Depression lets talk

Saturday, 8 April 2017

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 lets 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 worlds 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 ones 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, lets
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.]
Posted by Thavam