Conquering depression: you can get out of the blues

Conquering Depression

SEA/Ment/120 Distr: General

Authors Coordinating Author: Dr Sudhir Khandelwal Department of Psychiatry All-India Institute of Medical Sciences New Delhi, India

Co-Authors: Dr AKMN Chowdhury H.no. 6/C 12/10 Mirpur Dhaka, Bangladesh Dr Shishir K. Regmi Department of Psychiatry Institute of Medicine Kathmandu, Nepal Dr Nalaka Mendis Department of Psychological Medicine Faculty of Medicine Colombo, Sri Lanka Dr Phunnappa Kittirattanapaiboon Suanprung Psychiatric Hospital Chiang Mai, Thailand

© World Health Organization 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.

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Paintings on pages 9, 17, 21, 26, 36 and 41 have been contributed to WHO by Ms. Yogeeta, an eminent artist. Paintings on pages 13, 34, 39 and 45 are part of a WHO-sponsored global school contest on mental health for children aged 6-9 years. Computer graphics on pages 6, 15, 19, 23, 24, 28, 31, 33, 38, 43 and 46 were created at Exposure Multiples.

Conquering Depression: You can get out of the blues Contents INTRODUCTION HISTORICAL BACKGROUND MYTHS AND MISCONCEPTIONS ABOUT DEPRESSION WHAT IS DEPRESSION? DIAGNOSING DEPRESSION SOME FACTS AND FIGURES CONSEQUENCES OF DEPRESSION WHAT CAN BE DONE? 6 10 14 18 30 32 37 40

Message from the Regional Director Populations of Member Countries of the World Health Organization's South-East Asia Region have suffered for ages from many communicable diseases. While some of these have been successfully controlled, others continue as serious public health problems. However, recently, it has become increasingly clear that noncommunicable diseases, including mental and neurological disorders, are important causes of suffering and death in the Region. An estimated 400 million people worldwide suffer from mental and neurological disorders or from psychosocial problems such as those related to alcohol and drug abuse. Our Region accounts for a substantial proportion of such people. Thus, the Region faces the double burden of diseases -- both communicable and noncommunicable. Moreover, with the population increasing in number and age, Member Countries will be burdened with an ever-growing number of patients with mental and neurological disorders. As Dr Gro Harlem Brundtland, the Director-General of the World Health Organization says, "Many of them suffer silently, and beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death". While stigma and discrimination continue to be the biggest obstacles facing mentally ill people today, inexpensive drugs are not reaching many people with mental and neurological illnesses. Although successful methods of involving the family and the community to help in recovery and reduce suffering and accompanying disabilities have been identified, these are yet to be used extensively. Thus, many population groups still remain deprived of the benefits of advancement in medical sciences. Dr Brundtland has said, "By accident or design, we are all responsible for this situation today." The World Health Organization recently developed a new global policy and strategy for work in the area of mental health. Launched by the Director-General in Beijing in November 1999, the policy emphasizes three priority areas of work: (1) Advocacy to raise the profile of mental health and fight discrimination; (2) Policy to integrate mental health into the general health sector, and (3) Effective interventions for treatment and prevention and their dissemination. The South-East Asia Regional Office of the World Health Organization is committed to promoting this policy. Mental health care, unlike many other areas of health, does not generally demand costly technology. Rather , it requires the sensitive deployment of personnel who have been properly trained in the use of relatively inexpensive drugs and psychological support skills on an outpatient basis. What is needed, above all, is for all concerned to work closely together to address the multi-faceted challenges of mental health.

Dr Uton Muchtar Rafei Regional Director World Health Organization Regional Office for South-East Asia

Preface To express emotions, such as, happiness, anger, anxiety, fear or sadness, is normal for every human being. So for "sadness" and "depression", Emile Durkheim, the famous French sociologist and philosopher, has very appropriately written: "Man could not live if he were entirely impervious to sadness. Many sorrows can be endured only by being embraced, and the pleasure taken in them naturally has a somewhat melancholy character. So, melancholy is morbid only when it occupies too much place in life; but it is equally morbid for it to be wholly excluded from life". Depression is certainly not a new disease. It is only the recognition of its magnitude and the suffering it causes to people, which is a recent phenomenon. WHO data suggest that in 1990 unipolar major depression was already a leading cause of disability worldwide with the burden from depression increasing in both developed and developing countries. However, very few people are aware of the magnitude of the suffering from depression in the community. Despite the seriousness of depression as a disease and the availability of effective treatment, only 30% of cases worldwide receive appropriate care. Regrettably, the situation is much worse in the Member Countries of the WHO South-East Asia Region. With the availability of newer medications, non-pharmacological therapies like psychotherapy and cognitive therapy, and the abundant social and family support available to patients in our Region, there is absolutely no reason why any one should continue to suffer from depression. This document, prepared by a panel of experts from the Region, provides valuable information on the current state of knowledge about depression. More importantly, it describes ways and means by which anyone "can get out of the blues". Dr Vijay Chandra Regional Adviser, Health and Behaviour World Health Organization Regional Office for South-East Asia

INTRODUCTION

he emotions of feeling sad, unhappy or disappointed are part of a human being's normal existence, and are experienced by everyone almost on a daily basis. Such emotions may be associated with failure in academics, setback in a relationship, loss in a financial investment. break-up of a love affair, or with the death of a loved one. However, after feeling low for a few days. during which time there can be changes in the sleep pattern and appetite. disinterest in daily chores etc., the person undergoing depressive symptoms usually returns to normal within a reasonable period of time. On the other hand. there are times when this state of sadness or unhappiness may continue to such a degree and for such a length of time that it far outweighs the significance of the precipitating factor. The sufferer continues to be in a prolonged state of sadness and withdrawn from his/her personal, social and occupational activities. In such situations, a diagnosis of depression should be considered.

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Normally, emotions such as anxiety, anger, pride, love, pain or joy interact to motivate a person to a goal-directed action. However, when certain emotions predominate and persist beyond their usefulness in motivating people for their goal- directed behaviour, they become morbid or pathological. This is what happens in patients with depression. All human beings also have variations in their ‘moods’. Mood can be understood as the amalgam of emotions that a person feels over a period of time. The effects of mood on a person's behaviour are widespread and complex. Mood determines a person's attention, thought, behaviour and interests and, at the unconscious level, influences functions such as appetite and sleep. Many physical sensations, such as energy, pain, strength and sex drive are directly i n f l u e n c e d b y e m o t i o n s . Thus moods can cause a significant change in a person's behaviour. Depression is traditionally classified in all major classification systems under mood disorders or affective disorders. Depression as a disease should be clearly differentiated from depressive symptoms or depressive moods, which are an integral part of human emotions. There are qualitative as well as quantitative differences between a state of unhappiness in reaction to the adverse events in the world outside, and depression as a disease state. It is essential for doctors, the general public and health planners to u n d e r s t a n d t h a t

