Depression is one of the leading causes of avoidable suffering, affecting around 280 million people worldwide. It is also one of the world’s leading causes of premature mortality.
These statements are drawn from a recent report by the Lancet-World Psychiatric Association Commission: “Time for a united action on depression.” While the Commission is frank about the scale of the challenge, it also lays out a series of actions that could alleviate the suffering caused by depression.
Among the key findings is that, as common as it is, depression remains poorly understood. Many of the causes of depression remain unknown, as do the factors around why some treatments work for some people and not for others. Part of the solution here can be provided by further scientific discovery, but there is also work to be done in acknowledging the impact of depression on people, families and the wider society.
I think one of the strange benefits that has come out of the pandemic has been a very honest discussion about depression and anxiety, and an acknowledgment that anyone can experience these conditions, that they should have help available to them, and that that is OK.
Dr Sabin pointed to the example of HIV, where high-profile people talking about their experiences went a long way towards destigmatizing the condition and encouraging others to seek help:
It becomes very important to talk about the experience of depression among those who have had it, and those who are willing to take the issue on and talk about it as a common experience that any human being can experience at any point in their lives.
That process of understanding and education is central to many of the Commission’s recommendations. For example, it places an emphasis on prevention as an essential way to reduce the burden of depression around the world. That means addressing societal and economic factors, as well as being prepared to intervene at an individual level. Prof Helen Herrman, former President of the World Psychiatric Association and Chair of the Commission, explained that action on both of those levels begins with understanding:
In all kinds of societies, people struggle to understand that depression isn’t the result of some kind of dereliction on the part of the sufferer, or that there needn’t be some other explanation for how people feel and behave.
For people to receive the help they need, there needs to be a strong understanding of the realities of depression among the people observing them, including the medical practitioners. Prof Herrman explained:
Whether it’s a busy GP in London or Melbourne or a healthcare worker in rural India, our question is, ‘How can this person be helped to understand that’s it’s important to listen to and speak to a person exhibiting early warning signs for depression.’ We need to help those healthcare providers understand that resources and treatments are available, and that they’re not about to be drawn into a problem with no hope of a solution.
Dr Sabin agreed that professional awareness is an essential part of the solution. If intervention can work on an individual level, people need to be aware of the signs that someone may be at risk of depression:
How you recognize the signs and who might intervene can depend on where people are in life. Depression in children or adolescents can look different to depression in an adult, so we can teach people what to look out for in their kids, in their peers, in the classes people teach.
For example, Dr Sabin said, a child might withdraw from school or other activities, or lose interest in activities they used to enjoy.
Dr Sabin also suggested screening the elderly and new mothers during regular medical checkups:
Some countries have suggested that when someone goes in for their regular checkup, they’re asked a screening question. You can use that same approach for women who have just had a baby — a well-designed question related to post-partum depression can help identify people at risk.
The other key element of prevention happens at a societal level. That will require planning and coordination. That’s one of the most important ways the Commission’s recommendations will be put into action, according to Prof Herrman.
We’ve had several launches in various countries, and have some more planned, and one of the questions on everyone’s lips is ‘What do we do now?’ It’s clear we need to engage and consider mental health if we’re going to reach the sustainable development goals, so how do we manage that effort?
The answer Dr Sabin outlines involves some big ideas around the way we approach society. Education, prevention and intervention are critical, but the most lasting solutions are more fundamental, she said:
We need to look at how we design our societies so that people thrive. Addressing the conditions that affect people’s chances in life is essential also to reducing risks to mental health.
Those changes won’t happen in the short term, so in parallel, community action is needed. Dr Sabin continued:
People need to be confident in participating and taking action on a range of matters that relate to addressing mental health, from substance use and community violence prevention and treatment programs, through to how urban spaces are designed. At the same time, we need to specifically think about mental health policies and how we provide support to people struggling with poor mental health and its impact within social support systems among families and communities.
That distinction between mental health, poor mental health, and mental ill health is vital, she said, and relates again to the need for understanding and education. Helping people appreciate the difference is key to prevention; it gives them an understanding of how poor mental health can slip into mental ill health.
The psychiatrist George Vaillant talks about this. He draws an analogy between an Olympic athlete. Not all of us can be as fit as an Olympic athlete, but many of us are healthy.
However, she continued, people could be healthier if we made certain lifestyle changes, like eating differently or doing more exercise.
Prof Herrman also talked about the holistic element of mental health and the many factors that contribute:
Mental health is a product of where we live, how we live, what we do, as well as what we’re born with. As with physical health, we can do things as a community. We can advocate for changes of behavior. We can provide the conditions to thrive. A lot of what we do in the mental health field is to advocate for broader government policies and try to make mental health a part of public health — which is a change that is starting to happen.
A call for action
The Commission’s report concludes by calling for a united, “whole-of-society” approach to preventing depression:
This Commission provides a message of hope, not only in the form of robust evidence on what can be done to prevent and treat depression, but also on how such interventions can be integrated with wider health and social systems and implemented even in the least-resourced contexts. The evidence creates an opportunity for united action to transform mental health-care systems globally. …
Collectively, the impact will contribute to strengthening national economies and to the attainment of the Sustainable Development Goals. We cannot think of a more important set of investments, now more than ever before.
Since launching, the Commission has conducted digital regional launches in North America and Brazil. Further launch events are planned in Africa and India with a program of print and video publication and debate to follow, Prof Herrman said:
These activities engage and aim to raise awareness among people with lived experience and their families, practitioners, researchers and policymakers — all groups addressed in the report.
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