The most disabling health condition

which needs an overall approach

2017-04-07
Each year on April 7th World Health Day, important areas
of health are brought to the attention of the global
community under the sponsorship of the World Health
Organisation. The aim is to improve the health status of
people and communities by raising awareness, generating
interest and initiating activities among stakeholders. This
years theme being depression, I wish to bring to the
attention of the community a few important issues about
depression in the context of Sri Lanka and the challenges
faced in the country.
What do we know about depression?

Depression or sadness is a normal emotion. An abnormal and

excessive degree of sadness is interpreted in different ways
depending on the context and the circumstances. As a clinician,
my focus is on clinical depression, a health condition that impairs
physical and mental functions and is associated with personal
distress and a very complex and rich personal narrative.
Depression is characterized by pervasive and predominant
sadness associated with low motivation, an inability to be happy,
lack of initiative, short attention span, problems in concentrating,
fear and worry. Many other symptoms often occur in depression
such as disturbance of sleep, menstrual problems, impairment of
sex drive, weight loss, physical symptoms and preoccupation with
poor physical health, which significantly impacts the persons life.
On detailed assessment of the mental state, many patients would
go into detail on their mental world - worries, concerns, fears and
preoccupations, often using colloquial words such as thonthu,
kalakirila, asahnaya, kanagatu, duka, kanassalu. The diagnosis of
clinical depression depends entirely on a detailed interview and
criteria based on the international classification systems. The
patients medical history will reveal whether there are other
health conditions associated with mental dysfunction.

This cluster of symptoms found in depressive episodes are

associated with major depressive illness, and depressive
phases of bipolar illness, the latter being increasingly seen as a
different health condition. Similarly, many other health conditions
including alcohol abuse, eating disorders, other psychiatric
illnesses and physical illnesses including cancer, diabetes and
heart disease may be associated with depressive symptoms. It is
well known that sociocultural factors fashion the patients
presentation, selection of interventions and the outcome of
depression.

Based on the estimation of years lived with the disability (YLD)

due to a particular health condition or disease and the ranking of
the diseases by patients, care-givers, professionals and others,
depression has been found to be the most disabling health
condition affecting three hundred million people, or four percent
of the worlds population. Mental pain or distress associated with
depression is much greater than physical pain according to those
who experience these episodes and unlike physical pain, there are
no interventions that could relieve it immediately. Those with

depression have a shorter life span - being more

susceptible to a premature death from physical illness or suicide.
The economic impact due to the loss of productivity and
healthcare costs as a result of depression are staggering, going
up to an estimated figure of trillion dollars annually. Caring for a
family member with depression or managing an employee with
depression at the workplace could be challenging. While it is clear
that genetic factors and brain dysfunction have a major role to
play in the causation of depression, there is increasing evidence
to show that social factors such as poverty, deprivation, early
childhood experiences and psychological factors such as
emotional trauma also play important roles in causing and
influencing the course of the illness. The number of new
depression cases per year is increasing globally among all age
groups including children, adolescents and the elderly from all
social and economic backgrounds. Females are likely to have a
higher incidence of depression including after giving birth (post-
partum depression).

How do we manage people with depression?

We increasingly use the term comprehensive approach of

treatment towards depression, which aims to relieve symptoms,
prevent relapses and improve the quality of life of an individual.
WHO defines quality of life as an individuals perception of his
position in life in the context of the culture and value systems and
in relation to his goals, expectations, standards and concerns.
Drug therapy, other physical methods of treatment including
electro-convulsive therapy, trans-cranial magnetic stimulation and
psychological methods including mindfulness-based cognitive
behaviour therapy, other forms of psychotherapy and yoga are
used in treatment by psychiatrists as well as by other non-medical
mental health professionals. Public health professionals and
others undertake the primary prevention of depression through
health promotion activities. As regards treatment, the optimism
generated in the 1980s with the introduction of Happy Pills has
not been fully realized, for now it is known that even with newer
antidepressant drugs, improvement is hardly complete and some
residual symptoms remain.
Increasingly, the aim of mental health services is seen to reduce
the burden of mental health. The burden is measured by a
combination of two indicators; the number of years of life lost to
disease and the number of years lived with disability by people
suffering from depression. Modern services are community-
oriented and organized around specific geographical areas,
providing comprehensive services which are easily accessible and
affordable. Special psychiatric or mental health services are those
which are provided by a network of community-oriented mental
health facilities, interventions and personnel in a given
geographical area of the country. Since special services alone
cannot meet all mental health demands, general health, primary
care, social services, education and many other services have
integrated selected aspects of mental health care into their
programmes.