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depression as a disease, unlike depressive moods, is neither a normal variation of mood nor an appropriate reaction to severe stress. Also, depression does not constitute a failure of "will power" or "weak character" in a person. There are some people who periodically or chronically remain in a depressed state in spite of their having all social privileges and material comforts, severely compromising all their functions, culminating in about 15% of cases in suicide. Mood disorders are traditionally recognized and classified into two distinct groups: depression and bipolar disorders. Each of these have specific and distinct features and longterm course. However, the predominant symptom of any mood disorder is a distinct period of abnormal and persistently altered mood. Bipolar disorders, also known as manic depressive illnesses, are distinguished from depression by the occurrence of manic or hypomanic episodes in which patients becomes overly active, alternating with depressive episodes, while patients suffering from depression persistently feel sad. Although some patients have only a single episode of depression or mania in their lifetime, the longitudinal course in most of the patients is characterized by multiple episodes with intervening symptom-free intervals. Sometimes, patients with mood disorders may experience bodily symptoms such as headache or weakness, which may be the presenting complaints or manifestations. Depression is a significant public health problem because it is relatively common and its recurrent nature profoundly disrupts patients' lives. Though estimates from developing countries are not available, depression costs the US economy more than US$ 43 billion annually in medical treatment and lost productivity. General population surveys conducted in many parts of the world, including some SEAR countries, have revealed a high rate of depression with a lifetime risk of 7-12 % for men and 20-25 % for women. These rates of occurrence are unrelated to race, education, income, or civil status. Depressed patients show impairment in all major areas of functioning-p ersonal care, family responsib liities, and social and occupational functioning. T he gravity of such impairment/disabilities is alm o st equal to or greater than that for patients wit h other chronic illnesses like hypertension, diabe t es, coronary artery diseases, and arthritis. Pati e nts with depression spend more days away from wor k , become medically ill more often, suffer greater p h y s i c a l d i s a b i l i t y , a n d

Depression is a welldefined medical illness. The symptoms of depression ! ! ! are intense are prolonged and interfere with the person's daily activities.

These features differentiate depression from normal sadness.

Depression must be diagnosed and treated like any other medical condition. Good social support and medication are both needed for the patient to recover.

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die at a younger age tha n the general population. Depressive symptoms, but not meeting the medical criteria for depression, a re frequently seen in patients with other disease s and cause increased use of medical services as we ll as increased rates of morbidity and mortality. Unfortunately, despite the seriousness of depression and all the associated consequences which can be effectively treated at any level of care all over the world, only 30% of cases with these disorders are properly diagnosed or treated. The situation may be worse in SEAR countries. A number of factors may be responsible for this state of affairs: ! ! Psychiatric services are not available in all parts of the Region, and tend to be concentrated in the cities. General physicians, who are the primary health care providers, lack sufficient skills to diagnose and treat mental disorders. At the primary health care level, depressed patients may present primarily with bodily symptoms rather than emotional complaints. Thus, the diagnosis of depression is not made. In spite of recognizing depressive symptoms, many patients may want to overcome them by their “will power”. The prevalent stigma associated with mental illness may prevent many individuals from approaching a psychiatric facility.

Despite the seriousness of depression as a disease and the availability of effective treatment, only about 30% of cases worldwide receive appropriate care. The situation is much worse in the Member Countries of SEAR.

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Depression as a disease requires prompt diagnosis and intensive treatment.

In the last 50 years, rapid strides have been made in the treatment of depression. Newer drugs have been discovered with better efficacy, less side-effects and better tolerance, and are being used for short-term and long-term treatment. Besides drugs, non-pharmacological therapies like psychotherapy and cognitive therapy have been found beneficial. In the modern day and age, there is absolutely no reason why people anywhere in the world should continue to suffer from depression.

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HISTORICAL BACKGROUND

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istorically, depression has been recognized as a common disease and described by various names since antiquity.

Many mythological and religious texts contain descriptions. which fit very well into the current understanding of depression. Reference to states of depression has been made in the great epics of India - Ramayana and Mahabharata - wherein some characters have developed depressive features akin to current descriptions. In the Ramayana, King Dasarath, father of Lord Rama, developed clearly identifiable depression at different stages of his life. The last episode was precipitated when prince Rama, accompanied by his wife Sita and brother Lakshman, left for the forest abdicating the throne in fulfilment of the vow made by his father to his stepmother. Dasarath was overwhelmed by a state of depression in which he renounced all his duties as king and all worldly pleasures to die in such a state. Many well-known characters in Shakespearean plays, such as Hamlet, Macbeth, and Henry VI, have suffered from depression. Much of what is known today about symptoms of depression and related disorders was described by the ancient Greek and Roman physicians who coined terms like ‘melancholia’ and ‘mania’ and noted their relationship. In the fourth century BC, Hippocrates made an early reference to distress and melancholia. He described melancholia (black bile) as a state of “aversion to food, despondency, sleeplessness, irritability and restlessness”. Later, Galen (131 - 201 A.D.) described melancholia manifesting in "fear and depression, discontent with life and hatred of all people". Subsequent Greco-Roman medicine not only recognized the symptoms of melancholia in the form of fear, suspicion, aggression and death wishes, but also referred to environmental contributions to melancholia as immoderate consumption of wine, perturbations of the soul due to passion, and disturbed sleep cycle. Many of the original Greek texts on melancholia were transmitted to posterity through medieval Arabic texts in which connections between two major mood states were suggested, and the causes of the disease were speculated to be interactions between temperament, environment and the four humours (i.e. wind, phlegm, yellow bile and black bile). In the modern era, Robert Burton's text, Anatomy of Melancholy, published in 1621, was entirely devoted to depression. Burton categorized various forms of melancholy 10

and grief, and also described “causeless melancholias”. The latter term meant that it was possible to suffer from melancholia without having any apparent cause. Subsequent writers have provided graphic descriptions of the features of melancholia and its long-term outcome and consequences, including “melancholic patient starving himself to death”. Towards the nineteenth century, several attempts were made to clarify the concept of melancholia and bring it closer to what would now be equated with depression. Many physicians such as Esquirol (1820), Samuel Tuke (1813) and Henry Maudsley (1868) attempted to define the causation, nature and presentation of melancholia. Towards the later part of the nineteenth century, melancholia began to be viewed as an independent disease. Melancholia was considered to be associated with sadness, suicide, and preoccupation with the past. With the delineation of manic depressive illness as a distinct entity, renewed interest into the phenomenon of depression led to intense studies on various aspects of its clinical features, dynamics, neurobiology, epidemiology, classification and treatment. After the Second World War, the World Health Organization commissioned a task force to review the status of classification of psychiatry, and produce a revised edition of the International Classification of Diseases. Its subsequent revisions, along with the revised editions of the Diagnostic and Statistical Manual of the American Psychiatric Association, have revolutionized the approach to the study of mental illnesses. These official nomenclatures have established explicit operational criteria for diagnostic categories, including both inclusion and exclusion requirements which means that more is known on what constitutes depression and what does not. Although such an approach has been applied by the research community for some time, these have only recently been accepted by doctors in general practice.

Some famous people who had depression: Abraham Lincoln Theodore Roosevelt Robert Schumann Ludwig von Beethoven Edgar Allen Poe Mark Twain Vincent van Gogh Georgia O'Keefe Source: http://my.webmd.com/content /dmk/dmk_article_1460967, 24 Jan 2001

Description in traditional medical systems in India and South-East Asia In India and its neighbouring countries - Bangladesh, Nepal and Sri Lanka a highly developed and elaborate system of medicine known as Ayurveda (the sciences of life) has flourished for nearly 3000 years. There are many medical texts dating back to the first or second century AD which describe the principles of Ayurveda in detail, the two most common texts being attributed to the Ayurvedic physicians, 11

Charak and Susruta. These books were compiled some time between the third century BC and the third century AD. All major Ayurvedic texts, such as Charak Samhita and Susruta Samhita, have a separate section dealing with insanity (Unmada). In addition, there are chapters on spirit possession (bhutonmada) and epilepsy (apasmara). In the chapters on Unmada (insanity), six types of mental disorders are described, out of which three, Sampottonmad (caused by combined body humours), Vishaja Unmad (caused by external intoxications and poisons), and Shokaja Unmad (caused by excessive grief) bear close resemblance to depression and manic depressive illness. Many researchers have made serious attempts to equate some of these Ayurvedic descriptions with modern psychiatric diagnostic terms, yet the relationship between specific Ayurvedic categories and present day medical terms is complex. It would be overly simplistic to assume a direct correspondence between terms of the two systems. In the Islamic tradition, the social attitude towards the mentally ill is based on the sayings of Prophet Mohammad, that the mentally ill are dear to God. In Arabic medicine, the concept of mind and mental illness is roughly comparable to the writing in earlier Greek classics, where the soul is regarded as an entity separate from the body, and many psychological and moral attributes are linked with the soul. Medical texts describe conditions such as epilepsy, dementia, melancholia and hysteria. Melancholia was regarded to be due to an affection in the brain, or due to an affection in other organs along with some involvement of the brain.

