Depression – let’s talk

World Health Day is celebrated every year on 7 April and marks the anniversary of the founding of the World Health Organisation (WHO). The WHO has chosen the theme ‘Depression – let’s talk’ to celebrate World Health Day this year. The rationale for choosing this theme is due to the rising number of people living with depression across the world but a significantly low number of people coming forward seeking help. This is despite depression being a treatable illness. Stigma surrounding mental illness is considered as one of the main barriers for people accessing help. Therefore, the chosen theme to celebrate World Health Day is apt and an obvious one. This article is aimed at the public at large, aiming to generate a conversation about the what, how and why questions related to depression. The latter part is aimed at practitioners and policymakers in healthcare. 

What is depression?

Depression is an illness characterised by persistent sadness (note the word persistent) and a loss of interest in activities that one normally used to enjoy, accompanied by an inability to carry out daily activities for at least two weeks. In other words, functional impairment (usual daily activities being affected) should exist, whether at work, home or both. While we all feel sad and low from time to time, some people experience these feelings intensely and for longer periods – depression is more than just a low mood.

People with depression normally have several of the following symptoms; loss of energy; a change in appetite; sleeping more or less; anxiety; reduced concentration; indecisiveness, restlessness; feelings of worthlessness, guilt or hopelessness; and thoughts of self-harm or suicide. These symptoms may vary depending on the severity, which can range from minimal, mild, moderate or severe. It is important to note that depression is not a sign of weakness or something to be ashamed of as it can affect anyone at any time. A qualified healthcare professional would be able to diagnose someone with depression. 

How common is depression?

Depression is common across all ages, gender, ethnicities, religions/faiths and people from different socio-economic backgrounds. The WHO estimated that over 320 million people (4.4% of world’s population) are living with depression in 2015. Approximately 50% of them live in the South-East Asian and Western Pacific Regions. In Sri Lanka, this was estimated to be approximately 800,000 people or 4.1% of the population. Current estimates suggest a higher figure, approaching 1 million people living with depression in Sri Lanka. 

Recent studies conducted in the Northern Province in Sri Lanka suggest that prevalence of depression was common and perhaps slightly higher than other parts of the country. Studies in the post-conflict populations tend to generally show a definite increase in the incidence and prevalence of mental disorders, with women being more affected than men. Sri Lanka is no exception.

Depression is the single leading cause of disability and has devastating social and economic costs for individuals, communities and nations. This is estimated at $ 1 trillion globally. Depression accounts for loss in productivity, sickness and absence from work, relationship problems, worsening of existing physical health problems and so on. At the far extreme, if not treated, depression can cause suicide, which is the second leading cause of death among 15-29 year olds. Sri Lanka has one of the highest suicide rates in the world, with an average of 6,000 deaths per year; nearly 100,000 people will attempt suicide every year in Sri Lanka. 

What are the causes and risk factors?

Although it is difficult to single out a definitive cause for depression, it is understood that depression results from a complex interaction of social, psychological and biological factors. People who have gone through life events such as bereavement, unemployment, psychological trauma are at risk of developing depression. Additionally, exposure to prolonged stress and substance misuse (alcohol and/or drugs) may increase the risk. It is important to note that not all people will develop depression based on the above mentioned life events – it is also dependent on the coping mechanisms we have to deal with adverse life events and the supportive relationships we establish with people around us. 

Epidemiological studies show a two-times increase in depression in people with diabetes compared with the general global population, resulting in adverse effects on illness and death. The two conditions maintain a bidirectional relationship whereby diabetes contributes to depression and depression in those with diabetes is associated with non-adherence to diabetes treatment, increased diabetes complications, and poor control in blood glucose levels. The inter-relationship between physical health and depression extends to other conditions such as those with cardiovascular diseases (e.g. stroke and heart diseases), cancer, and chronic respiratory diseases (e.g. asthma). These diseases can lead to depression and the vice versa. 

How can we prevent and treat depression?

Everyone can make simple changes to their life to take better care of health and well-being. They can range from; eating healthy and keeping active; maintaining strong supportive relationships with family and friends; learning ways to cope and maintain a positive attitude; making time for activities that are enjoyable and taking breaks from work; learning relaxation or breathing exercises to de-stress; and recognising early signs of depression and seeking help. 

Research also suggests that meditation is effective in the prevention and treatment of depression. Recently, it has been widely used in Western countries as a treatment option. 

Psychological therapies such as Cognitive Behaviour Therapy (CBT) are well known to be effective in the treatment of depression. CBT helps people to learn new ways of thinking, practice positive behaviours and take active steps to cope and overcome situations and problems. Generally, a qualified healthcare professional can provide CBT and it may mean attending psychology sessions (more commonly used as counselling in Sri Lanka) for an agreed time period. 

A doctor may also prescribe medication, usually an anti-depressant, to help someone overcome depression. Anti-depressants generally take 2-4 weeks to work and prescribed for few to several months until the symptoms of depression have diminished and the person is able to cope without the medication. 

How can you help someone with depression?