The priority given globally today to emotional and mental health

has led to increasing numbers of people recognising depression
and seeking relief from health practitioners. The acceptance of
mental health as an integral part of health has resulted in people
today recognizing the emotional aspects of physical illness much
more than before. With a better understanding of the nature of
depression and the possibility of treatment, community attitudes
are becoming increasingly favourable towards mental health
resulting in less stigma being attached to the disease. The
reforms of mental health services have responded to the United
Nations resolution in 1991, calling for the protection of people
with mental illness and the improvement of mental healthcare.
This has led to a reduction of the traditional discrimination,
marginalisation and exclusion of people with mental health
problems. The increasing sensitivity attached to issues such as
confidentiality, privacy and respecting dignity in clinical practice
has improved patient care practices. The acceptance of the need
to provide an equitable distribution of services affordable to
people in local communities has led to reforms of traditional
centralized mental healthcare. Accordingly, in keeping with
national policies, each region, district or division based on
population size is allocated resources for the provision of
comprehensive mental health services.

What are the issues in Sri Lanka?

Over the years, we have seen increasing numbers of people from

different age groups, social classes and geographical areas of the
country seeking relief for mental health problems. About thirty
percent of patients seen by a psychiatrist are likely to have a
diagnosis of depression. Similarly we have seen mental health
services expanding significantly in the public sector, private
sector and in the non-government sector, providing a wide range
of services. At the same time, we continue to see very crowded
public sector health facilities with limited resources serving the
poor. Still, a large number of people suffering from depression in
Sri Lanka either do not receive treatment or have inadequate
treatment due to a numbers of major obstacles.

What then are the major obstacles preventing the development of

a better mental health service? The first obstacle is gaps in our
knowledge of mental health and depression in the context of our
culture. We still do not have a good understanding of many
aspects of depression, particularly the cultural influence on
manifestations, personal experiences and response to
psychological therapies in Sri Lanka. What influences do
mindfulness-based therapy, cognitive behavioural therapy or
yoga derived from eastern philosophies have on the treatment of
depression? A lack of knowledge on these prevents us from
providing adequate care. The second obstacle is the low priority
attached to emotional health including depression when
compared with physical health problems. This not only slows the
development of mental health services but also prevents or
delays individuals from utilizing available services. In Sri Lanka,
many tend to believe that emotional disturbance is the
responsibility of the individual and the need to seek expert advice
is not felt. The third challenge is stigma, which continues to be a
major obstacle in mental health. As a result of stigma, patients
are prevented from seeking relief, do not utilize services, do not
claim insurance benefits, do not claim leave entitlements and
eventually delay seeking and obtaining treatment, increasing
their chances of developing disabilities and even death due to
suicide.The fourth obstacle is the violation of rights of the
mentally ill. This is common and often results in discrimination,
marginalization or exclusion at the workplace, families or in the
community. In an institutional setting, there is often indifference
to respect of dignity, privacy or confidentiality. This is often
reflected in the way patients are interviewed in open spaces, the
free dissemination of medical information and treating personal
case records as public property.

The fifth obstacle is the compartmentalised approach towards

mental health care. Individual therapists tend to work in isolation,
fulfilling a few needs and leaving other needs unattended or
leaving it to the patient to seek relief on his or her own from
another source. Psychiatrists tend to treat patients using drugs,
with minimal attention to psychosocial issues. Non-medical
mental health professionals tend to focus on psychological
approaches with little attention to other health needs. There is
little coordination between education, social welfare, health and
other special services with mental health services.
Comprehensive care involves minimising symptoms, preventing
relapses, promoting health and providing social support with the
aim of improving the quality of life of the patient. Finally, a major
obstacle interfering with efforts to reduce the burden of
depression is the inadequate and inequitable distribution of
mental health services, with most services concentrated in
Angoda and a few urban centres, while rural communities have
minimal services.
How then can we overcome these obstacles or
minimise their impact?

This is the great challenge facing the government and agencies

responsible for providing mental health services. The process of
improving the quality of life in people with depression and
reducing the burden of depression is a long-term goal needing the
government, all institutions and communities working together for
the common goal.

The government should take the leadership and mandate the

relevant body to come up with a policy, plan, strategy and
resources to realize the stated objectives. Once this is achieved, it
is essential for all stakeholders including the health directorate,
mental health directorate, clinical services, public health services,
academic departments, training agencies and other relevant
institutions to be partners in its implementation.
Posted by Thavam