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Prajapati Shikha Jayeshbhai 13

MYTHS AND MISCONCEPTIONS ABOUT DEPRESSION

n spite of depression being a common illness, many myths and misconceptions are associated with it. Partly, the stigma attached to mental disorders, including depression, is responsible for some of these misconceptions. Such a stigma prejudices the public against people with depression. Attitudes like 'they are unpredictable; they talk and express ideas in a weird manner; they are themselves to blame; they will not recover or improve even if treated', are still widely prevalent. Also, there is inadequate understanding among general practitioners and primary health care physicians regarding appropriate diagnosis and treatment of depression. For these reasons, a large number of persons suffering from depression do not seek help for treatment.

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Myth: Depression is a problem of the western industrialized world and not of developing countries. Fact: Depression affects all people in all cultures across the world. However, in some countries ‘sadness’, particularly in old age, is considered ‘normal’ and not a disease to be treated by a doctor. Myth: Depression is due to the influence of witchcraft, magic or sorcery. Fact: Depression is like any other medical illness. It is caused by the interaction of biological and environmental influences, and manifests in psychological and physical symptoms. Myth: Even if depression is an illness, what can we do about it? We cannot treat it the way other diseases can be treated. Fact: Depression is a treatable disorder. There are many drugs available even in developing countries which are effective and affordable. Myth: Spending scarce resources for treating depression is wasteful expenditure when there are so many other communicable and noncommunicable diseases needing attention and which are still not under control in developing countries. Fact: Depression causes considerable suffering among patients worldwide. The burden caused by psychiatric disorders has been underestimated in the past. At present, out of the 10 leading causes of suffering worldwide, five are psychiatric conditions, including depression. By 2020, depression will become the second largest cause of suffering -- next only to heart disease. 14

Myth: There are not enough, and there never will be enough trained psychiatrists in developing countries to look after all the cases of depression. The situation is hopeless and will never improve. Fact: The number of psychiatrists is gradually increasing in the developing countries. Moreover, all cases of depression do not have to be treated by psychiatrists. General practitioners and primary health care physicians can satisfactorily treat this illness with some training. Myth: Depression is one's own creation. Fact: This is completely false. The sufferers cannot be blamed for the illness. Myth: Today's competitive world predisposes a person to depression. Fact: Yes, the world today is very competitive. This may lead to some anxiety and business loss can lead to a person being temporarily sad. However, a person should be able to handle such situations in daily life. Myth: If a person is depressed, there has to be an external factor bothering him. Fact: External factors are not always necessary to make a person depressed. It is now known that chemical changes in the brain can lead to depression without any external precipitating factor. Myth: Once depressed, a person remains depressed throughout his/her life. Fact: In most cases, depression lasts for a limited period. Adequate treatment leads to complete resolution of the symptoms and the person can return to a normal state of activity and health. Myth: There is no need to go to a medical doctor for treatment. One can cure depression by will power, a holiday, or at times by taking a peg or two of alcohol to lift one's spirits. Fact: Many communities continue to believe in such home remedies. Will power cannot cure depression. A depressed person experiencing lack of pleasure in his surroundings will not enjoy his holidays either. Alcohol may worsen the depression. Depression should be treated with prescribed medicines and social support of the family and community. Digital Creativity

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Myth: Drugs used for treating depressions are addictive. Fact: Drugs used for treating depression are not addictive or habit forming. When depression is in remission, the drugs can be slowly tapered off and stopped. Myth: When a depressed person expresses suicidal ideas, he does not mean to act upon them. Fact: Suicide is a major risk during the course of depression. The individual usually gives an indication of his suicidal intention before attempting suicide and this must be taken very seriously. Myth: If an individual is suspected to be harbouring suicidal ideas, one should not talk about depression, death or suicide. Fact: If the discussion about suicide is done sympathetically and tactfully, it gives an opportunity to the individual to express his/her ideas and feelings clearly and to receive appropriate care. In most cases, this prevents suicide. Myth: A depressed person should be in a sheltered, protected environment for the rest of his/her life. Fact: Once treated successfully, the person returns to his/her normal self, and can resume all personal, social and occupational activities. Myth: If you have everything in life, all material comforts, you cannot suffer from depression. Fact: Though low socioeconomic status may be a contributing factor for depression, it can affect people across all socioeconomic levels. Many rich and famous people have been known to have suffered from depression.

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WHAT IS DEPRESSION ?

epressed persons usually describe their mood as depressed, anguished, mournful, irritable or anxious. The patient explains it as a progressive loss of interest or pleasure in normally enjoyable activities, like reading a newspaper, watching television, going for a walk or participating in sports. However, very often, the patients may not admit to feeling sad, as they may consider it below their dignity to experience sadness in the absence of an appropriate cause, particularly in the presence of other family members or friends. But the patient's facial expression, voice and overall appearance may corroborate the presence of a sad mood. Frequently, there is a tendency to cry, and the patient may weep while alone or with a listener.

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“I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would be not one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better it appears to me.” Abraham Lincoln Source: http://my.webmd.com/content /dmk/dmk_article_1460967, 28 Jan 2001

The patient may complain of lack of energy and strength, and easily get tired of routine work like looking after personal appearance, household chores or occupational activities. A housewife may allow work to pile up, and a working person may remain absent from work. The patient starts getting feelings of personal inadequacy and has a low opinion about himself / herself: “I am good for nothing; I am a bad parent”. The patients may feel guilty or a sense of shame for no reason. He/ she may feel hopeless, that is, find no possibility of a solution even in future. Everything appears dark. The logical outcome, the patient may think, would appear to be suicide. The risk of suicide in any form of depression is substantial. The personality and the circumstances of the patient, along with the severity of depression, seem to determine if suicide is attempted or accomplished. Suicidal behaviour may take the form of morbid rumination, death-related ideas, fleeting suicidal ideas, suicidal plans, attempts or the completed act. Though depression is primarily a psychological illness, bodily symptoms are very common in depressed persons, especially in developing countries. Very often, these symptoms may be more prominent than the depressed mood itself. These symptoms may involve virtually any organ in the body, and often extensive investigations may take place with no positive findings. Headaches, generalized aches and pains, and symptoms affecting multiple organs are common complaints. Persistence of these symptoms may make the patients move from one medical facility to another at the cost of their time, energy and resources. Usually, patients do not admit to feeling depressed even on direct questioning and will blame the failure of modern medicine to detect the underlying 'lurking' illness. Bodily s y m p t o m s p r e s e n t i n g a s

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About depression… ! ! Depression is a prolonged and persistent state of sadness -- a pathological/morbid condition. Depression is a significant public health problem because of its high prevalence, the suffering, and sometimes death, that it causes. Depression leads to considerable dysfunction in all areas of life in an affected person. Depression is seen in many medical disorders, and persons with depression are more prone to develop secondary medical disorders. Suicide is a major risk during the course of depression. Despite effective treatment being available, a large number of depressed patients receive no treatment. Digital Creativty

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main complaints in a depressed person are found more commonly in some cultures. In the Indian concept, the body and the mind are not dichotomized but are closely associated, and believed to influence each other. A vast majority of patients complain of disturbed sleep, dreams, nightmares, and lack of freshness in the morning. Paradoxically, some patients may sleep excessively. Loss of appetite and associated loss of weight are experienced by a large number of patients. Loss of sexual interest is a common symptom. Women may complain of irregularities of the menstrual cycle. Bowel irregularity, especially constipation, may be a distressing symptom in those cultures where daily movement of the bowel is a mark of health. Slowness of thought and action is a very common disturbance manifested by paucity of spontaneous movements, slumped posture, downcast gaze, excessive fatigue, reduced speech, and taking more time to respond.

