UCL PUBLIC POLICY
Global Mental Health: Addressing
the Global Burden of Depression
UCL POLICY BRIEFING – JUNE 2014
AUTHORS
Kirsten Michell, Global Health and
Development
k.mitchell@ucl.ac.uk
Sarah Chaytor
Head of UCL Public Policy,
Office of the UCL Vice-Provost (Research)
s.chaytor@ucl.ac.uk
+44 (0)20 7679 8584
Introduction
This briefing note provides a summary of the discussions at a
UCL Grand Challenge of Global Health seminar on mental
health. Discussion focused on whether depression is considered
a biomedical condition, the diagnosis, treatment and prevention
of depression, issues in tackling global mental health, and the
experience of developing mental health services in Mozambique.
Key themes
Depression as a human health condition
KEY FINDINGS
• Depression is a biomedical condition which is inextricably linked to
social, cultural, environmental and existential factors.
• A number of risk factors can be identified which may contribute to
depression.
• Primary prevention of depression (ie preventing a first episode) is
extremely challenging, but there is strong evidence that secondary
prevention (of further episodes) can be successful.
• A population-level approach to prevention and treatment of milder
forms of depression (as well as very severe depression) should be
considered.
• Stigma remains a significant issue in global mental health.
• Access to services and continued treatment for patients with mental
health problems need to be urgently improved in developing countries
such as Mozambique.
Depression is a human health condition which may be considered
a creation of social and cultural phenomena, unique to western
society, rather than a biomedical condition. However, research
in Zimbabwe and India1 has shown that people do discuss
manifestations of the physical symptoms of depression but they
refer to them not as depression, but as an association between
how they feel and their social circumstances (often with spiritual
implications).
Although depression is a global human health condition, there
are differences in the way it is described, its expression, and its
conceptualisation and causes. There is also debate over whether
a health condition can exist without the presence of measurable
biochemical markers, with the view that the existence of a health
condition is predicated on the phenotypic condition which is
identified through a biological marker. Psychiatry as a profession
has struggled to define a phenotypic description of depression, but
diagnosis can draw on:
• face validity (using a description of a person with the syndrome
of depression without using any diagnostic labels which is
recognised by two different clinicians anywhere in the world as a
cause of human suffering that they see in their everyday practice);
Patel V., Abas M., Broadhead J., Todd C., & Reeler A. (2001) Depression in developing countries: lessons from Zimbabwe. BMJ 322(7284): 482-484;
Patel V., Araya R., de Lima M., Ludermir A. & Todd C. (1999) Women, poverty and common mental disorders in four restructuring societies. Social
Science and
• historical validity (the idea that a description of depression
can be seen in ancient Chinese and Indian texts indicating that
depression is not an export of American psychiatry in non-western
cultures)
• predictive validity (a diagnosis of depression can accurately
predict an increased risk of suicide)
• concurrent validity (demonstrating that a diagnosis of depression
has a consequence on someone else that can be explained by the
phenomena of depression – for example, postnatal depression is one
of the most important causes of infant under nutrition and stunting
– which is of particular significance for global health).
Depression is a real cause of human suffering and a biomedical
entity across world cultures, but social factors play an important
role in explaining the condition (as in other medial conditions).
Diagnosing depression
Depression as a continuum of severity
The symptoms of depression, such as low mood, fatigue and poor
concentration, are common amongst the general population. There
is no fixed division between what is ‘normal’ and what is not and no
point at which sadness becomes depression, although it is possible
to mark the point where depression becomes detrimental to health.
This means that the current approach to diagnosing depression is
based on an arbitrary cut off point, which has implications for those
with milder or more common forms of depression who are just
below that threshold.
The community burden of mild depression may be higher than is
realised, making it a public health issue that is under-addressed.
Whilst treatment is a priority for individuals with a more severe
form of depression, it can be argued that there is also a need for a
population health approach to milder depression.
Causes and risk factors for depression
Within the scope of risk factors associated with depression,
environmental stressors must be considered. This is a complex issue
because people respond to and interpret different environmental
stressors in different ways. Variation in psychological interpretation
of events contributes to variations in how people react and respond
to stress, including physiological mechanisms. The way in which
people react to events can also change the way in which they
interpret them, their behaviours, and their environments.
BACKGROUND
Non-Communicable Diseases – sometimes referred to as “chronic
diseases”– account for more deaths than any other cause worldwide.
