Depression is the leading cause of disability worldwide

For the first time, world leaders are recognizing the promotion of mental health and well-being (SDG Goal 3.4), and the prevention and treatment of substance abuse (SDG Goal 3.5), as part of the Sustainable Development Goals (SDGs).

This year, depression received special attention as the theme of the2017 World Health Day with the title Depression: let’s talk’. To find out more, read the following interview with Dr Shekhar Saxena, Director of the Department of Mental Health and Substance Abuse at the World Health Organizationin Geneva.

Carine Weiss: Dr Saxena, thank you very much for agreeing to take part in this interview. I have a background as a psychologist and, in addition, a master’s degree in public health, so I am very interested in hearing about your experiences as a psychiatrist and as the Director of the Department of Mental Health and Substance Abuse (MSD) at WHO’s headquarters. Let’s talk first about the burden of depression in the world – why is it important to talk about this subject?

Shekhar Saxena: I will start first by explaining what depression actually is. Depression is a mental disorder which is characterised by a sustained sadness in mood and a lack of interest in nearly all activities over a period of at least two weeks. A depressive disorder is quite different from the day-to-day sadness that many people experience from time to time but which is not sustained long enough to call a disorder. Depression also includes thoughts of hopelessness, death and suicide, often accompanied by loss of appetite and disrupted sleep patterns. These are the essential features which we call ‘depressive disorder’.

Over 300 million people worldwide suffer from depressive disorder; the percentage in the adult population is between 4 to 5%. Depression can affect anyone. It is found in all parts of the world and in every country, whether high, middle or low income, and in almost all ages from young to old, except in very small children. 

The burden of depression is very high. It is the number one cause of disability in the world and forms 7.5% of the total burden of disability from any health condition. It also causes mortality: 800,000 deaths per year are attributed to suicide (though not all are due to depression). A very large number of people are depressed when they commit suicide.

I had a black dog, his name was depression (World Mental Health Day 2012), WHO

Carine Weiss: What is WHO doing to raise awareness about this disease?

Shekhar Saxena: We at the WHO believe that depression must be defeated! People should seek and receive help but there are problems connected with both these issues.

People often don’t seek help because they either don’t realise that they have depression or they do not fully understand that depression is a disorder and can be treated successfully. A third cause for failing to seek treatment is the stigma involved: often, people don’t like to talk about depression and don’t like to seek help because they may feel stigmatised and discriminated against, for example, in their job or in other areas within society.

There are also problems in the supply of services: they are too scarce. Even in high-income countries, more than 50% of people who suffer from depression are not being treated. This is a big problem. We believe that depression should be treatable by non-specialist, general doctors, nurses, healthcare workers or humanitarian workers – though of course after some training and with adequate supervision and support. However, these people are often unable to identify and treat depression.

All around the world – and more so in middle and low-income countries – services for treating depression are scarce. The amount of money governments are spending on mental health is very small. The global average is about 3% of a country’s health budget and, in low and middle-income countries, this falls to less than 1%. Obviously, it is necessary to strengthen the healthcare systems for these disorders. Unfortunately, this is not something which is happening at the moment:in many countries, there is no training, no medicines available and no opportunity to train personnel to deliver psychotherapies.

This is a situation WHO believes needs to be addressed and we are working with national governments as well as civil society organisations to strengthen the capacity of the healthcare systems.

 Living with a black dog is a guide for partners, carers and sufferers of depression.

Carine Weiss: I have spent a lot of time in the field in Asia and Africa and, whilst there, I witnessed a lot of unemployed young people who suffered from substance abuse. What is your view on this and what needs to be done to address this issue?

Shekhar Saxena: Countries in Asia and Africa have a number of risk factors for depression. There is no single specific cause for depression. Depression may be triggered by stressful life events like bullying at school; parental separation or divorce; grief or conflicts with family members or friends. Depression can run in families, especially if a parent suffers from depression or mood disorders such as bipolar disorder (manic depression). In middle and low-income countries we can observe the following risk factors for depression:

•  poverty
• discrimination of any kind
• joblessness – recent job loss
• excessive abuse of alcohol and drugs

These, among other issues, are all risk factors for depression. And it is not surprising that young people who do not have a job, who have lost a job or do not have the opportunity to participate in the economic life of their communities and countries suffer from depression. Certainly, a higher proportion of them experience depression than amongst the general population.

Obviously, the overarching solution is to provide the kind of opportunities that young people need. However, if this is not possible or is delayed, there are other methods which can be used: for example,by identifying and treating the depressive disorders as they arise. But young people in particular are reluctant to seek help and address the problems they are facing.

Of course, there are also other methods – such as integration in their communities and giving young people encouragement, helping them to try their best to find a job and/or even financial assistance if the rules and regulations in their country allow it. Other solutions include creating more job opportunities and opportunities in general so that young people can start their own businesses – all these actions should certainly help them to overcome depression and to participate again in society and everyday life.

"We must remember that mental health is now part of the SDGs. This means it is not the responsibility of a particular department but, instead, of the overall government to make sure that adequate mental healthcare is delivered to the population." 

Shekhar Saxena, WHO

Carine Weiss: As you mentioned earlier, there is a large treatment gap for mental healthcare in low and middle-income countries, with the majority of people with mental, neurological and substance-use disorders receiving no or inadequate care. What needs to be done to strengthen health systems so they also address mental health?