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Mrs N has pain in her belly. She wants to know what is it due to. Mrs. N, a 45-year-old woman, who lives in a suburban area of Kathmandu valley, came to the psychiatric outpatient department on being referred by a gynaecologist. She had been complaining of persistent lower abdominal pain for three months. The problem had started gradually with Mrs N not being as energetic as in the past, getting tired even after doing mild physical work. On direct questioning, she admitted that she was feeling sad almost all the time. Further questioning revealed that the symptoms had started after her husband went to work abroad, leaving behind three teenage daughters under her responsibility. Although a bold, outgoing and socializing woman in the past, she gradually preferred staying alone. Two months ago, she started saying that she was having abdominal pain and was unable to move around. She said that due to the abdominal problem, she was not able to do routine household chores and she was of no use. For the past 15 days, she started expressing ideas that she had not been able to carry out the responsibility her husband had given her, and in such a state it would be better if she died. Although she had not been to any health care professional, she felt she would never get better and any attempt to treat her would be a waste of money and time. She would eat less, citing the pain in the abdomen as the reason behind it. She also blamed the pain to the sleep disturbance she was suffering from. Her eldest daughter then took her to a gynaecologist. Despite her complaints of continuous pain in the lower abdomen, the doctor could not detect any abnormality. Laboratory and radiological investigations carried out also did not display any abnormal finding. The gynaecologist thus referred her to a psychiatrist. Mrs N was dressed neatly; however, her hair was not combed. Her movements were obviously slow. She sat still on the chair, most of the time gazing at the ground, only lifting her head to answer the questions asked of her. She spoke slowly with long pauses between the words. She talked about her abdominal pain, and said that she did not have any hope of its being cured. Guilt for not being able to take care of the daughters was obvious. Although she would say that death would be preferable to such a life, she denied having any suicidal ideas. She was well-oriented and there were no other psychological symptoms. She denied having any problem other than the pain. The doctor said that Mrs N was suffering from a psychological problem technically called depression, locally called 'man-chinte rog' or 'udashinta'. She was told that this disease sometimes took the form of an illness. The teenage daughter was surprised how a complaint of pain in the abdomen ultimately turned out to be related to man or mind rather than 'sharir' or body?

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Mrs C's health suddenly deteriorated markedly. What could be the reason? Mrs C, a 50 year old woman, was married with six children. She had been in excellent health. Recently, she had been feeling frightened and worried and was not able to do any work at home. About six weeks ago, she experienced a sensation of tightness in her chest and heaviness of head accompanied by fear. During the next two weeks, she became increasingly tired, lost interest in household work and felt sad for no apparent reason. During this time, she started getting up in the middle of the night. Fear and apprehension prevented her from getting back to sleep. In a few weeks, she became very tense and distressed and the children had to be with the mother all the time to calm her. As the situation was getting worse and as she was very frightened to be alone at home, her mother had to be brought in from a distant place to look after her. She wanted her mother to be around her all the time. Her fear, worry, sadness and distress continued and there was total loss of interest in work. She would say: "My skin is burning, there is a fire inside my chest, my body is aching, I have no energy to do anything, what will happen to my children? Please help me to sleep, I cannot sit in one place, my body is trembling, I feel like walking up and down all the time, I am worried that I will get cancer, this keeps on coming to my mind all the time, I feel so sad at times I cannot stop crying, I cannot stop thinking of the worst happening to me". As her condition was getting worse, her husband, who was working in the Middle East, was requested to return home immediately and, at the same time, her brother, who was living in an adjoining village, was asked to help her. After listening to her story, the brother said that he also had a similar problem and was helped by a doctor in Colombo. He immediately made arrangements for her to go to Colombo. The doctor in Colombo listened to Mrs C, ordered some tests and finally diagnosed that she had depression. He advised her and her family about the nature of the illness, how to provide a supportive environment and to take medication. In eight weeks, she was much better.

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Master M spent nearly 2000 takas to undergo medical tests for diagnosis of his symptoms. All tests were normal. What could he be suffering from? Master M, a 27-year old student from Dhaka city, complained of discomfort in the belly, heartburn, body ache, pressure in the chest and difficulty in breathing. He had difficulty in sleeping which was also disturbed several times during the night. He complained of reduction of sex drive and passage of whitish material during micturition. These started about one year ago. He was addicted to Phensedyl (cough syrup), which he gave up about the same time that he developed the symptoms. He consulted a general practitioner who performed all the laboratory tests with negative results. Endoscopy only showed some minor changes in the gut but there was no ulcer. He was treated with antacid and other drugs without benefit. He went to an Ojha (traditional practitioner) who claimed to maintain Jinni (a term used to describe spirits) for the purpose of healing of patients. Jinni suggested that there was bad wind, which had to be driven out of his brain. He performed some rituals but this did not help. He consulted a psychiatrist at the suggestion of an expatient. He was diagnosed as suffering from depression and treated, resulting in marked improvement.

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Depending on the nature and severity of symptoms, the depressive episode may be classified as mild, moderate and severe, or with psychotic features. About 15% of severely depressed cases suffer from what is termed as the 'psychotic form' of depression where they have symptoms which signify their being out of touch with reality. They have delusions (false fixed ideas not amenable to correction) and hallucinations (perceiving something through sense organs without anything being there). Thus, severely depressed persons may have delusions of worthlessness, or may believe that they deserve punishment and that their bodily functions are totally deranged with no hope of recovery. They may hear voices condemning them or threatening them. Psychotic symptoms may occur repeatedly in a person and are a major risk for suicide. Depression may, at times, be masked behind an alcohol or drug problem. A person may take refuge in alcohol, tobacco, or drugs because of a feeling that this would help to fight the sinking mood.

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Is help available? Mr B, a 32-year-old tricycle driver, had migrated to the city without his family. He had been admitted in Suanprung Psychiatric Hospital, Bangkok, several times since 1995 because of alcoholism. Each time after a bout of uncontrolled drinking, he would go to the hospital. He complained that he used alcohol because he was under stress. A couple of years ago, he received detoxification during admission. After evaluation, it was found that he also had depressive symptoms and suicidal ideas, especially while intoxicated. He was diagnosed as suffering from severe depression and alcohol abuse and responded well to treatment. Unfortunately, he did not have a family or caregiver to take care of him after discharge from the hospital. He discontinued medication and started drinking again. His depressive symptoms and suicidal ideas reappeared. He said that he had financial problems in getting treatment, so he used alcohol instead, which was cheaper. A social worker was consulted to look for appropriate health insurance for him. Now, he gets treatment regularly. His depressive symptoms have resolved. He still drinks alcohol sometimes but it does not disturb his function. Solution… Though the patient did not have any family, he knew that he could get help from the hospital. Every time he felt depressed and suicidal, he asked for admission in the psychiatric hospital by himself. Fortunately, the social worker was able to help him obtain health insurance. Points to note… ! Underlying depression is quite common in alcoholism, particularly when alcohol is used as selfmedication. Very few people in SEAR countries have health insurance; so, cost of treatment is a major concern. Moreover, patients may not know how to seek insurance. Cost of medical services can be a problem for the patient to get appropriate treatment. Doctors may not realize why the patient discontinued the treatment. 25