Showing that you care by listening is one simple way of helping someone with depression. Although it may sound simple, active listening and empathy towards the person without making any judgment can be extremely helpful. A depressed person may not find it useful to hear things like ‘get over it’, ‘snap out of it’, ‘you are weak and you should be stronger’. Offering emotional support, reassurance and encouragement to seek professional help are also recommended. 

Healthcare practitioners and policymakers

This section focuses on mental health policy and practice, aimed at healthcare practitioners and policymakers. We do know that Sri Lanka has a good primary healthcare system (first level of contact for majority of people – e.g. health centre doctor, local dispensary and surgery as commonly known) with increased access to free healthcare services when compared with some other countries in the region. 

The majority of people with common mental health problems (depression and anxiety) will access primary healthcare services, an area now recognised as important for screening and detection of depression and anxiety. Many people with somatic complaints (pain, neurologic problems, gastrointestinal complaints) often see doctors in primary healthcare settings and usually complain of a lack of sleep, palpitations, tightness of the chest, loss of appetite, back, neck or shoulder pain, dizziness and many more. In the absence of a physical health condition, these can be regarded as concealment of their mental state. Research suggests that people from cultures within this region frequently present to primary healthcare with above symptoms, which can explain an underlying mental illness. 

More affluent communities in Sri Lanka may access medical services from a wide range of specialists – simply because of affordability and the trend that has been established in urban areas. While some may call this ‘doctor shopping’, these specialist doctors examining patients should take a good history of help seeking behaviour of patients and consider if there are any underlying somatic ailments/mental illness.

There is an urgent need to fully integrate mental health into the role of doctors practicing across the healthcare system. There are a number of simple screening tools (usually several questions to ask) that has been validated across different cultural settings to detect depression and anxiety. The Patient Held Questionnaire 9 (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7) are widely used in primary healthcare settings throughout the world. Doctors who are comfortable talking about psychological factors should be encouraged to use PHQ9 and GAD 7 in their routine practice. 

The benefits of the detection and management of common mental health problems will secure huge benefits not only for the patient and loved ones, but there is good evidence to suggest that the frequency of subsequent patient visits to healthcare facilities will lessen thus reducing the burden on the healthcare system as a whole. Furthermore, addressing the mental health of patients will significantly improve their physical health.

The development of national clinical guidelines on depression to standardise clinical practice across all healthcare settings is another area for policymakers to consider. Implementation may require training across the health sector, which needs to be carefully planned and cascaded to ensure that the conversation of mental health is not a one-off event and that it is well embedded into routine practice of doctors. Training and education should also include addressing the stigma attached to mental illness, as research conducted among Sri Lankan doctors and undergraduates shows stigmatising attitudes towards mental illnesses as some see patients as blameworthy.

Mental health prevention and promotion work should also target the pubic, using mass media campaigns to normalise mental health problems, which can help increase the uptake of treatment services. Stories of people who are in recovery are widely used in the western societies and are known to be powerful in terms of carrying specific messages related to mental health. Many Sri Lankans use smart phones and active on social media – another area for mental health promotion and prevention.

While the healthcare system has a significant role to play in terms of mental health promotion, prevention and treatment of depression, there is also a need to move beyond urgency-driven medical solutions and incorporate public health perspectives, policies and approaches in managing depression. Considering that approximately one million people are estimated to be living with depression in Sri Lanka, depression needs to be framed within the context of a public health problem that requires a multi-sectorial response. 

Similar to the emphasis given on diabetes and other non-communicable diseases, depression needs to be recognised and placed on the national agenda as an illness that requires a public health response. This is in the context of the rapidly ageing population in Sri Lanka, who are at increased risk for developing depression. The burden on the healthcare system would be immense due to the complexities that can arise from co-morbidity among the elderly. 

Many studies have demonstrated the link between poverty and common mental health problems such as depression and anxiety in low and middle income countries. The experience of insecurity and hopelessness, low levels of education, rapid social change, risk of violence and physical illness are postulated as links between poverty and poor mental health. Poor mental health worsens the economic situation, setting up a vicious cycle of poverty and mental disorders. Population-based strategies of meeting basic needs of clean water, sanitation, nutrition, immunisation, housing, health and employment and initiatives for gender justice have been suggested as strategies to reduce distress and suicide.

Good mental health is a sense of well-being, confidence and self-esteem that enables one to fully enjoy life. Along with taking care of one’s physical health, having strong relationships, social connections and caring loved ones play an important role in improving the sense of overall well-being. The conversation on depression should not be limited to slogans. The recent evidence on the number of people experiencing depression is a timely wake-up call to re-think if existing systems to help people with depression are working or not. In conclusion, everyone should know that depression is an illness and that it is treatable. So, let’s talk.

[The writer, Dr. Nimesh Samarasinghe (PhD, MSc, BSc (Hons), DipHE) has extenstive experience working in the British National Health Service in clinical, managerial and commissioning roles. He is currently working as a Consultant, assisting the State of Qatar to develop and modernise their health services.]