SPECIAL ARTICLE

Depression: An Indian Perspective

Sujit Sarkhel*

*Assistant Professor
Institute of Psychiatry, Kolkata
E-mail: sujitsarkhel@gmail.com



Depression is a common mental disorder characterized by persistent low mood or feeling sad for at least two weeks with loss of interest or pleasure in activities once enjoyed, changes in appetite, decreased sleep, loss of energy or increased fatigue, difficulty in concentrating or making decisions and in most severe cases, thoughts of death or suicide. 1Depression can vary in severity from mild to severe and also in duration from months to years. Depression often follows a chronic course characterized by periodic remissions and exacerbations.

According to WHO, more than 300 million people of all ages suffer from depression globally and it is the leading cause of disability worldwide. Depression accounted for 2% of global Disability Adjusted Life Years (DALY) in 2015. Worldwide, the proportion of the population with depression is estimated to be 4.4%.2 As per National Mental Health Survey (2015-16) carried out by NIMHANS in India, one in 20 (5.25%) people over 18 years of age havesuffered from depression at least once in lifetime resulting in a total of over 45 million persons with depression in 2015.3The most serious fate of depression is suicide and nearly800,000 people every year die due to suicide, mostly 15-29-year-olds. Various studies have shown that the probability of suicide in depressed individuals is as high as 15%.

Women suffer from depression more than men and it is even more evident in elderly population.4 Studies have also found that depression is more prevalent in socially, economically and educationally disadvantaged people.5



What is depression?

Depression presents with low mood for a persistent period along with its associated symptoms indicating a mind with helplessness, hopelessness and worthlessness. It is a chronic and recurrent condition, having severe effect on one’s ability to work or on daily activity. Depressive disorder is the leading cause of disability for both sexes. However, the prevalence of depression is 50% higher for females than males.6

Serious life events or stressor, childhood adverse experiences were thought to be the primary cause of depression earlier but advances in neurosciences proved that it is a complex brain disorder having its root in gene-environment interaction and there are imbalances of various neurochemicals, particularly serotonin, in brain during depression. Depression is a syndrome and may develop in various psychiatric conditions like in unipolar depression, bipolar depression, perinatal depression, dysthymia, seasonal affective disorder and in psychotic depression. General medical conditions like diabetes mellitus, rheumatoid arthritis, chronic kidney disease and coronary artery diseases have high comorbidity of depression and vice versa.7 Hence, the current understanding is that depression is multifactorial and several biological, social, economic, cultural and environmental factors operate together in a vulnerable individual to cause depressive illness.



Treatment of Depression



Depression can be easily and reliably diagnosed and treated in primary health care. Combined approach with antidepressant and cognitive behavior therapy along with proper social support can resolve symptoms of depression earliest and prevent its recurrence. Effectiveness of early intervention has been established all over the world. A trial conducted in India has shown that those patients with depression who were treated by trained counselors had early recovery from depression.8

Thus, proper and timely intervention is known to effectively treat depression. However, many people do not receive treatment for this condition. There is a large treatment gap for depression, both globally and in our country. A treatment gap of more than 90% has been reported for depression in low and middle income countries. In the recently concluded National Mental Health Survey, it has been reported that the treatment gap in our country for depression is 86% and for any suicidal behavior is 80%.3Patient related factors contributing to treatment gap include lack of awareness as well as denial of illness. Treatment related factors include insufficient and unevenly distributed health care services, poor condition of mental health services as well as inadequate training of primary care physicians in detection and treatment of common mental disorders.

Prevention of Depression



Only more than half of adult with depression receive treatment of any kind for depression and patients who received 'adequate' treatment for depression is even lower. Again, individuals who receive treatment from specialists other than psychiatristsare less likely to receive adequate treatment. 9In India, shortage of mental health manpower worsens the picture further(0.07 psychiatrists per 100000 population).

Present approach of treatment of depression is individual approach. But it has to be generalized towards all populations in the societyfor early reporting of depression to appropriate health personnel to reduce disease severity, incidence of suicide, financial burden and overall disability. Prevention strategies also highlight the importance of promoting positive mental health, including improvement in diet, exercise, sleep quality, and social support. 10Selective interventions have also to be taken to prevent the onset of depression, most of which are targeted for adolescent age group.

Another important step could be integration of mental health care with primary health care services. It would be cost effective if the care of common mental disorders (depression and anxiety being the commonest) is integrated into conventional care being provided for the care of people with non communicable diseases (cancer, diabetes and cardiovascular disorders), HIV/AIDS, maternal health care and child and adolescent health programmes. Moreover, it would also help in early detection and treatment at primary care level.



Reference:

  1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association. 2013.

  2. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017

  3. National Mental Health Survey of India, 2015–16. Prevalence, Pattern and Outcomes. [website]. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2016

  4. Reddy MV, Chandrashekhar CR. Prevalence of mental and behavioural disorders in India: A metaanalysis. Indian J Psychiatry. 1998;40:149–57.

  5. Nandi PS, Banerjee G, Mukherjee SP, Nandi S, Nandi DN. A study of psychiatric morbidity of the elderly population of a rural community in West Bengal. Indian J Psychiatry. 1997;39:122–9.

  6. Tiwari SC. Geriatric Psychiatric morbidity in rural Northern India: Implications for the future. IntPsychogeriatrics. 2000;12:35–48.

  7. Nutt DJ. Relationship of neurotransmitters to the symptoms of major depressive disorder. J Clin Psychiatry. 2008;69Suppl E1:4-7.

  8. Patel V., Weiss H.A., Chowdhary N., et al .Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): A cluster randomised controlled trial (2010) The Lancet, 376 (9758), pp. 2086-2095.

  9. Kessler RC, Walters EE. Epidemiology of DSM-III-R MDD and minor depression among adolescents and young adults in the National Comorbidity Survey.Depression & Anxiety. 1998;7:3–14.

  10. Institute of Medicine. Depression in parents, parenting, and children. Washington, DC: National Academies Press; 2009.