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Some other forms of depressive disorders Some forms of depression are defined by the role of a particular factor in precipitating the episode. Seasonal depression Many of our bodily functions like temperature regulation and hormonal secretions depend on certain biological cycles called circadian rhythms, which depend upon the season and length of the day. These rhythms perhaps tend to precipitate the onset of depression during the winter months. Besides having typical symptoms of depression, as discussed earlier, patients suffering from seasonal depression tend to be excessively lethargic, sleep excessively, and overeat. Experiments suggest that this depression may be related to light deprivation. Besides using standard drugs for the treatment, phototherapy (using bright lights) may be effective in ameliorating depression in such patients. Postpartum depression The postpartum period, that is, soon after childbirth, gives an increased risk for depression for women. About 10% of women develop postpartum depression, a debilitating illness which, if not recognized and treated timely, can have devastating effects on the patient and her family. This condition is distinct from the transient “baby blues” that 50% of women experience for a few days immediately after giving birth. Women with personal or family history of depression or other mood disorders are particularly at high risk. Though the symptoms of postpartum depression are generally the same as other forms of depression, mothers may feel especially guilty about not being able to respond fully to the needs of the newborn infant. Depression in children It was earlier believed that children and young adolescents are incapable of experiencing depressive symptoms and hence cannot suffer from depression. It is possible that many cases of childhood depression were being treated as school phobia or behavioural or temperamental aberrations. Subsequent careful investigations into childhood psychiatric problems, as well as that of suicides in children, has revealed that depression as a full-blown illness is quite common during childhood.

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The risk of occurrence of major depression is between 15 and 20% among children and adolescents, which is almost similar to that of adult populations. Complicating the picture, however, is the fact that a large number of children and adolescents suffering from depression have other associated psychiatric illnesses such as anxiety, disruptive behaviour and drug abuse. The symptoms of depression among this group remain largely the same as in an adult group; however, most of the manifestations due to the illness pertain to adjustment with peers and friends, problems in school, and indifferent or deteriorating scholastic performance. Children also appear sad, cry easily, manifest loss of interest and withdrawal, complain of bodily symptoms, and express pessimistic ideas. However, suicide among children has remained infrequent, yet a disturbing rising trend has been observed in the last one decade, and suicide is reported to be the third leading cause of death among adolescents in the western world. Depression in the elderly Depression in the older age group is significant for a variety of reasons. Approximately 20% of elderly people above the age of 60 have some depressive symptoms, but an identifiable diagnosis of depression is made only in 5% of the elderly population. However, depression occurs frequently among the medically ill elderly population where nearly 30% have associated depression. Depression is very common among residents of old age homes also. In spite of its common occurrence, depression among the elderly frequently remains undetected. Very often, depression is attributed to the ageing process and no intervention is sought or provided. Elderly people have a much higher risk of suicide than the general population. Data from Member Countries of SEAR indicate that suicide rates among the elderly may be lower than in western countries, perhaps because of the protective role of the joint family system. Elderly people in traditional societies do not suffer from isolation and deprivation. However, with social values changing rapidly in the developing countries, elderly people are likely to face increasing stress and strain. With the rapidly increasing elderly population in the countries of this Region, it is imperative that adequate provisions be made for the care of psychiatrically and medically ill elderly people.

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Depression and medical illnesses The rate of occurrence of depression among medically ill persons is much higher than in the general population. Nearly 30% of persons suffering from various illnesses simultaneously suffer from depression. Excessive utilization of medical services due to the onset of depression in medically ill persons tends to increase the cost of treatment. Depression also negatively affects the outcome of the physical disorder by increasing the suffering of the patient. The features of depression can be easily identified; however, some problem may arise at times, since many symptoms usually seen in depression, such as weight loss, sleep disturbances, lack of energy and excessive anxiety and concern over physical symptoms, are also caused by the primary medical disorder. It is not entirely clear how a medical disorder and associated depression are related. Either the illness may directly cause depression or it may just trigger off depression in a vulnerable individual; a person may psychologically react to a particular disease and become depressed; or some drugs being used to treat the disease may cause depression as a side-effect. Some of the common medical disorders more often associated with depression are brain disorders, hormonal disorders, heart disease, chronic pain and cancer. Many brain disorders have consistently been shown to be associated with depression during the course of the illness. Thus, stroke, Parkinson's disease, Huntington's chorea, dementia, head injury, and certain brain tumours are often associated with depression. A variety of hormonal diseases (diabetes, thyroid disorders, adrenal gland disease) are associated with depressive symptoms or depression. Depression may be the first manifesting symptom of these disorders in a number of cases. The relationship of depression and other psychological factors with heart disorders is quite complex. Many psychological factors, including stress, personality factors, substance abuse with tobacco and alcohol, and depression, may precede the occurrence of a heart disease or accompany it during the course of the illness. The number of patients of various forms of depression who have had a heart attack is estimated at above 40%. Unfortunately, depression in these patients is seldom diagnosed or treated.

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The diagnosis of cancer can be as catastrophic as the news of the death of a loved one. The initial reaction of the individual is shock and denial, which is generally followed by anxiety, depressed mood, poor concentration, and impairment of daily activities. Such an emotional reaction is normal and expected, and with social support it is usually resolved within a few weeks; however, studies on cancer patients have revealed that as much as 40% of these patients may have mild or moderate degrees of depression. Advanced stage of cancer is associated with marked disability and discomfort and such patients are more often prone to depression. Many drugs used in the treatment of cancer have depression as their side-effect. It is possible that cancer patients run an additional risk for suicide if the illness occurs in a setting of pre-existing depression, advanced age, poor social support, family history of depression and suicide, disfigurement due to disease or surgery, and severe pain. Patients who have suffered from chronic pain, as in advanced arthritis or some forms of cancer, are at a high risk for depression. Thus, patients suffering from a primary medical illness are more vulnerable to depression. Since most often it remains undetected, clinicians should assess the risk of depression and suicide in these high-risk patients.

Depression during pre-existing medical disorders ! Depression occurs in approximately 30% of patients with other medical disorders. ! The presence of depression increases the cost of medical services. ! Depression increases the suffering due to primary medical disorders. ! Patients with long-term medical illnesses are at increased risk for concurrent depression. Depression occurring in the setting of a physical disorder remains unrecognized and untreated in a significant number of cases.

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DIAGNOSING DEPRESSION

he term 'depression' may signify many things. It may be viewed as normal when occurring under certain circumstances, for example, in response to a death or loss of business. It is viewed as abnormal when it occurs under inappropriate circumstances, when it is of inappropriate severity, continues for a long time and interferes with a person's activities of daily living. As a symptom, depression is associated with a number of psychiatric disorders. Depression by itself has a predictable course, associated biological abnormalities, genetic inheritable pattern and treatment response.

T

A mild depressed effect or mood does not signify the presence of a serious disorder. To determine whether a depressed mood or effect is of clinical significance, there must be a complete evaluation to determine the clinical context of the depression. This means that it should be possible to define a threshold at which a constellation of depressive features becomes a condition distinct from the ordinary blues. According to the current definition, a person who responds to a setback with lowered spirits and self-doubt, difficulty in sleeping and concentration, and decreased appetite and libido for at least 14 days qualifies for diagnosis of a major depression. However, it is necessary to have more specific criteria to differentiate depression from adjustment reactions to life situations, and validate the diagnosis.

Some important aspects of depression ! Depression can be incapacitating. In fact, impaired work performance is often an early manifestation. ! Depression is a distinct break from a person's usual premorbid self. ! The sufferer experiences depression as qualitatively distinct from grief or other understandable reactions to loss or adversity. ! Sometimes there may be a history of similar episodes in the past. ! There may be a history of similar episodes and/or suicide in the family.

