By Dr. Suresh Thapaliya, Nepalgunj Medical College
6 April 2017
Case 1: A middle-aged English teacher from western Nepal presents with symptoms of depression. It turns out that she lost her father to suicide a year ago; he poisoned himself, possibly due to depression. For the first few months, she was badly affected by his sudden death. She began to feel low throughout the day and no longer enjoys teaching her students. She does not feel like interacting with anyone at home or in the community. She thinks her life is futile and gets teary often. She gets fatigued even after simplest of physical activities and has poor attention and concentration.
In the last few weeks, she has had thoughts of ending her life just the way her father did. Thankfully, her strong sense of responsibility towards her family has saved her from these thoughts of self-harm. The final words her father said to her before he committed suicide, “Be a good teacher”, also helps her overcome her suicidal thoughts. But she cannot understand why he took his life in the first place. This makes her feel guilty in a way, that she couldn’t help him. She knows that what she is going through is not normal. She tries her best to control but she cannot. She feels very isolated from rest of the world and is scared that she may end her life like her father.
Case 2: A 14-year-old boy with a history of epileptic fits has developed low mood. He now has less interaction with his family members and suffers from frequent irritability towards siblings and parents, disturbed sleep, appetite and poor academic interest for the last few months.
These are just few examples of individuals who were diagnosed with depression in a medical college OPD last week. Every week, we see at least two to three dozen such cases with different stories and background and most of them do well on medication and psychological intervention as required. Some of them even have recent history of suicidal attempts and are not responding to treatment as expected and prominent psychosocial factors seem to be the reason.
Globally, as per WHO, more than 300 million people of all ages suffer from depression. The Global Burden of Disease Study 2013 (GBD 2013) showed that depression ranked second highest specific cause of Years of life lost to disability LDs in both developed and developing countries. These disorders are therefore of considerable public-health importance in both high income and low- and middle-income (LAMI) countries alike. Extrapolations from GBD 2013 data indicate that depression among the top ten causes of YLDs in South Asia, which includes Nepal. Although most of the mental illnesses invariably increase the risk of suicide, it is the mood disorder especially the major depressive disorder which have been shown to account for the highest risk. A nationwide cross-sectional study found that depression was present in nearly 5% of the subjects, higher among women compared to men. Some of the studies in Nepal have also highlighted that depression is more prevalent among women. It is important to understand that specific issues such as gender based violence esp. secondary to alcoholism in men, interpersonal conflicts such as marital problems, inter-caste marriage, chronic medical illness are some of the contributors to depression among women. Depression and suicide also seems to be common among adolescent unmarried women including students. Factors such as academic stress, failure in romantic relationships, interpersonal conflicts, sexual abuse have been recognized. Besides, among men, drug use, psychosocial stressors such as loss of loved ones, debt, unemployment are some of the factors. Depression has also been found prevalent among specific communities such as geriatric age group, adolescents, gender minorities, migrant workers and recently the disaster affected population. In the last few years, we have been exposed to news about depression among celebrities. We have also heard of celebrity suicides and it is likely that untreated depression is culprit.
At present, government spending is less than 1% of its total healthcare budget on mental health. Mental health services are mainly concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per a population of 100,000.This has led to a huge treatment gap with over 90 percent of the population who needs mental health services having no access to treatment. In the South Asian country Nepal which has a high suicidal rate of 24.9 per 100,000 people and suicide being currently the leading cause of death for Nepalese women aged 15–49. As per the hospital based studies from different parts of Nepal, majority of the suicidal attempters had depression as the most common psychiatric diagnosis complicated by psychosocial stressors such as marital conflict, interpersonal issues, socio-economic status. Unfortunately, in Nepal, the role of mental illness and depression in particular may be underestimated and factors other than mental illnesses such as bad fortune, life stresses, social conflict and evil spirits may be blamed alone. Further, the stigma of mental illness may generate negative attitudes and feelings such as shame, disgrace, fear, disgust or hate leading to reluctance to seek help from health care services, isolation and social exclusion.
The clinical presentation of depression is highly variable. A depressive episode is Depression is categorized as mild, moderate, severe depending upon severity of clinical symptoms and impairment in functioning. It can be single episode or recurrent episodes called Recurrent depressive disorder. Depression can also alter with a period of excessive excited or irritable mood called manic episode. This is another variant called Bipolar depression. The management of Bipolar depression differs from recurrent depressive disorder in that this diagnosis warrants the use of mood stabilizers and cautious use of antidepressants Similarly, dysthymia is chronic low grade depression that can be disabling and needs to be treated well. It is equally important to understand that depression is biological in nature and psychosocial factors may be just predisposing, precipitating or perpetuating the illness rather than causing it. Depression has a genetic basis and neurological findings such as alteration in brain neurotransmitters, body harmones, immune system have been identified. Hence, timely consultation with mental health professional and use of appropriate mental health services such as judicious use of antidepressant medication and psychological therapy is indicated for treatment of moderate and severe cases. Currently, a range of antidepressants are available which can be used according to treatment response and side effect profile. Their effective use has been known to curve the burden of depression and suicide in the community. Currently, a number of psychological therapies are also available as a monotherapy for mild, moderate cases and as adjunctive for severe cases. However, access to these services in Nepal is limited. Further, few of the individuals may not respond to adequate treatment what is called Resistant Depression. At present, Electroconvulsive Therapy (ECT) is one of the therapies for resistant cases which is effective, safe and available in most of the centres of Nepal. Newer modalities such brain stimulation techniques are available outside Nepal.
Like other mental illnesses, some of the myths seem to be prevalent in the general public regarding depression which needs to be addressed.
Myth 1: Depression cannot affect me or my family.
Depression is highly prevalent and anyone can get the illness irrespective of age, gender, race, occupation or educational status.
Myth 2: Depression is not a real medical problem.
It is as real as Hypertension or Diabetes. It is treatable like any other medical illness
Myth 3: Depression is something that strong people can “snap out of” by thinking positively.
Depression has a very strong neurobiological basis and the symptoms are not under the control of the victim irrespective of person’s previous psychological strength and coping skills.
Myth 4: Depression only happens when something bad happens in your life, such as a breakup, the death of a loved one, or failing an exam.
Depression can occur without any apparent life stressors.
Myth 5: Depression will just go away on its own.
Few individuals may have spontaneous resolution. But, untreated depression leads to several complications such as suicide, recurrence, poor response to further treatment, co-morbid physical and psychiatric conditions and cognitive impairment in long run
Myth 6: Antidepressants are addictive and change personality.
A judicious use of antidepressants is indicated for treatment of moderate to severe depression. Antidepressants will help to restore mental health though some symptoms may persist for a longer duration and eventually subside. A sudden discontinuation of high dose of certain medications without doctor’s opinion may cause discomfort for few days but that doesn’t mean that antidepressants are addictive. One episode of depression will require at least nine to twelve months of treatment to prevent further episodes whereas multiple episodes may require longer duration of treatment. Antidepressants are not addictive or change the personality of the individual. It is rather untreated chronic depression that prevents individual from returning to his or her normal life.
Myth 7: Talking about depression only makes it worse.
Talking about depression in fact leads to early recognition, treatment and improved outcome. It also provides psychological support to the individual.
The theme of the World Health Day 2017 is Depression: Let’s talk.
Dr. Thapaliya, an MD in Psychiatry from AIIMS (New Delhi), is based in Banke district of Nepal.