Eighty per cent of these deaths occur in the world’s poorest
countries. NCDs include heart disease, lung disease, diabetes,
cancer and mental illness.
The Grand Challenge of Global Health NCD season is a series of
events and exhibitions to highlight the global rise of NCDs which aim
to challenge, provoke and inform. Each symposium is accompanied
by a policy briefing summarising the key points of discussion.
However, there are several known risk factors for depression, which
can be used to detect those who are at risk for depression and
possibly target these individuals for primary prevention. A large
study in Europe and Latin America2 examined all risk factors
for depression and distilled them to a core set that can be used to
predict depression, with a trial showing that general practitioners
were able to predict those at risk for depression using these set risk
factors and to implement interventions successfully. This is a further
confirmation that depression is both predictable and measurable.
Primary prevention on a population level has proven less successful,
however, with trials looking at poverty, physical exercise, schoolbased interventions, and computer-based programmes showing
little proven effect. Given the difficulties in implementing and
demonstrating the success of intervention on a population level, it
may make more sense to focus on secondary prevention, for which
there is more evidence.
Whilst depression is a medical illness, a large number of existential
issues (such as personality, meaning of life and loss) are all factors in
life difficulties; it is thus unlikely that depression can be eradicated.
However, it is necessary to acknowledge such factors when
managing depression.
Tackling global mental health
Stigma
The stigma of mental health can be extremely difficult for people to
deal with and lead, for example, to ostracisation from friends and
family; being unable to discuss mental health freely and feeling the
need to hide mental health problems and emotional guilt. These
can compound mental health problems.
Rather than separating biological and social causes of depression,
depression should be viewed from a bio-psycho-social model which
takes into account all of these causes.
Key aspects in addressing global mental health
Prevention of depression
• the relationship between mental health professionals and their
beneficiaries
• the isolation of mental health service users in developing countries
• the need to implement a system, supported by beneficiaries, with
no stigma and where services are available to anyone in need.
Prevention is an important part of the medical management of
most conditions. In mental health, primary prevention refers to
preventing a first episode of depression and secondary prevention
to a further episode. Depression responds well to secondary
prevention with pharmacotherapy as well as psychotherapy (such
as mindfulness-based cognitive behavioural therapy) but primary
prevention is more difficult because so many causes of depression
are unknown.
Some key issues to consider in tackling mental health on a global
scale include:
King M., Weich S., Torres-Gonzalez F. et al. (2006) Prediction of depression in European general practice attendees: the PREDICT study. BMC Public
Health 6(6): 1-8.
Building a mental health system in a developing
country: lessons from Mozambique
For a long time it was thought that depression did not occur in
countries such as Mozambique (the high number of maternal
suicides illustrates the failure to address depression). However, both
the presentation and the incidence of depression in Mozambique
are similar to those in western countries. Improved accessibility
and availability of treatment in Mozambique are therefore urgently
needed to decrease suicide rates and the prevalence of depression.
Mozambique has a population of 21 million; mental health
services in the country comprise just nine psychiatrists, together
with 78 clinical psychologists, 122 psychiatric technicians and 23
occupational therapists.
Their primary goal is to expand service coverage, acknowledging the
difficulties in guaranteeing the quality of the services.
One of the main problems regarding access to mental health care is
that patients often present to services after a suicide attempt because
depression has not been diagnosed prior to this. Even when a
patient presents after a suicide attempt, depression is infrequently
diagnosed. An additional problem is that if a patient is referred to
a mental health service, the treatment is over a 6-month period,
meaning that the cost of continually returning to hospital can
prevent patients from completing treatment; instead they return to
traditional healers.
Another difficulty in Mozambique is the absence of a stock of
psychotrophic medications. This results in only a few people
getting the full course of treatment; these tend to be those in larger
cities or those who receive treatment as part of inpatient services.
This results in what is likely to be less than 1% of those with
depression actually receiving a full course of treatment.
SPEAKERS
Dr. Palmira Fortunato dos Santos
Ministry of Health, Department of Mental Health, Mozambique.
Dr. Michael King
Professor of Primary Care Psychiatry, UCL Division of Psychiatry
Dr. Glyn Lewis
Professor of Psychiatric Epidemiology, UCL
Jagannath Lamichhane
Principal Coordinator of the Movement for Global Mental Health and
Founder of the Nepal Mental Health Foundation
Dr. Vikram Patel
Professor of International Mental Health, London School of Hygiene
and Tropical Medicine