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The clinical interview is the most effective method for detecting depression. The interview elicits the nature, degree and severity of depressive symptoms. It also helps to identify various types of depression, the course and outcome of the disorders, and various factors like stressors, psychosocial support, physical disorders, concomitant medications, family history and alcohol and substance abuse. The interview helps to determine if the patient has suicidal ideas, and if so, how grave the intention is. It also records the patient's level of functioning and the presence of psychotic features like delusions or hallucinations. If there are indications in the history to suspect a medical disorder, appropriate physical examination and laboratory investigations must be carried out to detect the specific disorder. It must also be determined if the disorder has a causal link to the depression. For the primary care setting, a number of self-reported screening instruments are available which help to identify potentially -- depressed patients. Such patients should be further evaluated by clinical interview to determine whether the symptoms meet the criteria for depression. Several rating scales are also available for doctors. They offer greater specificity to detect depression, and are sensitive to monitor the course of treatment.

When should a person consult a doctor? ! If symptoms as outlined persist for at least two weeks. ! When there is significant impairment of social and occupational functioning. ! If normal stresses of life do not explain the symptoms. ! When rest and relaxation have not helped.

Symptoms of depression ! Depressed mood ! Loss of interest and enjoyment ! Reduced energy, being easily fatigued, diminished activity ! Marked tiredness on slight effort ! Reduced concentration and attention on a task ! Reduced confidence and self-esteem ! Feeling of guilt and unworthiness ! Bleak and pessimistic views of the future ! Ideas or acts of self-destruction or suicide ! Disturbed sleep ! Diminished appetite and libido ! Unexplained physical symptoms. Source: International Classification of Disease, WHO (1992)

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SOME FACTS AND FIGURES

How common is depression in the community? With well-defined diagnostic categories and reliable operational criteria available, the frequency of depression can be measured in the community. High-risk population groups can be identified in the community and the effectiveness of various treatments and preventive measures determined. Historically, disease burden has been based on mortality statistics. However, these statistics underestimate the burden from non-fatal conditions such as neuropsychiatric disorders. The World Health Organization has introduced a new concept of measuring suffering of populations based on time lived with disability which has been described as, Disability-Adjusted Life Year (DALY). According to World Health Report 1999, in 1998, an estimated 39% of all DALYs lost in low and middle-income countries, in which most Member Countries of WHO SEAR fall, were attributable to noncommunicable diseases, of which, 10% of the disease burden was due to neuropsychiatric conditions. A large proportion of the burden of disease resulting from neuropscychiatric conditions is attributable to unipolar major depression, which was the fourth leading cause of overall disease burden in 1990, while in adults aged 15-44 years, it was the leading cause of DALYs lost wordlwide. The disease burden resulting from depression is estimated to be increasing both in developing and developed regions. However, establishing a diagnosis of depression versus a normal fluctuation in mood is a crucial issue in estimating the true frequency of depression in the community. This is relevant not only for doctors who must distinguish normal variations in mood from depression for the purpose of treatment, but also for health planners and policy-makers for making provisions for mental health care in the community. It is estimated that 5-10% of the population at any given time is suffering from identifiable depression needing psychiatric or psychosocial intervention. The life-time risk of developing depression is 10-20% in females and slightly less in males. Persons under 45 years are much more likely to suffer from depression than persons 45 years or older. This means that the illness is more likely to affect people during their most productive years of life.

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Women have a relatively higher rate of occurrence of depression than men. The gender differences are consistent across the life cycle, but are much more prominent in young adult and middle-aged women. It is believed that certain factors, such as maintaining multiple roles as home-makers, professionals, wives, and mothers may explain the higher frequency of depression in women. The rate of occurrence of depression does not vary significantly by race or ethnicity. Socioeconomic or educational differences may contribute to some differences observed between ethnic groups, but on statistical correction of these factors, there is no variation in risk by ethnic groups.

Some facts and figures about depression ! Nearly 5-10% of persons in a community at a given time are in need of help for depression. ! As much as 8-20% of persons carry the risk of developing depression during their lifetime. ! The average age of the onset of major depression is between 20 and 40 years. ! Women have higher rates of depression than men. ! Race or ethnicity does not influence the prevalence of depression. Digital Creativity

Why do people get depression? Depression is a complex disorder which can manifest itself under a variety of circumstances and due to a multiplicity of factors. The biopsychosocial model is useful to understand the causation of depression where biological (genetic and biochemical), sociological (stressors) and psychological (development and life experiences) factors interact to produce a picture of depression. Research during the last 50 years indicates that there is no single factor which can explain the cause for depression. Genetic factors It has been consistently observed that depression tends to cluster and run in families. Surveys conducted in the general population and among the families of affected persons h a v e 33

shown that parents, siblings and children of severely depressed patients have a 10-15% risk for depression as against 1-2% in the general population. Children of depressed parents are especially at high risk; up to 50-75% of children are likely to get depression if both parents are suffering from depression. Early identification of children at risk is thus important. Genetic factors, however, play a role in some, but not all patients, since depression also occurs among individuals with no family history of depression. Genetic or chromosomal markers are yet to be discovered for making any accurate predictions. It is hoped that molecular genetics may identify specific defects in the brain that cause either spontaneous disturbances of mood or a vulnerability to decompensate under stress. Biological factors Shabeba Ahmed

Aberrations of the chemical and physiological functions of the brain have been studied to explain the manifestation of depression and other mood disorders. A drop in the level of these chemicals known as neurotransmitters may produce depression. However, the assumption that depression is the direct result of such an abnormality may be an oversimplification. It is still a matter of debate whether the abnormalities in various neurochemical systems in the brain cause depression, or are themselves the result of depression. Psychological factors Since depression is a psychological disorder, it is logical to search for its cause among psychological factors. How and what a person thinks may also determine the onset of depression. If people have distorted thinking by which they view everything around them including themselves and their future negatively and pessimistically, then their mood also becomes sad, completing the picture of depression. Risk factors for depression Community-based and clinic-based surveys have identified certain risk factors which increases the chances for the onset of depression. Each factor may not be significant in itself, but multiple risk factors together may lead to depression. Gender: Women are twice as likely as men to experience depression. However, no mechanism for this apparent increased risk has been established. The social environment of women and a tendency among men not to report

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depressive symptoms may account for the increased association of women and depression. Age: The average age for onset of depression is between 20 and 40 years. But many studies have confirmed that depression can also occur in childhood. Genetic and social factors appear to place persons at greater risk at a younger age. Marital status: Unmarried status appears to be one of the most consistent risk factors for both depressive symptoms and depression. Separated and divorced persons have the highest risk, while single and married persons carry the lowest risk. Recent widowhood is associated with higher rates of depression. However, the relationship of marriage and the onset of depression may be complex, with many associated variables such as quality of relationship, partnership, children and adequacy of support during crises determining the outcome. Family history : Individuals suffering from depression have a consistently higher number of relatives suffering from depression. Besides depression, cases of suicide and alcoholism are also seen more often in the families of depressed patients. Most experts attribute the increased risk for depression to a genetic predisposition, yet shared family environment may also contribute to increased risk. Parental deprivation: Parental loss in early childhood is a welldocumented risk factor for the onset depression in adulthood. A deprived and disrupted home environment also constitutes a risk. Several investigators have noted that separation from parents early in life or the actual loss of a parent may predispose a person to depression. Traumatic childhood experiences like neglect, abuse, or deprivation make the child grow up with inadequate coping mechanisms. The child does not learn to tolerate adverse feelings, and this impaired adaptation contributes to subsequent development of depression. In this context, the importance of relationship and coping skills have been emphasized. It is believed that social losses in a patient's life contribute to depression, while improved interpersonal relationships alleviate the symptoms of depression. Social stressors: Social stressors may play a significant role as risk factors for depression at any age in a person's life. Researchers have identified three kinds of stressors - life events, chronic stress, and daily hassles. A life event like bereavement is an easily identifiable, sudden, o v e r w h e l m i n g

Who is at risk for getting depression? ! Women are at greater risk than men. ! Separated and divorced people. ! A person having a close family member with depression. ! Early parental loss. ! Negative stressful events and chronic stress. ! Lack of social support. ! Family type and those living in urban areas compared to rural areas.

