Depression: A Global Crisis

Today is the 20th anniversary of mental health day. Twenty years back Richard Hunter thought of telling the world that there is no health without mental health and he proclaimed 10th October as me...

Today is the 20th anniversary of mental health day. Twenty years back Richard Hunter thought of telling the world that there is no health without mental health and he proclaimed 10th October as mental health day to focus the world attention on improved care for mental health issues. The world woke up to the reality of mental health and 10th October became the regular affair world over to recognize and register the epidemic of mental health problems. Mental disorders have a substantial impact, globally accounting for 12% of all disability adjusted life years (DALYs), and 31% of all years lived with a disability (WHO 2001). In Europe alone, they account for 20% of all disability adjusted life years, and 43% of all years lived with a disability. Globally, they include 3 of the top 20 causes of disease burden in the general population, (unipolar depressive disorders, self-inflicted injuries and alcohol use disorders), and 6 of the top 20 in the 15-44 age group (additionally schizophrenia, bipolar depressive disorder and panic disorder).
Furthermore the incidence of age related cognitive disorders in the next two decades is expected to increase markedly, and the proportion of DALYs attributed to mental health disorders are expected to increase to 15% by 2020. Poor mental health also has a significant impact on other aspects of health. The level of co-morbidities and (non-suicide related) mortality in people with mental illness has been observed to be significantly higher than those in the general population.
In addition to the burden on overall individual health, mental health disorders generate substantial costs not only to health and social care services but also in many other sectors of the economy, including notably criminal justice. The social impact is also profound. The stigmatization and social exclusion of those with mental health disorders, can affect all aspects of an individual's life limiting their access to employment and housing, hampering social relationships and reducing self-esteem. Family relationships may suffer; relatives may have little choice but to provide substantial amounts of informal care, much of which is not valued in economic burden studies.
Mental disorders that occur in childhood can also have a significant impact on educational attainment, depression has been shown to be correlated with poor school grades. Those with untreated common childhood mental disorders may experience higher rates of unemployment, poorer relationships, and greater contact with the criminal justice system in adult life.
The WHO has chosen this year, the 20th anniversary, as the year for DEPRESSION awareness and the theme is "Depression: A Global Crisis". Depression is recognized since prehistoric times and was thought due to an imbalance in the four basic bodily fluids, or humors. Melancholia was described as a distinct disease with particular mental and physical symptoms by Hippocrates in his Aphorisms, where he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.
Melancholia was a far broader concept than today's depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fears, anger, delusions and obsessions were included. The Muslim world developed its own ideas about melancholia. Ishaq ibn Imran (d. 908) combined the concepts of melancholia and phrenitis. The 11th century Persian physician Avicenna described melancholia as a depressive type of mood disorder in which the person may become suspicious and develop certain types of phobias. His work, The Canon of Medicine, became the standard of medical thinking in Europe about melancholia. Moral and spiritual theories also prevailed, and continue to dominate the eastern cultures.
World Health Organization has ranked unipolar depressive disorders as third leading cause of the global burden of disease in 2004 and will move into the first place by 2030. Depression is a significant contributor to the global burden of disease and affects people in all communities across the world. Today, depression is estimated to affect 350 million people. The World Mental Health Survey conducted in 17 countries found that on average about 1 in 20 people reported having an episode of depression in the previous year. Depressive disorders often start at a young age; they reduce people's functioning and often are recurring. For these reasons, depression is the leading cause of disability worldwide in terms of total years lost due to disability. The demand for curbing depression and other mental health conditions is on the rise globally. A recent World Health Assembly called on the World Health Organization and its member states to take action in this direction.
The impact on employment and productivity is substantial, e.g. one UK study estimated that depression alone accounted for a third of absenteeism from work. In another recent study it was estimated that 86% of the total costs of bi-polar disorder (£2 billion in total) were attributable to lost productivity.  In the United States costs of lost productivity attributable to mental illness were estimated to be $76 billion in 1990. Those with mental health disorders may drift into poverty and are at greater risk of becoming homeless.
Kashmir, witness to one of the worst conflicts of modern era with huge human costs and mental health, is one of the worst casualties. Lifetime prevalence of major depression is at all-time high. The economic costs of this huge mental health burden are tremendous. Annualized work loss due to major depressive disorder in various departments of Kashmir is huge both due to absenteeism and presentism. In lower socioeconomic class the costs are more gruesome. Mental health problems lead to economic depression which leads to inadequate treatment or no treatment which leads to perpetual and vicious circle leading to social drift hampering employment, relationship, and many other severe social problems. In urban areas the problem is compounded by lack of social networking leading to further social exclusion and stigmatization. There are no income tax benefits for most of mental health problems even though WHO recognizes them as costliest diseases. Insurance doesn't cover any mental health problem. NGOs and social groups don't provide any long-term treatment benefits in form of drugs, investigations etc. to mentally ill. This is more serious because mental health problems in Kashmir are afflicting young productive age group furthering the economic burden. Because of depression combined with substance use and other mental health problem the indirect costs on criminal justice are also increased. Because of somatization the indirect costs on existing health system are too difficult to understand and estimate but everybody in Valley based hospitals knows that maximum unwanted procedures – diagnostic and therapeutic are done on the people with mental health problems and with privatization the costs are even higher and sometimes cruel.
Depression is a common mental disorder that presents with depressed mood, loss of interest and/or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide. Almost 1 million lives are lost yearly due to suicide, which translates to 3000 suicide deaths every day. For every person who completes a suicide, 20 or more may attempt to end his or her life. The hallmark of depression is dangerousness to self, that is, suicide. Depression is a risk factor for suicidal thinking (there are many more attempts at suicide than there are completed acts). Good mental health care can reduce the risk. Suicide ranks 9th among causes of death in developed world. Whenever figures on suicide are presented or discussed there is always the question of their reliability (more so in developing world), since in some instances and for several reason suicide as a reason for death can be hidden; thus real figures are higher. According to WHO estimates for the year 2020 and based on current trends, approximately 1.53 million people will die from suicide and 10-20 times more people will attempt suicide worldwide. This represents on an average one death every 20 seconds and one attempt every 1-2 seconds. Kashmir, a predominantly Muslim society had lowest suicide rates in whole India at 0.5 / 100,000 comparable to Kuwait which has 0.1/ 100,000, lowest in world. Past few years has shown spurt of suicides, Para– suicides and deliberate self-harm. This increase in suicides, Para suicides and deliberate self-harm is really alarming and lot of this is contributed by rising depression rates in valley.
The 2012 theme – Depression a global crisis- will try to bridge the gap in information about depression as a treatable illness, and to make people understand that recovery is possible and achievable. In the under developed world and developing countries the burden of illness because of communicable diseases and other illnesses is so huge that the reality of epidemic of depression in these countries is hugely under-recognized and under-scored in planning for health, that there is great danger of increased mortality and morbidity because of depression which our existing health system will not be able to deal in an effective manner. World Mental Health Day 2012 aims to encourage governments and civil society around the world to address depression as a widespread illness that affects individuals, their families and their peers, and to recognize that it is a treatable condition. People should be alert to the early signs of depressive disorder—it can affect anyone, from young to old, men and women, children or adults. Treatments are usually easy and cost effective and should be sought at the earliest. There is no shame in getting treated for depression. We together have to dare to care and remove stigma and re-kindle the smiles and defeat depression.
Author is Assistant Professor Department of Psychiatry GMC Srinagar.

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