DEPRESSION AND ITS BURDEN

Cases of depression have been recognized as a health problem from the dawn of medicine.  The torments of King Saul, referred to in the Book of Samuel, would today be clearly recognized as a typical case of depression.  It was probably Hypocrates, in the 4^th. century BC, who first made a clinical description of depression as melancholia, in line with the theory of the four humours then prevailing. 

Nowadays, depression is a common mental disorder affecting about 150 million people worldwide, of all genders, ages, and backgrounds. This represents 1%-10% (depending on the methodology of the study) of the general population: Women (especially young mothers), persons with a personal or family history of depression, those suffering from different chronic diseases (subs hypertension, diabetes, rheumatism, etc), those who are poor, socially isolated, or are experiencing severe life stressors are at particularly high risk for depression.

The risk of depression increase with age and tend to be associated also with the occurrence of other mental health problems (particularly alcoholism) and of different chronic physical health problems (e. g.  hypertension, diabetes, stroke, Parkinson’s disease, tuberculosis and HIV/AIDS).  This condition is called co-morbidity and its appropriate management represents one of the major challenges of current Public Health.

Diagnostic criteria for depression include symptoms such as sad or low mood, loss of interest or pleasure, disturbed sleep, poor concentration, guilt or low self-worth, disturbed appetite, poor energy, decreased interest in and enjoyment of sex, physical agitation or slowing, and thoughts or acts of suicide.  People with major depression experience 5 or more of these symptoms nearly every day for 2 weeks or more.

At its worst, depression can lead to suicide, a tragic fatality associated with the loss of nearly 1 million lives per year. Untreated depression may remit after a number of weeks or months, but depression is a recurrent or chronic problem for more than 50 % of those affected.

It is also associated with substantial losses in daily functioning and productivity, and greatly contributes to reduce the quality of life. It  is currently the leading cause of disability and the fourth major cause of the global burden of disease (GBD).  If we look at specific groups, it is the leading cause of disease burden for women between 15 and 44 in both developed and developing countries, and is the second leading cause of disease burden for men in this age group. It is predicted that depressive illness will be the leading cause of disease burden worldwide by the year 2020, representing 7.1% of the total burden of disease.

DEPRESSION AND PRIMARY HEALTH CARE

Approximately  5% – 15 % (once again, depending on the methodological factors) of patients seen in primary health care, for whatever reasons, are depressed.  However, only approximately 50 % of depressed patients are recognized in primary health care settings, and fewer than 25 % receive effective treatments such as antidepressant medications or appropriate psychotherapy (in some countries fewer than 5 %).

There are several effective interventions for depressive illness, both pharmacological and psychosocial. In spite of the possibility of these being delivered even by non-physicians, there is a wide gap between their availability and widespread implementation.

Antidepressant medications and brief, structured forms of psychotherapy are effective in 60 – 80 % of patients with depression; both antidepressant medications and psychotherapy can be delivered in primary health care settings by primary health care personnel.

Unfortunately, antidepressants are often not used at sufficient doses or for a sufficient period of time. Many depressed patients unduly receive sedative medications that are not effective for depression and can cause dangerous side effects or drug dependence, whereas antidepressant medications are not addictive.

In the best case scenarios (i.e. in countries with well developed health systems), it has been estimated that not more than 35% of persons suffering from depressive illness receive treatment. In other countries such as Sub-Saharan Africa and China, treatment rates for depression are as low as 5%.

If depression is not so difficult to be diagnosed, if more than one modality of effective treatment exists, why is it that so many people with depression are not treated appropriately? Why so large a treatment gap?

