Depression is one of the most important mental health conditions and is characterized by low mood, loss of interest or pleasure in activities that are normally pleasurable, increased fatigue, low self-esteem, diminished ability to think or concentrate, sleep and appetite disturbances, and in severe cases, suicidal behaviour. It is one of the most disabling conditions, and in India it is already one of the top five leading causes of Years Lived with Disability (a metric used to quantify and compare morbidity across populations). Depression alone accounts for around 3% of the total burden of disease in India. Most importantly, its contribution to the burden of disease has increased 50% in the last two years and is projected to increase further during the next 25 years as a consequence of epidemiological and demographic transitions in India.
Contrary to popular belief, there is strong evidence linking depression with gender and factors related to social disadvantages such as poverty and illiteracy. Low levels of education, food insecurity, poor housing and financial stress exhibit a relatively consistent and strong association with the risk for depression. Poverty and depression interact in a vicious negative cycle. There are dire economic consequences as people with depression spend more days being unable to work due to their illness, which is further worsened by the high costs of healthcare due to depression.
Depression is a risk factor for a number of non-communicable diseases such as diabetes and cardiovascular disease, and these conditions in turn increase the risk for depression. Co-morbidity complicates help-seeking, diagnosis and treatment, and affects the outcomes of treatment for the above-mentioned conditions, including disease-related mortality. Depression in mothers during the perinatal period potentially has far more detrimental effects on the child’s nutrition and overall development.
There are a wide range of drugs, and psychological and social interventions that have been shown to be
cost-effective and that can transform the lives of people affected by depression. Despite this evidence, very few people with depression (around 5%) seek services for the same and among them, very few actually receive evidence-based interventions. There is an urgent need to scale up services for treating depression by focusing on the following policy interventions:
First, the draft Mental Health Care Bill, which enshrines access to mental health care as a right and an entitlement, needs to be enacted as soon as possible. Beyond the narrow domain of treatment, the Bill makes the state responsible for the implementation of the programme for promotion of mental health, and prevention of mental health problems and suicide. These provisions in the Bill could well serve as a key legal foundation for scaling up of evidence-based services for depression.
Second, the National Mental Health Policy, along with the rejuvenated District Mental Health Programme (DMHP), should be finalized. This will facilitate implementation of evidence-based interventions for depression through the public health system. The new DMHP recommends recruitment of a new cadre of community mental health workers, based at the primary health centres, who can play a vital role in identifying persons with depression and providing them basic psycho-social interventions, which have proven efficacy in treatment of mild to moderate depression. They can serve as a link between the patient and the specialist. This collaborative care model based on a task-sharing approach needs to hit the ground as soon as possible, which in turn can ensure increased access to these treatments.
Third, programmes for depression as well as other mental health programmes should be integrated with the National Rural Health Mission and the project implementation plans for the same should include components of screening and treatment for depression in mothers (in perinatal period), and in people with diabetes and cardiovascular diseases.
Fourth, stigma and discrimination against depression should be systematically addressed by organizing mass campaigns, which can improve mental health literacy and change negative attitudes towards this condition, ultimately resulting in increased help-seeking behaviour.
Fifth, long-term investment in implementation science research is needed to bridge the huge knowledge gap between what we know (the evidence-based interventions) and how to deliver them on various platforms or channels for service provision. This can be addressed by focusing on some of the key research questions related to quantifying the treatment gap for realistic goal-setting, capacity-building approaches for achieving and maintaining key skills, and competencies by health workers to provide mental healthcare and development and evaluation of interventions for depression delivered using a “task-sharing” approach in the “real-world” setting.
As a nation, our developmental indices will improve only if the society is healthy. There can be no health without mental health, and so it is high time we acted on and checked the growing burden of depression.
The author is assistant professor, Centre for Mental Health, Public Health Foundation of India.