people in the Americas. J Adolesc Health. 2014;54(3):262-8.

55. Rodríguez MV, Fernández R, Esther C, Zayas AG, Palacios S, Riccis S, et al. Mortalidad por causas violentas en hombres de la provincia de Santiago de Cuba durante 2011. MEDISAN. 2013;1 7(5):767-73.

56. Zulueta TDP. Gender disparities in mortality: challenges for health equity in Puerto Rico. Acta Colomb Psicol. 2013;16(2):103-14.

57. Ekundayo OJ, Dodson-Stallworth J, Roofe M, Aban IB, Kempf MC, Ehiri JE,

et al. Prevalence and correlates of depressive symptoms among high school students in Hanover, Jamaica. Sci World J. 2007;7:567-76.

58. Lowe GA, Lipps G, Halliday S, Morris A, Clarke N, Wilson RN. Depressive symptoms among fourth form students in St. Kitts and Nevis high schools. Sci World J. 2009;9:149-57.

59. Maharaj RG, Alli F, Cumberbatch K, Laloo P, Mohammed S, Ramesar A, et al. Depression among adolescents, aged 13-19 years, attending secondary schools in Trinidad: prevalence and associated factors. West Indian Med J. 2008;57(4):352-9.

60. Maharajh HD, Ali A, Konings M. Adolescent depression in Trinidad and Tobago. Eur Child Adolesc Psychiatry. 2006;15(1):30-7.

61. Kukoyi OY, Shuaib FM, Campbell-Forrester S, Crossman L, Jolly PE. Suicidal ideation and suicide attempt among adolescents in western Jamaica: a preliminary study. Crisis. 2010;31(6):317-27.

62. Rudatsikira E, Muula AS, Siziya S. Prevalence and associated factors of suicidal ideation among school-going adolescents in Guyana: results from a cross sectional study. Clin Pract Epidemiol Ment Health CP EMH. 2007;3:13.

63. Wagenaar BH, Hagaman AK, Kaiser BN, McLean KE, Kohrt BA. Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti. BMC Psychiatry. 2012;12:149.

64. Machado AV, Rodriguez RR, Martinez AO. Epidemiologia del intento suicida en el servicio de urgencia. Rev Hosp Psiquiátrico Habana. 2009;6(2).

65. Veranes MC, Sánchez AG, Alvarez G, María L, Laera YM, Naranjo JN. Tentativa de suicidio en la población mayor de 15 años durante el bienio 2011-2012. MEDISAN. 2013;17(10):6072-9.

66. Abel WD, Bailey-Davidson Y, Gibson RC, Martin JS, Sewell CA, James S, et al. Depressive symptoms in adolescents in Jamaica. West Indian Med J. 2012; 61(5):494-8.

67. Balogun O, Koyanagi A, Stickley A, Gilmour S, Shibuya K. Alcohol consumption and psychological distress in adolescents: a multi-country study. J Adolesc Health Off Publ Soc Adolesc Med. 2014;54(2): 228-34.

68. Canino G, Shrout PE, Rubio-Stipec M, Bird HR, Bravo M, Ramirez R, et al. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry. 2004;61(1):85-93.

69. Menéndez J, Guevara A, Arcia N, León Díaz EM, Marín C, Alfonso JC. Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean. Rev Panam Salud Pública Pan Am J Public Health. 2005;17(5-6):353-61.

70. Mullings JA, McCaw-Binns AM, Archer C, Wilks R. Gender differences in the effects of urban neighborhood on depressive symptoms in Jamaica. Rev Panam Salud Pública Pan Am J Public Health. 2013;34(6):385-92.

71. Sousa RM, Ferri CP, Acosta D, Albanese E, Guerra M, Huang Y, et al. Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 dementia research group population-based survey. Lancet Lond Engl. 2009;374(9704):1821-30.

72. Zunzunegui M-V, Alvarado B-E, Béland F, Vissandjee B. Explaining health differences between men and women in later life: a cross-city comparison in Latin America and the Caribbean. Soc Sci Med. 2009; 68(2):235-42.

73. Alvarado BE, Zunzunegui MV, Béland F, Sicotte M, Tellechea L. Social and gender inequalities in depressive symptoms among urban older adults of latin america and the Caribbean. J Gerontol B Psychol Sci Soc Sci. 2007; 62(4):S226-36.

74. Prina AM, Ferri CP, Guerra M, Brayne C, Prince M. Co-occurrence of anxiety and depression amongst older adults in low- and middle-income countries: findings from the 10/66 study. Psychol Med. 2011;41(10):2047-56.

