Defeating Despair

Lancet World Psychiatric Association Commission on global depression maps route to hopeful future

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More than 280 million people are living with depression around the globe, a number that has been steadily rising over recent decades, according to the Global Health Data Exchange. While the emotional and psychological effects associated with the disorder can be severely debilitating on their own, depression also increases the risk of suicide, heart disease, diabetes, and cancer, making it one of the leading causes of premature death in the world.

Yet it doesn’t have to be this way, according to the Lancet and World Psychiatric Association Commission on depression, in a report published online on Feb. 15.

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“The Commission’s findings offer a clear message of hope, both for decision makers struggling with addressing the rising tide of depression in their populations, and for individuals who are experiencing the profoundly disabling symptoms of depression,” said Vikram Patel, the Pershing Square Professor of Global Health in the Blavatnik Institute at Harvard Medical School and one of the chairs of the commission. “There is much we can do to prevent and care for depression.”

The COVID-19 pandemic, which was associated with more than 50 million additional cases of major depressive disorder worldwide in 2020 alone, according to estimates published in the Lancet, served as a wake-up call for people everywhere about the dire need for a united global action to improve mental health in general and combat depression specifically, Patel said.

“The pandemic presents a historic opportunity to enhance investments and promote concerted actions across sectors to implement these interventions,” said Patel, who is also professor in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health.

The commission is made up of 25 experts in diverse disciplines from 11 countries around the world, including Patel and Ronald Kessler, the McNeil Family Professor of Health Care Policy at HMS. Its report synthesizes the latest understanding of the complex interplay between genetics, neurophysiology, social factors, and individual experience in depression. It also describes the varied symptoms and signs of depression and analyzes the progression of the disease over the life of an individual and the epidemiology of the illness across different cultural groups.

The authors focused particularly on the growing body of evidence that cost-effective preventive measures and community-based therapies designed to address depression as part of an integrated health care, social, and policy response can help relieve the suffering of millions of people.

The report included recommendations for how health care practitioners, policymakers, community members, and people with depression can work together to build sustainable solutions in response to the mental health crisis.

Integrating mental health

At an online event to celebrate the global release of the commission report, Patel was joined by commission chair Helen Herrman from Orygen and the University of Melbourne, and co-chair Christian Kieling, associate professor of child and adolescent psychiatry at the Universidade Federal do Rio Grande do Sul in Brazil. Richard Horton, editor-in-chief of the Lancet, and Afzal Javed, president of the World Psychiatric Association, also participated. The WPA partnered with the Lancet to present the commission.

Representatives of the World Health Organization, the U.S. Department of Health and Human Services, and international health care provider associations and patient advocacy organizations also participated in the program, providing reflections on the report.

Soumya Swaminathan, WHO chief scientist, noted that it will be crucial to fully integrate mental health care into all aspects of health care, noting that only about half of the nations in the world include mental health in their planning or goals.

She added that the WHO could play an important role in developing multicountry research initiatives to improve the implementation of prevention efforts and mental health care delivery across diverse cultures and health systems.

U.S. Surgeon General Vivek Murthy discussed the programs he has developed to address bullying, domestic violence, and other traumas. He emphasized the importance of building a culture that nurtures community, caring, and kindness as an antidote to the chronic toxic erosion of self-esteem in societies that tie self-worth to external factors like wealth and fame.

“That’s a race that few of us can ever win,” Murthy said.

Anna Stavdal, a primary care physician and president of the World Organization of Family Doctors said that the familiar notion that it takes a village to raise a child also applies to mental health care.

“It takes a community to heal a depression,” she said, noting that family physicians and other frontline primary care practitioners are in an ideal position to assess their patients’ health within the context of their home, work, and personal lives and to facilitate potentially therapeutic engagement within the patient’s existing social structure.

Community education, patient advocacy, policy development, and the strengthening of health systems must happen at the level of society and community, the authors of the report said, but depression must also be treated in partnership with the specific individual with the disease.

“No two individuals share the exact life story and constitution, which ultimately leads to a unique experience of depression and different needs for help, support, and treatment,” Patel said.

Prevention, intervention, follow-up

A comprehensive multifaceted approach is crucial to addressing the complex interrelated drivers of depression, according to the commission’s findings. Its proposals include plans to deal with depression at many different phases of the disease, including preventive efforts, early intervention before severe illness sets in, and long-term follow-up to prevent reoccurrence. The approach is modeled on similar efforts to tackle other major diseases.

“Similar to cancer care, the staged approach looks at depression along a continuum—from wellness to temporary distress to an actual depressive disorder—and provides a framework for recommending proportional interventions from the earliest point in the illness,” Patel said.

In addition to highlighting the development of community-based affordable prevention and treatment options, with a focus on both physiological and social drivers of mental wellness and illness, the commissioners noted that developments are being made to make it possible to treat more complex cases.

“Scalable treatments have been developed over the past decade and now make it possible to address the problem of massive unmet need for treatment, both in low-resource settings and in places like the United States, that have a relative wealth of mental health care providers but still struggle to provide care for all of the people with depression,” said Ronald Kessler.

Recent advances in precision therapeutics also provide new hope for people with treatment-resistant depression,” Kessler said.

“As the commission reports highlights, the time is now for the global community to come together and apply these advances to help the hundreds of millions of people who suffer from this devastating disorder,” he said.

The commission was funded by the World Psychiatric Association, the University of Melbourne, the American Foundation for Suicide Prevention, Harvard Medical School, the Wellcome Trust, and UNICEF.