THE TREATMENT GAP IN DEPRESSION

A series of factors and elements conspire to this state of affairs.  Primo, a lack of awareness in both the population and in primary health care staff on the early signs of depression and of the means available to combat them.  Secundo, the stigma and discrimination still attached in many places to mental disorders in general  - including depressive states - which limits (a) the degree to which patients present for treatment, (b) the degree to which doctors and health workers have been trained adequately as well as their willingness to intervene, and (c) the willingness of decision-makers to fund depression-related programmes.  Tertio, the poor or limited application of cost-effective mental health interventions due to: inadequate undergraduate curriculum of health schools, lack of national care guidelines, scarcity of skilled policy makers and health professionals, restricted availability of essential psychotropic drugs (including modern antidepressants) particularly at lower levels of the health system. Quarto, a lack of facilities and care management for systematically following up those who have had a recognized episode of depression.

In brief, barriers to effective care of people with depression include the social stigma associated with mental disorders including depression, the lack of resources and the lack of trained providers.

OVERCOMING THE PROBLEM

Traditionally, the initiatives taken by different agencies (universities, professional organizations, departments of mental health, etc) to overcome this situation have classically concentrated on either (i) the production and dissemination of resources for improving depression care, target most frequently at mental health care professionals, as well as workshops to strengthen their capacity to identify and treat depression or (ii) events to increase awareness about depression and to reduce the stigma associated with depression.  More recently, programmes on quality improvement programmes for depression have been tested in a few places and have shown positive results.

However, in view of the magnitude of the problem, and the nature of the existing effective interventions, a need is felt to adopt other approaches, basically centred on the primary health care strategy. Primary care based programmes for depression have been shown to improve the quality of care, satisfaction with care, health outcomes, functioning, economic productivity, and household wealth at a reasonable cost.

In this respect, the following activities should be put into action:

§         The improvement of the capacity of countries to create policies supportive of improving care for depression and to provide effective management of depression in primary care, in the framework of the Primary Health Care strategy.

§         Educational activities aimed at patients, family members, providers, and policy makers on depression and its treatment.

§         Training of primary health care personnel in the early diagnosis and management of depression.

RECENT INNOVATIONS

In relation to the latter point, a few recent and innovative initiatives deserve our attention and further reflection.

Recently, a training programme on the detection and treatment of depression was tested by the PAHO/WHO.  In it, nurses working in primary health care clinics were  randomized into two groups, one of which was exposed to the training programme and the other one was not (control group).

The content of the training included diagnostic issues, treatment options and side effects of treatment.  The nurses who underwent the training programme showed a statistically significant improvement in knowledge and detection of depression; in addition, they increased their notification and referral of patients with depression to physicians.  No change was noted in the control group.

Also, an experimental programme exploring the potential of hairdressers to identify depression among their clients and refer them to health services is right now going on.  This is far from the traditional medical approach but fits very well within the primary health care strategy, on the use of community resources to overcome health problems.  We hope to be able to report on the follow-up of this project soon.

THE ROLE OF SPIRITUAL LEADERS

And here comes another innovative idea; the integration of spiritual leaders into the process that aims at reducing the gap between treated and untreated depression.

The very nature of the pastoral action brings spiritual leaders into contact with people who are suffering in different ways an we have reasons to believe that for many of them depression  is an important component of their suffering.  Without denying the spiritual dimension of the suffering, there could be room for the consideration of depression as another dimension of that suffering.  In such cases, the referral of the person to a health care facility would be much appropriate; this could be facilitated by previous contacts between spiritual and health leaders.

CONCLUSION

People with depression are hundreds of millions (the problem), cost-effective treatments exist (technology), facilities and personnel to care for people with depression also exist (infrastructure).  There is no reason why someone suffering from depression – irrespective of age, sex, social class or place of residence – should not receive appropriate treatment.  There is no reason why not to mobilize current technology and infrastructure to benefit those people.

It has been estimated that the Global Burden of Disease attributable to depression could be reduced by more than 50% if all individuals with depressive illness were treated with methods currently available. Improving treatment rates will reduce disability and health care costs and will also improve economic and social productivity.

The challenge is ahead of us to find intelligent solutions with the elements available and to identify new ones. There is no justification to remain inactive or, worse, repeating errors and mistakes of the past.

Dr. B. SARACENO
Director, Department of Mental Health and Substance Dependence
World Health Organization
Geneva, Switzerland