Depression: Treating a global killer

Overwhelming figures: An estimated 400 million people in the world suffer from depression, and there are about 3,000 reported suicide deaths every day.

Depression is one of the most widespread of disorders, and often coexists with other serious illnesses.

Today, it is one of the leading causes of disease in the world. What this means is that depression is a major contributor worldwide in terms of total years lost due to disability.

An estimated 400 million people in the world suffer from depression and there are about 3,000 reported suicide deaths every day.

These alarming figures are significant because the overwhelming majority of people who commit suicide are persons with mental illness, particularly depression.

The degree of pain of a person with depression can be understood if one considers that many prefer death to their suffering.

The figures mentioned here should be a wake-up call for us to address depression as a global issue. Thus, "Depression: A Global Crisis" has been chosen as the theme for World Mental Health Day 2012. This day is commemorated all over the world on October 10 each year, and it provides an excellent opportunity to highlight issues concerning mental health.

Symptoms of depression

It is important to differentiate between normal sadness and depression. Under adverse situations, like death of a relative, personal humiliation (loss of face), disappointment, or loss of social or financial status, a psychological reaction is expected, and is of course, normal.

Over a period of time, one can get over this sadness. This is an "adaptive" response to an upsetting situation.

A dysfunctional response, which means a prolongation of symptoms, usually for more than two weeks, can result in clinical depression.

A person suffering from depression may present with low mood, loss of interest in pleasurable activities (anhedonia), decreased energy, feelings of guilt or low self worth, disturbed sleep or appetite, and poor concentration.

Of these, the two significant symptoms are low mood and anhedonia. These problems can become chronic, leading to substantial impairment in an individual's ability to take care of his or her every day responsibilities.

At its worst, depression can lead to suicide, or even homicide.

People who experience depression are often unable to complete daily tasks and do not enjoy activities they previously took pleasure in. They would often worry too much about the future and have negative thoughts about themselves and their circumstances.

Often, they experience irritability and agitation, and may complain of exhaustion. They may become more easily upset with those around them. Irritability, agitation and fatigue are often made worse by changes in sleeping patterns.

Depression can lead to individuals feeling trapped or hopeless about their situation, and suicidal thoughts are commonly experienced. In severe depression, these thoughts are acted upon.

On rare occasions, untreated depression can lead to danger to others as well. For example, in severe post partum depression, the suicidal mother may not want to leave the child "alone", and therefore may murder out of love, and then commit suicide.

Suicide by motor vehicle is dangerous to others as the driver has no control of the actual outcome.

Sometimes, depression can express itself in different ways. It can hide behind a variety of conditions, from being accident prone to sexual dysfunction.

It can also occur together with a great number of conditions like anxiety, panic attacks, alcoholism and drug abuse.

It can also result from physical illnesses like cancer, diabetes and chronic pain.

In some cases, depression could be masked. This is also known as "depression without depression", or "smiling depression". In such cases, the cardinal symptom of depression - low mood - is difficult to elicit and requires great clinical skills and experience on the part of the clinician.

Causes of depression

It's likely that with most instances of clinical depression, the transmission of certain chemicals in the brain called neurotransmitters is disrupted. These chemicals carry signals from one part of the brain to the next.

The three important neurotransmitters that affect a person's mood are serotonin, noradrenaline and dopamine. When these mood-regulating neurotransmitters fail to function properly, symptoms of depression appear.

The causes of depression, however, are often likely to be the result of a number of inter-related factors. Besides abnormal functioning of chemicals in the brain, other factors like hereditary, stress and personality contribute to the development of depression.

Having a family history of depression does not mean that a person will necessarily develop depression, but it does mean that the risk of developing depression can be higher.

There are usually other stressful life events, like failure in an examination, or a relationship breakdown, or even a chronic illness like cancer that may act as a trigger for the onset of a depressive episode.

Some personality types are more likely to develop depression. There is evidence that people who experience high anxiety levels, are very sensitive to criticism, or those who have a perfectionist personality, have a higher risk of developing depression.

Treating depression

There are two major forms of treatment for depression that may be used individually or in combination, depending on the type of depression.

Psychological treatments for mild depression provide a supportive environment for a person to work through difficulties.

Mental health professionals like psychiatrists and clinical psychologists can help by providing skills and strategies to change negative thinking patterns and behaviours that contribute to depression and to lessen underlying sensitivity to future episodes of depression.

There are a number of psychological treatments that have evidence supporting their effectiveness.

One defining aspect of clinical depression is a change in the balance of chemicals in the brain that impact on mood. Antidepressant medications, prescribed by psychiatrists, are drugs that help restore the brain's chemical balance to improve mood and relieve other symptoms of depression.

For some types of depression, particularly more severe depression, a combination of both antidepressant medication and psychological treatment has been shown to be most helpful.

Antidepressant medication helps change a person's mood and increases their responsiveness to psychological treatment.

The psychological treatment provides support and strategies to change depressed thinking and behaviour, and improves long-term coping skills to minimise future relapse.

If the depression is severe and debilitating, or if the urge to act out the suicidal thought becomes overwhelming, a brief stay in an inpatient setting might be extremely beneficial.

Prioritising mental healthcare

Investing in mental healthcare, particularly primary healthcare, can generate enormous returns in terms of reducing disability as a result of depression.

In Malaysia, we have one psychiatrist to a population of 115,000, which is admirable, although ideally, as per WHO recommendations, it should be one psychiatrist to a population of 50,000.

The number of clinical psychologists in the country, however, remains extremely low, and there is an urgent need to employ more clinical psychologists, particularly in the public sector.

In recognition of the need to prioritise mental healthcare, Health Minister Datuk Sri Liow Tiong Lai had set up the Mental Health Promotion Advisory Council, which operates directly under his supervision.

As a result of the council's recommendation, teachers from six schools across the country have been given training to provide necessary mental health intervention for students needing help.

This is a pilot project under the "Sekolah Minda Sihat"programme.

Another pilot project is the "Klinik Kesihatan Minda Sihat", where several government primary care clinics benefited from special training in mental health with the aim of having the capability to provide comprehensive mental health services to the community.

While the government takes a serious view of mental health issues, the private sector too must play it's part.

In developed countries like the United States, it has been estimated that 35-45 per cent of absenteeism from work is due to mental health problems, namely depression. Corporate houses in our country have not woken up to the fact that depression at the work place, often disguised as physical complaints, can result in a huge loss in productivity.

It would be advisable for big corporations to invest in some form of Employee Assistance Programme in order to take proactive measures to prevent work place stress and depression.

Finally, suffering from depression is not something to be ashamed of, or something to feel guilty about. It is not a character flaw or a sign of weakness. Neither is it a lack in discipline or personal strength.

However, it is also not just a "mood" that someone can "snap out of". Depression is a serious condition that can burden not only the individual, but also the nation at large. A holistic approach towards tackling this crisis is necessary.

Early diagnosis, improving accessibility to services, greater empathy, and the reduction of stigma and discrimination will go a long way towards facing this crisis.

The government, non-government organisations and corporate bodies must each play their role in the removal of barriers towards accessing appropriate healthcare for those suffering from depression.

In addition, every effort must be made to promote good mental health for all as part of our transformation towards the status of a developed nation.

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