Daily Times

Although mental health is a sensitive topic the world over, the prevalence of mental illness and its consequences can no longer be overlooked. While mental disorders include a range of illnesses such as anxiety, schizophrenia, and autism, depression is the most common and is pervasive worldwide. Clinical depression is considered to be the “common cold” of outpatient populations. Up to 50 million people in Pakistan alone meet criteria for some type of depressive disorder in a given year. The term depression refers to a core experience of feeling sad or down, and to associated symptoms that vary widely.

An advertisement sponsored by a drug company that manufactures an antidepressant asserts, “While the cause (of depression) is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription works to correct this imbalance.” Using advertisements such as this one, pharmaceutical companies have widely promoted the idea that depression results from a chemical imbalance in the brain. Much of the general public and a section of mental health experts seem to have accepted the chemical imbalance hypothesis uncritically.

The general idea is right that it is a deficiency of certain neurotransmitters, which interferes with transmission of nerve impulses, causing or contributing to depression. However, depression cannot be boiled down to just an excess or deficit of any particular chemical or even a suite of chemicals. Cause-and-effect relation between any brain or psychosocial dysfunction and depression almost certainly does not result from just one change in the brain or an environmental factor. A focus on one piece of the depression puzzle is short sighted. Chemical imbalance hypothesis is sort of last-century thinking. Clinical depression is much more complicated than that.

Experts are more convinced that crucial role of psychosocial factors such as stress and anxiety; apprehension and uncertainties from modern warfare and terrorism in addition to the stress from loss of someone close to you or a failure to meet a major life goal are all significant to cause depression. Of course, all these influences ultimately operate at the level of physiology, but understanding them requires explanations from other vantage points. That said, some processes may be more common in depression, and awareness of these processes would help to limit what could be a vast assessment of many potentially irrelevant variables.

In order to avoid psychiatric labels, depressed individuals in our society choose to not associate themselves with mental health clinic or professionals, refusing diagnosis and rejecting mental health care. But due to the lesser stigma of physical symptoms as well as cultural idioms revolving around the physical body, depression is often expressed as physical symptoms. In parallel, explicit mood symptoms such as hopelessness, self-deprecatory thoughts, and worthlessness, are uncommon. In particular, women ultimately diagnosed with depression frequently first present with “conversion” disorders like intractable headache, pseudo fits and no self-recognition of psychological distress or sadness. These significant cultural differences with respect to gender put women at especially high risk of diagnosis and treatment of depression in our communities.

Although mental health care has improved significantly over the last decades, many people still choose not to seek treatment or quit prematurely. A number of possible factors contribute to these disparities with stigma being perhaps the most significant. The stigma of mental illness is perhaps the biggest challenge to confronting depression head on. This hurts individuals with depression and their communities, and creating injustices that sometimes lead to devastating consequences.

Lack of awareness of the condition as an illness category causes many people to delay seeking care. It is a strong contributor to underreporting of the disease and a barrier to using the available interventions. But bringing attention to the pervasiveness of depression can help combat the stigma surrounding the disease and overcome the obstacles to acceptance and understanding of depression.

While it is not a significant cause of mortality, depression seriously reduces the quality of life for individuals and their families, is a risk factor for suicide, and often worsens other physical health problems. Unfortunately, this mental illness is particularly problematic where interventions are not available and there is a difficulty reaching those who need them because of a number of overwhelming challenges which include lack of facilities and trained mental health personnel, and the general stigma surrounding mental disorders.

The tunnel-vision approach to treatment of depression is reminiscent of a classic story in which a group of blind men touch an elephant to learn what the animal looks like. Each one feels a different part, such as the trunk or the tusk. The men then compare notes and learn that they are in complete disagreement about the animal’s appearance. To treat depression, we have to see the entire elephant — that is, we must integrate what we know at multiple scales, from molecules to the mind to the world we live in.

Even if our ability to diagnose depression remains constrained to the seemingly old-fashioned approach of an interview, we do know how to help affected people recover and, most importantly, without the need for mental health professionals who are an extremely scarce commodity in our country. Despite this knowledge, though, the vast majority of people with depression go without any treatment, waiting for the spontaneous remission which will, thankfully, ultimately occur in a significant proportion of people. However, the delay in recovery, and the chronic and relapsing course that some may experience, leads to profound impairments in their lives.

Despite both psychological and pharmacological treatments, many people continue to relapse into depression. Could the beauty of treatment lie in not only helping people to get better, but also keeping them better? A particular challenge lies in the fact that as most people who suffer depression often do so in the shadow of some crisis in their lives, it is hard to distinguish the understandable misery which is so very normal in everyday life from a ‘clinical condition’.

The writer is a professor of Psychiatry and consultant Forensic Psychiatrist in the UK. He can be contacted at fawad_shifa@yahoo.com