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change in life that disrupts normal behaviour and threatens the person's well-being. Chronic stress includes long-term situations which threaten a person's well being; for example, interpersonal difficulties, persistent threat to security like living in war/conflict zones. Some routine activities of modern living may be perceived as stressful. Different events or stressors have different meanings for individuals. In fact, it is the perception of the event that is more important than the event itself. Social support: Availability of meaningful, appropriate and protective support provides a hedge to an individual against various stressors mentioned above. Lack of adequate social support tends to prolong the suffering caused by an episode of depression. Family type: Societies in the countries of SEAR have traditionally lived in a joint family system. However, with rapid and increasing urbanization and industrialization, nuclear families are increasing. Many surveys in India have shown an increased rate of occurrence of psychiatric problems, including depression in nuclear families. It is believed that the joint family system can counteract the effects of bereavement of early parental loss, leading to a lower rate of occurrence of depression.

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Yogeeta

T age.

he most disturbing consequence of depression is death by suicide. Depression not only leads 15% of its victims to committing suicide, it kills them at a younger

CONSEQUENCES OF DEPRESSION

However, the number of suicides associated with depression does not truly represent the burden of suffering caused by depression on society. The number of deaths does not take into consideration the age at which death occurs. Diseases that kill at a younger age are a greater public health concern than those that affect predominantly older individuals. A major study by WHO, the World Bank and Harvard University on the Global Burden of Diseases has found that depression was the fourth leading cause of disease burden in the 1990s worldwide, including fatal or non-fatal cases, but in terms of death, depression ranked 95th among 107 diseases and injuries included in the study. To adequately represent the true burden of a disease requires an approach that takes into account (i) both death and disability, (ii) the age at which death or disability occurs, (iii) the duration of disability, and (iv) the severity of disability due to disease. Thus, worldwide, the loss of DALYs from neuropsychiatric disorders is more than 10%, about the same as caused by cardiovascular diseases, and depression accounted for nearly one-third of all neuropsychiatric DALYs. Thus, depression causes significant disability in the social and occupational functioning of the individual. Moreover, caregivers of depressed people may themselves suffer from impairment in their functioning, adding to the burden of disease in the patient. Depressed people also tend to suffer more from various medical disorders, and die prematurely. Thus it has been reported that patients above the age of 55 with depression had a death rate four times higher than those without depression. Most of these deaths occurred from heart disease or stroke. Also, depressed people tend to use medical services more often, as they suffer from various medical disorders from time to time, thus raising the cost of medical services to the community at large.

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The risk of suicide in patients with depression Nearly 15-20% of patients with affective disorders eventually commit suicide. Suicidal behaviour is the most lethal complication of depression. A depressed person may think of suicide to end the pain of depression, or to convey this pain to others. Many patients would not contemplate suicide actively, but would welcome death by a sudden heart attack or accident. Some would make impulsive suicidal gestures to convey their despair to others without a definite plan to die. A person who is determined to die and makes active plans of when (time) and how (method) to carry out the act is at greatest risk. A clinician must always ask his depressed patient about suicidal ideas and attempts. It is sometimes feared that asking about suicide “will make it happen”. On the contrary, patients are often relieved that the clinician has appreciated the gravity of their illness. Patients welcome this enquiry, and the clinician can assess whether the patient is just harbouring a death wish, or attempting to carry out this wish passively, or is making a definite and elaborate plan. A clinician, therefore, must always be alert to the possibility of suicide. Male gender, divorced or widowed status, old age, unemployment, alcoholism, poor response to treatment, a history of past attempts, and a family history of suicide increase the risk of suicide.

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Sayan Banerjee 39

WHAT CAN BE DONE ?

ith the advancement in pharmacological sciences and a better understanding of the biochemical basis of depression, a number of drugs have been introduced for the treatment of depression and prevention of relapses on a long-term basis. However, it is ironic that even in the affluent west, only one-third of persons with such disorders are under appropriate treatment. The situation is worse in the countries of South-East Asia, where such cases remain underdiagnosed and undertreated, despite the fact that these drugs are now quite affordable and easily available everywhere. The reasons usually cited for this state of affairs are:

W

! ! ! ! ! ! !

Patient's disbelief in medications; Sense of hopelessness; Viewing illness as untreatable; Physician's failure to recognize illness; Illness factors like marked lethargy, disinterest and death wishes; Poor recognition of consequences, and Society's negative attitude towards illness and medication.

What the family can do The role of the family in looking after a depressed person cannot be overemphasized. The family can provide help and support in the following ways: ! ! By early appreciation / recognition of onset of depression; By helping the patients to start treatment at an appropriate facility, and helping them to continue with the treatment; By providing adequate supervision and support to minimize the risk of suicide; By helping the patients to resume their activities and role in life on recovery, and By getting all the necessary guidance and information to prevent further recurrence.

! ! !

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The most important thing family members can do for depressed persons is to help them get an appropriate diagnosis and treatment. Patients may not recognize the illness themselves; may blame a physical illness for their bodily symptoms; may consider the entire situation arising out of a sad mood as totally hopeless, and may refuse any treatment; may hide their illness fearing rejection because of social stigma, or may contemplate suicide. All these reasons may interfere with early recognition of illness and its proper treatment. The families can help the patients to reach the appropriate treatment facility and accompany them to the doctor. Family members may be helpful in providing necessary details to the doctor for making a proper diagnosis and planning an effective treatment strategy. The family has to monitor whether the patient is taking the prescribed medication. The patient's progress on the treatment should be modified by the family, since this will decide when to revise the treatment strategy, or when to hospitalize the patient. The risk of suicide has to be appreciated from the patient's behaviour and body language. Remarks about death or suicide should not be ignored. If there is such a risk, the patient will require constant supervision; all objects capable of causing physical harm must be removed from the patient's reach. The family also has an important task in providing emotional support to the patient. This involves understanding the patient's own emotional state and helplessness, exercising patience when the recovery is slow, showing affection when the patient is having very low self-esteem, and encouraging him/her to take on responsibilities gradually as they improve. When the patient begins to recover from a serious episode of illness, he/she should be allowed to approach life at his/her own pace and regain him/her self-confidence. Participation in activities that once gave him/her pleasure, such as hobbies, sports, religious or cultural activities should be encouraged, but the depressed person should not be pushed to undertake too much too soon. He/she has to regain his/her self-esteem and become comfortable again at home, at school, among friends and on the job. Depressed persons should never be accused of laziness or of faking illness, or be expected to just shrug off the symptoms. Eventually, with treatment most people get better. The depressed persons should be reassured that, with time and

Yogeeta

The family's responsibility increases manifold while looking after a suicidal patient.

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Some issues which are important from the patient's viewpoint: ! Emotional consequences of a severe episode; ! Consequences of awareness of diagnosis; ! Stigmatization; ! Impaired self-esteem; ! Fear of recurrences; ! Impaired psychosocial functioning; ! Interpersonal difficulties; ! Issues related to marriage and parenting, and ! Social and legal consequences of suicide -- whether attempted or completed.

help, they will get better. The depressed family member must be reassured that he/she is cared for. Living with a person who has depression can be a great strain on the caregiver or family member. The illness may give the impression that the patient is being uncooperative or hostile. If possible, family members should take turns to look after the patient's needs so that one family member does not feel overburdened. Family members should alleviate their own stress by remaining focused on events and activities requiring their attention.