Shekhar Saxena: There are several steps. Firstly, we need to put in more money as part of the strengthening of healthcare systems; secondly,we need to train non-specialists who can deliver most of the care,with the supervision and support from specialists; and thirdly, we need to make essential medicine available at all levels of the healthcare systems including in primary healthcare.

We also need to cooperate with other departments working within the area of health, e.g. the maternal and child health department; the HIV healthcare sector; the humanitarian healthcare sector. And we need to involve sectors outside of health, e.g. the education and labour departments, the law and order department, and the humanitarian sector overall. We need to make them all aware of the need to increase their own capacity to identify, treat or refer people who have depression.These are all first steps: we must remember that mental health is now part of the SDGs. This means it is not the responsibility of a particular department but, instead, of the overall government to make sure that adequate mental healthcare is delivered to the population.

Carine Weiss: It was a huge success to have mental health now included in the SDGs…

Shekhar Saxena: Absolutely. Mental health was not part of the MDGs (Millennium Development Goals). But now we have a situation where mental health is connected to sustainable development and this should not just be on paper but also fully realised in the governments that are acting to implement the SDGs.

For people living with depression, talking about it can be the first step towards recovery. James Chau shares his personal experience of depression.

Carine Weiss: I spent two years living in Myanmar on the border with Bangladesh where the humanitarian situation for a Muslim minority (the so-called ‘Rohingya’) was very serious. These people were suppressed by the Burmese military government. We met a young woman in the field who was very thin and was not eating properly. I asked her what happened and I was told she was depressed because her husband had fled and left her behind. I started to investigate how mental health can be addressed in such situations. One of the NGOs was prescribing antidepressants for people with severe depression. What is your view about prescribing antidepressants in such situations?

Shekhar Saxena: The WHO guidelines recommend two ways to treat moderate to severe depression:i) by psychotherapy or psychological interventions, which are sometimes delivered by non-specialists, and ii) with essential medicine. We do believe that medicines are effective for moderate to severe depression, but not against mild episodes. The actual choice of intervention depends on the clinician who examines the patient, uncovers what the situation is and decides which intervention is necessary: either psychotherapy, medication, or both.

It must be emphasised that both medical and psychological interventions should be delivered by trained professionals: the treatment should be delivered according to specific indications and a follow-up should be ensured. Any other difficulties which the person may be experiencing in the areas of nutrition, physical healthor adverse situationsalso need to be addressed. So it is not only about the medicine alone: the overall treatment must be emphasised.

Carine Weiss: Which role do you see for NGOs? How can they contribute to mitigating the burden of depression and poor mental health in general?

Shekhar Saxena: Civil society has a very large role to play. There are several things which civil society organisations can do:

• Increase awareness about depression as a significant cause of disability: As mentioned earlier, many people do not understand that depression is a disorder and that treatment can be available.
• Assist in the management of depression: Many CSOs are working in humanitarian aid as well as in providing healthcare. Professionals working in NGOs need to be aware that depression is a common problem and they should either increase their own capacity to manage it or find out where to refer the patient.
• Work with policy makers and governments to put more pressure on the governmental system to increase the awareness and treatment of depression
• CSOs have a role to play in preventing suicide which is one of the consequences of depression: There are various suicide prevention hotlines and crisis lines on websites which can play a significant role in sensitising people about mental health and/or depression and explain where people can go to seek help.

These are all areas where CSOs can play a crucial role. Of course, each NGO needs to select their area of intervention based on their added value and how they can contribute to the overall effort to defeat poor mental health.

Thank you for the interview!

Dr Shekhar Saxena, Director of the Department of Mental Health and Substance Abuse at the World Health Organization. Saxena is a psychiatrist by training and has worked at the World Health Organization since 1998. His responsibilities include evaluating evidence on effective public health measures and providing advice and technical assistance to ministries of health on the prevention and management of mental, developmental, neurological and substance-use disorders and on suicide prevention. His work also involves establishing partnerships with academic centres and civil society organizations and global advocacy for mental health and substance-use issues. Dr Saxena is leading WHO’s work to implement the Comprehensive Mental Health Action Plan, which was adopted by the World Health Assembly in May 2013, and in scaling up care for priority mental, neurological and substance-use disorders.

References

World Health Day (7 April 2017): Depression: let’s talk
http://www.who.int/campaigns/world-health-day/2017/en/

Posters - Depression: let's talk
http://www.who.int/campaigns/world-health-day/2017/posters-depression/en/

Handouts on depression: the handouts available on this page provide general information on the characteristics of depression and how depression can be prevented and treated.
http://www.who.int/campaigns/world-health-day/2017/handouts-depression/en/

Videos about depression: these short videos have been produced as part ofWHO’s ‘Depression: let’s talk’ campaign.
http://www.who.int/campaigns/world-health-day/2017/videos/en/

Stories on mental health: these stories provide examples of the setting-up or scaling-up of mental health services.
http://www.who.int/campaigns/world-health-day/2017/stories-mental-health/en/

Fact sheets: mental health
http://www.who.int/topics/mental_health/factsheets/en/

Mental health action plan 2013 – 2020
http://www.who.int/mental_health/publications/action_plan/en/