World Mental Health Day 10th October 2012

Depression - A Global Crisis

Prof Fareed A MinhasHead Institute of Psychiatry

Rawalpindi Medical College

Depression

Depression is a mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration.

Moreover, depression often comes with symptoms of anxiety and sometimes with unexplained bodily complaints.

DepressionAt its worst, depression can lead to suicide.

Almost 1 million lives are lost yearly due to suicide, which translates to 3000 suicide deaths every day

For every person who completes a suicide, 20 or more may attempt to end his or her life

(WHO, 2012)

BurdenBurAbout 350 million people worldwide live with depression.

In most Regions of the world only less than 30% of those who need treatment do receive it. In many countries this is even less than 10%.

Depression in women is 1.5 times more prevalent than in men.

In high income countries one in ten and in low and middle income countries one in five of women who give birth to a child develop depression.

In Pakistan

M en1 0 % (M u m ford 2 0 0 0 )- 3 3 % (Javed 1 9 9 4 )

W om en2 8 .8 % (R ab b an i)- 6 6 % (M u m ford 1 9 9 7 )

R an d om C om m u n ity S am p le3 3 .6 2 %

In Rural Punjab

66% of women & 25% of men suffered from Depressive and Anxiety disorders

Levels of emotional distress increased with age in both genders

Women reported more distress than men

British Journal Of Psychiatry(1997),170,473-478

In Urban Rawalpindi

25% of women & 10 % of men suffered from Depressive and Anxiety disorders

Levels of emotional distress increased with age

Higher levels of education were associated with lower risk of common mental disorders

British Journal of Psychiatry (2000)-177,557-562

Impact

People with depression can not perform well at work, home or at school.

Depression is the leading cause of disability worldwide in terms of years lost due to disability (YLD).

In its most severe forms, depression may lead to suicide.

Every year one million people kill themselves. Many of them as a consequence of untreated depression.

ImpactDepression is the leading cause of disability for

both males and females, whereby the burden of depression is 50% higher for females than males (WHO, 2008)

Depression is the leading cause of disease burden for women in both high-income and low- and middle-income countries (WHO, 2008)

Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children (Rahman et al, 2008).

Depression and chronic physical illnesses

The comorbidity of depression and many chronic conditions is well established.

Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Preventing Chronic Disease 2005;2:A14

Depression can be considered as an etiologic and prognostic factor for ischemic heart disease ( it may cause ischemic heart disease)

Nicholson A, Kuper H, Hemingway H. Depression as an etiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006;27:2763-74

A 2012 meta- analysis supports that even subclinical psychological distress as measured by GHQ-12 increases over all medical mortality especially cardiovascular death.

Russ TC. et al Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. BMJ 2012; 345:e4933.

Reported prevalence of depression in patients with physical illnesses

Surveys show patients with physical illnesses have high prevalence of depression:Rheumatoid arthritis1 15–36%Parkinson’s disease2 17%Following myocardial infarction3 20%Diabetes4,5 11*–15%Dementia6 40–50%Breast cancer7 10–25% Cancer (receiving palliative care)8 5–26%

1. Bird H, Broggini M. J Rheumatol 2000;27:2791-7; 2. Reijnders JS et al. Mov Disorders 2008;23:183-9; 3. Thombs BD et al. J Gen Internal Medicine 2005;21:30-8; 4. Anderson RJ et al. Diabetes Care 2001;24:1069-78;

5. Gavard JA et al. Diabetes Care 1993;16:1167-78; 6. Wragg RE, Jeste, DV. Am J Psychiat 1989;146:577-87; 7. Fann JR et al. Gen Hosp Psychiatry 2008;30:112-26; 8. Hotopf M et al. Palliative Medicine 2002;16:81-97;

9. ESEMed/MHEDEA 2000 Investigators. Acta Psychiatr Scand 2004;109(Suppl 420):21-7.

Prevalence of depressive episode in people with chronic physical conditions

Moussavi et al, Lancet 2007; 370, 851-8

No ch

roni

c ph

ys. c

ondi

tion

Angi

na

Arth

ritis

Diabe

tes

Asth

ma

Two

or m

ore

cond

ition

s0

5

10

15

20

25

InterventionDepression can be reliably diagnosed and treated

in primary care, as outlined in the WHO mhGAP Intervention Guide

Preferable treatment options consist of basic psychosocial support combined with antidepressant medication or psychotherapy, such as cognitive behavior therapy, interpersonal psychotherapy or problem-solving treatment.

Intervention effectiveness in resourceconstrained settings

Over the past decade, a number of clinical trials have shown the effectiveness of treatment for depression across a range of resource settings.

A trial carried out in rural Uganda, showed that

group interpersonal psychotherapy substantially reduced the symptoms and prevalence of depression among 341 men (Bolton et al, 2003)

Intervention effectiveness in resourceconstrained settings

In India a trial was conducted to test the effectiveness of an intervention led by lay health counselors in primary care settings

The trial found that patients in the intervention group were more likely to have recovered at 6 months than patients in the control group, and therefore that an intervention by a trained lay counselor can lead to an improvement in recovery from depression (Patel et al, 2010).

For non specialist health care providers

To accept and understand people with depression. Give them an opportunity to talk

To increase their knowledge and skills on depression,

its identification and management. (http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/index.html)

To respect confidentiality principles and encourage patients' companies, family and friends to support them

For schools and community care provider

Recognize depression. Accept and support people with depression

Do not exclude them from education or work. Do not blame them. Depression is not laziness

Encourage and involve people with depression in sports and social activities

Encourage them to seek treatment

Reducing the burden of depressionThe global burden of depression poses a

substantial public health challenge, at the social, economic as well and clinical level

There are a number of well-defined and evidence-based strategies that can effectively address or combat this burden.

The key interventions are treatment with generic antidepressant drugs and brief psychotherapy.

Reducing the burden of depressionEffective community approaches to prevent depression

focus on several actions surrounding the strengthening of protective factors and the reduction of risk factors.

School-based programs targeting cognitive, problem-solving and social skills of children and adolescents

Exercise programs for the elderly.

Interventions for parents of children with conduct problems aimed at improving parental psychosocial well-being by information provision

Conclusion

Depression is a mental disorder that is pervasive in the world and affects us all. Unlike many large-scale international problems, a solution for depression is at hand.

Efficacious and cost-effective treatments are available to improve the health and the lives of the millions of people around the world suffering from depression.

On an individual community, and national level, it is time to educate ourselves about depression and support those who are suffering from this mental disorder.

Thank you