75. Lipps GE, Lowe GA, Halliday S, Morris-Patterson A, Clarke N, Wilson RN. The association of academic tracking to depressive symptoms among adolescents in three Caribbean countries. Child Adolesc Psychiatry Ment Health. 2010;4:16.

76. Lipps G, Lowe GA, Gibson RC, Halliday S, Morris A, Clarke N, et al. Parenting and depressive symptoms among adolescents in four Caribbean societies. Child Adolesc Psychiatry Ment Health. 2012;6:31.

77. Lowe GA, Lipps G, Gibson RC, Halliday S, Morris A, Clarke N, et al. Neighbourhood factors and depression among adolescents in four Caribbean countries. PLoS One. 2014 23;9(4):e95538.

78. Abel WD, Sewell C, Martin JS, Bailey-Davidson Y, Fox K. Suicide ideation in Jamaican youth: sociodemographic prevalence, protective and risk factors. West Indian Med J. 2012;61(5):521-5.

79. Maharaj RG. Depression and the nature of Trinidadian family practice: a cross-sectional study. BMC Fam Pract. 2007;8:25.

80. Sicotte M, Alvarado BE, León E-M, Zunzunegui M-V. Social networks and depressive symptoms among elderly women and men in Havana Cuba. Aging Ment Health. 2008;12(2):193-201.

81. Lowe GA, Lipps GE, Young R. Factors associated with depression in students at the University of the West Indies, Mona Jamaica. West Indian Med J. 2009;58(1):21-7.

82. Monroe CE, Affuso O, Martin MY, Aung M, Crossman L, Jolly PE. Correlates of symptoms of depression and anxiety among clinic patients in western Jamaica. West Indian Med J. 2013;62(6):533-42.

83. Reyes-Rodríguez ML, Rivera-Medina CL, Cámara-Fuentes L, Suárez-Torres A, Bernal G. Depression symptoms and stressful life events among college students in Puerto Rico. J Affect Disord. 2013;145(3):324-30.

84. Maharaj RG, Reid SD, Misir A, Simeon DT. Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad. West Indian Med J. 2005 Dec;54(6):369-74.

85. Pérez G, Nora R, Sosa Zamora M, Reyes C, Luís J, Mojena Orue D, et al. Algunos factores favorecedores de la depresión neurótica en longevos hospitalizados. MEDISAN. 2012;16(9):1366-72.

86. Suau GM, Normandia R, Rodriguez R, Romaguera J, Segarra L. Depressive symptoms and risk factors among perimenopausal women. P R Health Sci J. 2005;24(3):207-10.

87. World Federation for Mental Health. Depression: A global crisis. 2012. http:// depression_wmhd_2012.pdf?ua=1. Accessed 8 Jun 2016.

88. World Health Organization. World report on violence and health. 2002.

World%20report%20on%20violence%20and%20health%202002. pdf?sequence=1&isAllowed=y. Accessed 1 Jun 2016.

89. Eggerman M, Panter-Brick C. Suffering, hope, and entrapment: resilience and cultural values in Afghanistan. Soc Sci Med. 2010;71(1):71 -83.

90. World Health Organization Map Production: Health Statistics and Information Systems. Age-standardized suicide rates (per 100,000 population), both sexes, 2012. 2014. Files/Maps/Global_AS_suicide_rates_bothsexes_2012.png?ua=1. Accessed 1 Jun 2016.

91. Central Intelligence Agency: The World Factbook: Suriname. 2016. https:// Accessed 1 June 2016.

92. Central Intelligence Agency: The World Factbook: Guyana. 2016. https:// Accessed 1 June 2016.

93. Radhakrishnan R, Andrade C. Suicide: An Indian perspective. Indian J Psychiatry. 2012;54(4):304-19.

94. Miller L, Wickramaratne P, Gameroff MJ, Sage M, Tenke CE, Weissman MM. Religiosity and major depression in adults at high risk: a ten-year prospective study. Am J Psychiatry. 2012;169(1):89-94.

95. Scott KM, Wells JE, Angermeyer M, Brugha TS, Bromet E, Demyttenaere K, et al. Gender and the relationship between marital status and first onset of mood, anxiety and substance use disorders. Psychol Med. 2010;40(9):1495-505.

96. Okereke OI. Prevention of late-life depression: current clinical challenges and priorities. New York: Humana Press; 2015.

