Treatable but stigmatised

October 08, 2012


THE use of ‘depression’ in everyday nomenclature has witnessed a surge in popularity in recent times. This is probably because at a basic level, it is used to describe subjective distress in relation to socioeconomic difficulties.

This is a common emotional reaction that is usually transient and does not cause any impairment of function. Medically, however, ‘depression’ is used to describe a mental illness that is ultimately very common and is in fact the fourth leading cause of disability and disease across the world.

These statistics are expected to worsen and the trend is likely to see an exacerbation making depression the second leading cause of disability by the end of this decade.

These statistics are expected to worsen and the trend is likely to see an exacerbation making depression the second leading cause of disability by the end of this decade. As a result of this mounting health burden and its serious consequences, World Mental Health Day on Oct 10 has been dedicated to ‘Depression: A Global Crisis’.

As a result of this mounting health burden and its serious consequences, World Mental Health Day on Oct 10 has been dedicated to ‘Depression: A Global Crisis’.

Like globalisation, depression knows no boundaries. It can occur irrespective of people’s age, gender, cultural or environmental background. An estimated one in four women and one in 10 men, at some point in their lives, require treatment for depression. Simultaneously, nearly a third of all people who go to see a doctor suffer from depression.

Common symptoms include loss of interest in life, feelings of guilt or reduced self-worth, disturbed sleep or appetite, low energy and poor concentration. Depression can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities. It is commonly the result of a complex interaction of biological, psychological and social factors.

There might be a history of depression in the family but this link is generally not as well-recognised between generations as in the case of hypertension or diabetes. This could be partly because of general ignorance or because of the stigma associated with mental illness.

Psychosocial factors, for example unemployment, poverty, divorce, etc, increase overall vulnerability towards the illness. Some people are predisposed because of their poor adaptive mechanisms to stress. Our susceptibility to depression increases with physical illnesses, such as diabetes, cardiovascular disease or arthritis. Additionally, people who live with chronic pain are particularly likely to become depressed.

So what happens if depression is not treated? Depression is a major cause of impaired quality of life, not just for the person but for their entire family. It causes immense distress and leads to negative emotions and behaviour. This may trigger family problems, academic or occupational decline, the neglect of children, marital difficulties and even domestic violence. Loss of self-confidence and fear of stigma may worsen social functioning. One’s ability to work effectively declines, and gradually there is a sharp decrease in the contribution to family and society.

Sometimes depressed people resort to addictive substances for relief, sparking off a vicious cycle. The condition has a negative impact on health by exacerbating pain, distress and disability associated with physical diseases and can increase the risk of death from heart disease. In addition to reduced productivity, the overall healthcare cost escalates if depression remains untreated.

Perhaps the most tragic aspect of this underrated global menace is that it can lead to suicide. Statistically, one million people kill themselves every year, accounting for nearly one per cent of all deaths in the general population, while another 10-20 million attempt to harm themselves.

Approximately, therefore, and in general terms, one person commits suicide and nearly 10 others attempt to do so in this city every day. Suicide occurs across all cultures, religions, and social or economic boundaries; this grim reality is all the more tragic because most suicides are preventable.

This brings us to the second reason why World Mental Health Day has been dedicated to grappling with depression. As a disease, depression can be reliably diagnosed and treated by any doctor without the help of a specialist. Antidepressant medication (costing as low as Rs300 per month) and counselling are effective for 60 to 80 per cent of those affected and can be delivered by any trained doctor.

Unfortunately, however, there is a huge treatment gap and less than a quarter of all patients receive effective treatment — either because they do not have access to medical facilities or because their doctors fail to recognise or treat depression.

Instead, patients undergo repeated medical consultations, unnecessary investigations and harmful medication. Why does this happen? To begin with, the stigma attached to this condition is a massive handicap. Most sufferers would rather stay silent about it, not speaking up because they are embarrassed or in denial. There is a general fear of being labelled depressed, even though being labelled diabetic or hypertensive is considered socially acceptable.

Perhaps more agonising is the existence of the stigma amongst the medical community itself. Most of them recognise elements of anxiety, distress and insomnia in these patients, but instead of updating their knowledge and offering a scientific solution, they resort to easy solutions such as prescribing sleeping tablets (which are addictive) for symptomatic relief.

Regrettably, specialist doctors also resort to invasive investigations and long lists of medication even when the symptoms are clearly not suggestive of physical ailments.

The World Health Organisation has developed the Mental Health Gap Action Programme to overcome the existing treatment gap so that all doctors may detect and treat depression effectively.

Pakistan has a primary-care health system which, unfortunately, is decaying. There is an urgent need to train doctors to deal with straightforward cases and refer more complex ones for specialist attention.

Ultimately it is the responsibility of all stakeholders involved in mental healthcare to address stigma and help alleviate human suffering, mortality and the loss of productivity caused by what is in reality a highly treatable illness.

The writer is an associate professor of psychiatry at the Rawalpindi Medical College.