Amin A. Muhammad Gadit ( Discipline of Psychiatry, Memorial University of Newfoundland, Prince Philip Drive, St. John's, NL A1B 3V6 Canada. )
Depression has been identified as a serious mental health problem world-wide. It harbours a number of complications like suicide, exacerbation of physical ailments, decline in social functionality and much more. Its magnitude is very high on the global scenario and by the year 2020 it will occupy second position among the ten top diseases.1
It affects 121 million people worldwide, is the leading cause of disability worldwide, can be reliably diagnosed and treated in primary care.1 A number of depression specific risk factors have been identified including parental depression, depressogenic cognitions, inadequate parenting, child abuse and neglect, stressful life events and bullying.2
WHO in its documents has emphasized upon the prevention of depression and has launched an initiative on depression in public health with the objectives of spreading education about depression, to reduce stigma, train primary care personnel and to improve the capacity of countries to create supportive policies in this regard.1
Controlled studies show a significant reduction in depressive symptoms after intervention.3 Hence, intervention and early detection can go a long away in reducing the morbidity of this condition. There are a number of ways by which one can address this issue. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial and found it feasible and that depressive symptoms can be reduced in even low income, minority population.4 Adherence to antidepressant treatment could also improve depression outcomes in high-risk patients as compared with usual primary care.5 In patients suffering from malignancy Antidepressants as a prophylaxis were found beneficial in a trial.6 Internet has been identified as a useful medium involving cognitive behaviour therapy (CBT) for prevention of depression.7 A type of cognitive behavioural therapy called Mindfulness-Based Cognitive Therapy (MBCT) has also been found effective to prevent relapse/recurrence of depression.8 A lot of work is also being done to prevent depression among children and adolescents. A pilot study that involved teaching students depression management strategies and positive coping skills indicated effectiveness in prevention of depression.9
A review10 examining psychological/educational intervention for prevention of depression among children and adolescents and another study11 advocating exercise as prevention strategy remained inconclusive.
Reverting back to local scenario, a number of local studies have reflected a high prevalence of depression among the population. Systematic population-based studies are however, not visible on the academic horizon.12 Many individuals in the population do not meet the full criteria of depression but suffer from distressing symptoms of depression with gross disturbance in personal, social and occupational functioning. Such cases of subthreshold depression may carry a serious magnitude for development of full blown major depressive disorder.13
The WHO recommends that in order to prevent depression, it is important to introduce school-based programmes targeting cognitive, problem solving and social skills of children and adolescents, exercise programmes for elderly, home based counseling services and interventions to reduce child abuse, neglect and bullying.2 The consensus paper by European Communities has suggested a number of steps in order to prevent depression: effective national mental health policies, promotion of healthy life style, restriction of access to drugs, mental health literacy, promotion of strong formative relationships, curbing drug abuse, health education in schools with focus on prevention of mental illness, healthy work environment, combating social isolation for elderly, training of health professionals in this respect, mental health awareness for general public and combating stigma.14 What do we need to do in Pakistan? We have a number of problems that can either cause or aggravate depression like violence and terrorism, unemployment, economic disparity, social upheaval and political disturbances. These problems are further compounded by absence of basic needs like water, electricity and personal safety. Still mental health is way back in the list of government priorities. There is an urgent need for developing means to identify risk factors for depression and to treat this illness promptly upon identification. Mass mental health education through electronic and print media, attention by the government to current social adversities and training of primary care physicians may go a long way in preventing this serious illness. It has been rightly said that there will be no vaccine for prevention of depression.15 A few steps taken by us individually and collectively may help in reducing the morbidity. But are we ready to put some efforts in promoting research in order to assess its real magnitude, initiate intervention and then measure the outcome? Should we set the ball in motion?
1.WHO Mental Health-Depression. (Online) 2009 (Cited 2009 July 23). Available from URL: www.who.int/mental_health/management/depresion/definition/en/.
2.WHO Prevention of Mental Disorders: Summary Report, 2004, World Health Organization, Geneva. p: 39.
3.Jane-Llopis E, Hosman C, Jenkins R, Anderson P. Predictors of efficacy in depression prevention programmes. Meta-analysis. Br J Psychiat 2003; 183: 384-97.
4.Munoz RF, Ying YW, Bernal G, Perez-Stable EJ, Sorensen JL, Hargreaves WA, et al. Prevention of depression with primary care patients: a randomized controlled trial. Am J Community Psychol 1995; 23: 199-222.
5.Katon W, Rutter C, Ludman EJ, Korff M, Lin E, Simon G, et al. A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry 2001; 58: 241-7.
6.Musselman DL, Lawson DH, Gumnick JF, Manatunga AK, Penna S, Goodkin RS, et al. Paroxetine for the prevention of depression induced by high dose interferon alfa. N Engl J Med 2001; 344: 961-6.
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9.Hannan AP, Rapee RM, Hudson JL. The prevention of depression in children: a pilot study. Behav Change 2005; 17: 78-83.
10.Merry S, McDowell H, Hetrick S, Bir J, Muller N. Psychological and /or educational interventions for the prevention of depression in children and adolescents. Cochrane Database Syst Rev 2004; (1): CD003380.
11.Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev 2006; 3: CD004691.
12.Gadit AAM. Psychiatry in Pakistan: 1947-2006: A new balance sheet. J Pak Med Assoc 2007; 57: 453-63.
13.Gadit AA. Subthreshold Mental Disorders. J Pak Med Assoc 2003; 23: 42-3.
14.Wahlbeck K, Makinen M (eds). Prevention of depression and suicide. Consensus paper. Luxembourg: European Communities, 2008.
15.Sutton JM. Prevention of depression in youth: a qualitative review and future suggestions. Clin Psychol Rev 2007; 27: 552-71.