What the patients can do for themselves The treatment of depression and the prevention of further recurrences requires careful planning and strategy, and demands a strong commitment, both from the patient as well as the doctor. There are issues which may be unique for each patient and these need to be appreciated, understood and resolved before patients commit themselves to treatment, especially long-term treatment. It is essential to evaluate these issues to sufficiently motivate the patients to adhere to a plan, since the course of illness or treatment may be characterized by high dropout rates, noncompliance, and premature exit from the treatment programme. Unfortunately, many people do not recognize that a sad mood can be a manifestation of depression, or that depression is a treatable illness. So, if they suspect the onset of mental illness, they should think in terms of obtaining appropriate help rather than denying its existence and consequently delaying the treatment. Many kinds of myths, misconceptions, and stigmas associated with the illness may prevent them from seeking help. Hence it is essential that they be better informed to look after themselves. If it is suspected that the symptoms may be the manifestation of depression, the patient should consult the family physician or a nearby medical facility for confirmation of this suspicion. Sometimes the patient's own physician may detect signs of depression when consulted for some vague bodily symptoms. Besides the patient's own family physician or general practitioner, other people who have received training in mental health, such as a psychiatrist, psychologist, social worker, or a psychiatric nurse, can provide help. At the primary health care level, community health workers can also assist in obtaining the requisite help.

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It is important that the patients share information with their doctors, to help them gauge the severity of illness. The general medical history, physical examination, and basic laboratory tests can help the doctor learn if a physical disorder is the cause of the depression, as is the case in 1015% of depressed patients. Thoughts of suicide or death are often a part of depression and such thoughts should be communicated to the doctor immediately. Close family members or friends should also be taken into confidence, and they should provide the necessary support. People with depression may often try to ward off symptoms by consuming alcohol or other drugs which only make matters worse. Medical advice regarding medication should be scrupulously followed. Not following the advice or prematurely stopping the drugs may lead to recurrence of symptoms. It is very important that antidepressant medications are continued long after the depressive symptoms have disappeared and taken according to the doctor's prescription. Generally, taking medication for three to six months is considered essential for relief from symptoms. Depending on the nature and severity of their illness, patients may be advised to continue the medication even for a longer period. It must be remembered that antidepressant medicines are not habit-forming or addictive. The patients should not blame themselves or feel ashamed of their symptoms. They should get adequate treatment, learn new skills to cope better with stresses, and should not lose hope.

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What the medical community can do It is very essential for the health professional to understand the burden caused by depression on the community. In spite of its common occurrence in the community, depression remains unrecognized and poorly treated even by doctors. It is thus imperative that the medical community is better informed about the manifestations of illness, process of diagnosis and proper management of depression. Many myths and misconceptions associated with depression are also shared by medical personnel. Their role is significant in fighting the stigma caused by these disorders. 43

The burden of depression is caused by… ! direct medical cost of treatment of the illness; loss of income from absenteeism from work; lost productivity because of inability to perform at optimum capacity, and premature death from adverse effects of the illness.

!

Many people with depression can be successfully treated by general practitioners. However, some people need specialized treatment, because either the first line of treatment does not work and they need an alternative or combination of treatments, or because the depression is very severe or lasts a long time. Most of the time, the treatment is provided on an outpatient basis; however, some patients may require hospitalization. Whenever a depressed person approaches a doctor, the latter has to take into consideration the following: ! ! ! ! ! Making a diagnosis, and understanding its possible cause; Appreciating the risk of suicide; Deciding whether to provide outpatient treatment or to hospitalize the patient; Advising whether the patient should continue to work or take temporary leave; Taking the family into confidence to ensure regularity of treatment of the patient, and providing the family members with all the necessary knowledge about the illness; Explaining that alcohol or other such drugs are not helpful in treating or avoiding depression; What mode of treatment is to be used: pharmacological, electroconvulsive, or psychotherapeutic; or a combination of these; Explaining to the patient what to expect from the treatment and that side-effects may appear earlier than therapeutic response; Telling the patient how frequently he/she should visit the clinic; Ensuring drug compliance; Advising the patients when and how to resume their family, social and occupational activities, and Assessing the scope and implementing the strategy for prevention of relapse of depression.

!

!

! !

!

! ! ! !

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There are well-established treatments available to alleviate symptoms effectively. Such treatments are drugs (antidepressant medication), non-pharmacological interventions like psychotherapy, or a combination of drugs and psychotherapy. In some cases, other treatments, such as electroconvulsive therapy, are also useful. At many places, locally available indigenous treatments like herbal medications are also used with varying degrees of success. Yoga, meditation, and naturopathy may also advised as supportive measures. St. John's wort is the most prescribed anti-depressant in Germany. Hypericum is extracted from its flowers and leaves. Some consider it effective in treating depression, but its efficacy has not been scientifically tested. The medical community has a significant role in educating the public at large about depression, its consequences, and the therapeutic and preventive measures that can be undertaken. They must actively liaise with the health planners and administrators so that they give adequate attention to these disorders in health planning. Since it has now been shown that the burden of depression is much more than what was believed earlier, resources must be appropriately allocated.

Ma Thiri Nanda Shwe War Phone

What the government can do Mental health is an important aspect of public health that has long been segregated and neglected. That mental disorders are a significant cause of disability and account for more than 10% of the global burden of diseases has come as a surprise to many. Despite the current availability of efficacious treatments, surprisingly little has been put into practice for the management and prevention of such disorders. Governments all over the globe, and especially in SEAR Member Countries, should attempt to change the current scenario. Governmental efforts in this direction should be guided by a set of goals. Such goals must aim to change the negative perception of mental disorders by the public, reduce the risk of occurrence of mental disorders, including depression, and provide adequate care and rehabilitation of the sufferers. The government policy must aim at maximizing scarce public resources, formulating clear strategies to reduce the disability associated with mental disorders and promoting research on preventive and promotional aspects of mental health. 45

Traditional beliefs in supernatural causes and remedies strongly influence people's attitudes towards mental illnesses leading to negative responses and stigmatization of mentally ill persons. Governments should give priority to public education since many aspects of mental health care require active collaboration of the community. Governments should make adequate provisions for the delivery of health care and social services. In developing countries, where a majority of the population is rural-based, primary health care facilities are the main source of medical care; hence adequate manpower and supply of effective and affordable drugs must be ensured. Training programmes for primary health care -- setting doctors and general practinioners should be conducted on a regular and ongoing basis. Families are the main support system for the care of mentally sick individuals. However, severe mental disorders may deplete the resources of even the most willing and able families. Policies must be framed to bring families together and encourage them to create consumer groups. Legal provisions for the protection of the mentally ill from unjust discrimination are becoming common in the developed countries. Such provisions must also be adopted in the Member Countries of the South-East Asia Region. The human rights of the mentally ill must be upheld with relevant legal provisions. Governments must allocate sufficient funds for training and research in mental disorders. Only adequate research can form the basis for a sound mental health policy. Wherever manpower is scarce, enough training opportunities must be created for increasing the number of mental health professionals. Sufferers of mental illnesses are at a severe disadvantage to express their need for care. They are easily marginalized with regard to social services and health care. The economically disadvantaged have the least access to health services and care. Health policies should recognize such inequities and seek to prevent them. Policies must be framed to nurture positive mental health. Wars, internecine strife, crime and natural disasters disrupt social and community life, leading to psychological disorders in large numbers of people. Governments and health policies must take into account the impact of such social upheavals and make whatever provisions possible to reduce their negative effects on the psychological health of the victims. 46

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World Health Organization Regional Office for South-East Asia New Delhi