97. Dechartres A, Ravaud P. Better prioritization to increase research value and decrease waste. BMC Med. 2015;13:244.

98. World Health Organization: Mental Health Systems In the Caribbean Region. World Health Organization; 2011.

99. Ali A, Maharajh HD. Social predictors of suicidal behaviour in adolescents in Trinidad and Tobago. Soc Psychiatry Psychiatr Epidemiol. 2005;40(3):186-91.

100. Disdier-Flores OM. Association of major depression and diabetes in medically indigent Puerto Rican adults. P R Health Sci J. 2010;29(1):30-5.

101. Fox K, Gordon-Strachan G, Johnson A, Ashley D. Jamaican youth health status 2005. West Indian Med J. 2009 Dec;58(6):533-8.

102. González-Tejera G, Canino G, Ramírez R, Chávez L, Shrout P, Bird H, et al. Examining minor and major depression in adolescents. J Child Psychol Psychiatry. 2005;46(8):888-99.

103. Guerra L, Carlos J, Guerra Hernández, A M, Perera Miniet E. Comportamiento de las enfermedades crónicas no transmisibles en adultos mayores. Rev Cuba Med Gen Integral. 2008 Dec;24(4).

104. Laborde JE, Sáez-Santiago E. Association between obesity and symptoms of depression of adults in Puerto Rico. P R Health Sci J. 2013;32(3):132-7.

105. López JN, Vázquez MM. Factores de riesgo de intento suicida en adolescentes. MEDISAN. 2010 Apr;14(3).

106. Maharajh HD, Neuro D, Ali A. Adolescent depression in Tobago. Int J Adolesc Med Health. 2004;16(4):337-42.

107. Martin JS, Neita SM, Gibson RC. Depression among cardiovascular disease patients on a consultation-liaison service at a general hospital in Jamaica. West Indian Med J. 2012;61(5):499-503.

108. McFarlane S, Younger N, Francis D, Gordon-Strachan G, Wilks R. Risk behaviours and adolescent depression in Jamaica. Int J Adolesc Youth. 2014;19(4):458-67.

109. Nichols SD, Dookeran SS, Ragbir KK, Dalrymple N. Body image perception and the risk of unhealthy behaviours among university students. West Indian Med J. 2009;58(5):465-71.

110. Otero AG, Pradesdela Rosa E, Quintana MF, Legra YL, Medina CZ. Evaluación de los estados funcional y afectivo en la población geriátrica del área de salud "28 de Septiembre.". MEDISAN. 2013;17(2):205-12.

111. Slama F, Merle S, Ursulet G, Charles-Nicolas A, Ballon N. Prevalence of and risk factors for lifetime suicide attempts among Caribbean people in the French West Indies. Psychiatry Res. 2011;190(2-3):271-4.

112. Fox K, Gordon-Strachan G. Jamaican Youth Risk and Resiliency Behaviour Survey 2005. Jamaica Ministry of Health. Report No.: TR-07-58. 2007. http:// Accessed 22 Feb 2016.

113. Bunker CH, Patrick AL, Konety BR, Dhir R, Brufsky AM, Vivas CA, et al. High prevalence of screening-detected prostate cancer among afro-Caribbeans: the Tobago prostate cancer survey. Cancer Epidemiol Biomark Prev. 2002; 11(8):726-9.

114. World Health Organization. Global school-based student health survey (GSHS) [Internet]. 2016. Accessed 22 Mar 2016.

115. Bird HR, Canino GJ, Davies M, Duarte CS, Febo V, Ramírez R, et al. A study of disruptive behavior disorders in Puerto Rican youth: I. Background, design, and survey methods. J Am Acad Child Adolesc Psychiatry. 2006;45(9): 1032-41.

116. 10/66 Dementia Research Group. Research Studies. 2015. uk/1066/research.php. Accessed 22 Mar 2016.

117. Division of Population Health, Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System 2016. https:// Accessed 10 Feb 2016.

118. Wilks R, Younger N, McFarlane S, Francis D, van den Broek J. Jamaican Youth Risk and Resiliency Behaviour Survey 2006. Report No.: TR-07-64. 2007. Accessed 22 Mar 2016.

119. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica Health and Lifestyle Survey 2007-8. Report No.: IS09001:2000. 2008. http://www. Accessed 22 Mar 2016.

120. Vera M, Perez-Pedrogo C, Huertas SE, Reyes-Rabanillo ML, Juarbe D, Huertas A, et al. Collaborative care for depressed patients with chronic medical conditions: a randomized trial in Puerto Rico. Psychiatr Serv Wash DC. 2010; 61(2):144-50.