the future of depression in scotland

the good, the bad and the controversial

Introduction

Depression is classified as a mood disorder. It is characterised by low mood, loss of pleasure in activities previously enjoyed by the individual, lack of motivation and energy, disrupted sleep patterns (either sleeping too much or not enough), disrupted appetite and poor concentration (see DSMIV, 1994 for full diagnostic criteria1). These symptoms can be very disabling and at worst may lead to death as a result of suicide.

In 2004, there were 835 deaths in Scotland by intentional self-harm and undetermined intent (see www.chooselife.net). Furthermore, the rate of suicide in Scotland is higher than in any other parts of the UK - 50% more in men and 100% more among women.

It is estimated that depression affects approximately 1 in 6 individuals throughout Britain. It is one of the most common reasons for people visiting their GP with 320,900 individuals seeking support in 20052. These figures are likely to under represent the true number given that approximately 50% of people suffering from depression do not seek the help they need.

The World Health Organisation projects that by the year 2020, depression will be one of the biggest disease burdens in the developed world in terms of death and disability, second only to heart disease3. As well as the personal cost of depression in terms of poor health and suicide, there is an increasing cost to society as a whole. For example, the symptoms of depression may prevent sufferers from engaging in employment. According to a recent report, in the UK alone this amounts to a cost of approximately £7 billion pounds in lost revenue and incapacity benefits each year4. Therefore, depression is everybody's business.

How can we improve our society's mental health to ensure a brighter, happier future for all? In order to answer this question, we need to consider the historical development of our understanding of mental illness.

We can chart our future clearly and wisely only when we know the path which has led to the present

Adai Stevenson

a short history OF DEPRESsION

Depression has been recognised from the dawn of recorded history. The Ebers Papyrus, a medical document from ancient Egypt, describes a disorder of extreme despondency that is comparable to our current definition of depression. The Egyptians believed that the cause of depression was possession by an evil spirit.

Throughout history, theories into the cause of depression have been influenced by the science and cultural attitudes of the time. By the end of the 18th century, scientists commonly thought that depression was a disorder of the brain. However, as understanding of human behaviour improved, other theories about the causes of depression gained popularity, including the influence of social or cultural factors. More recent understanding of depression continues to follow the "nature v. nurture" debate.

Research investigating the genetic component to the development of depression has estimated that the risk of developing depression is approximately four times higher in individuals with a first degree relative who has depression5. However, although research indicates that genetic factors may create a susceptibility to depression, the disorder is not caused or 'determined' by the genes alone - environmental influences also have an impact.

Research that considers environmental influences on the development of depression has mainly focused on the child-parent relationship. Children who are securely attached to a caregiver are more resilient to mental illness. In contrast, children who are insecurely attached are more likely to develop mental health difficulties. In addition, research suggests that stressful life events can increase the risk of developing depression. This is especially so with regards to major life transitions, such as having a baby, or experiencing the death of a loved one. Yet, this begs the question: why is it that some people experience depression while others, in similar life circumstances, do not? Also, why do individuals experience depression in different ways?

In general, understanding of depression adopts a multi-factorial model that focuses on the interaction of genes and the environment. Kendler, Kessler, Walters found that individuals who are genetically predisposed to mental illness are twice as likely to develop depression following a severe life event when compared with people at low genetic risk6. This is supported by twin and adoption studies, which indicate that a combination of both genetic make-up and individual environment contribute to the development of depression.

THE FUTURE

The Bad

Treating depression is expected to require increasing resources over the next 20 years. Yet, even when sufferers do seek support, many are not given access to the full range of psychological support as a result of limited resources. If current trends continue, future demand for services will continue to outstrip supply, with the majority of depression sufferers not accessing appropriate treatment. This is not only problematic for sufferers, but will have a negative economic impact on society as a whole. Current estimates suggest that approximately 50% of depression goes undiagnosed and untreated. This has serious implications for the many people who are suffering unnecessarily and not accessing the support they need. More needs to be done to improve access to services, reduce stigma and raise awareness about available treatment options.

The Good

We have witnessed huge advances in terms of the diagnosis and treatment of mental illness over the last 50 years, with an ever-increasing evidence base and consequent good practice guidelines available to mental health workers. National guidelines recommend that treatment for depression should involve a combination of anti-depressant medication and psychotherapy, particularly Cognitive Behaviour Therapy7.

Although it is recognised that we have a significant deficit in terms of meeting the psychological needs of individuals with depression, as identified by Work Force Planning, this is currently being addressed through various NHS Education for Scotland (NES) initiatives. Over the last three years the number of Clinical Psychologists being trained at doctoral level has doubled as a result of a new flexible training route. Furthermore, six Clinical Associates in Psychology have recently been recruited to fill new posts within Lothian following the completion of a new postgraduate training course in adult mental health.

However, although the investment in training has grown steadily, it has been estimated that it may take another 30 years to reach adequate levels of provision. However, Clinical Psychologists are finding new ways of working in order to meet increasing demands. This includes the provision of consultation and supervision to other health care workers to provide psychological treatments.

NHS Lothian, along with 18 other European regions, has recently become involved in the European Alliance Against Depression project (EAAD). EAAD is a European Commission funded project which aims to share information and resources in order to improve the diagnosis and treatment of depression. In the future, it will be increasingly important to share resources and knowledge through similar networks to better meet the needs of sufferers with depression.

There have also been exciting advances in molecular genetics and the identification of susceptibility markers can be expected in the near future. By identifying vulnerable genotypes, it will also be possible to identify negative environmental factors that precipitate or even predispose an individual to depression. Multi-disciplinary working will help enhance our understanding of the workings of depression and develop our knowledge of what makes for effective treatment for individuals and their environments.

The Controversial

Advances in molecular genetics give the promise of being able to identify a single gene responsible for depression. Identifying such a gene would have huge implications in terms of developing accurate diagnoses of depression and more effective and targeted treatments. Genetic screening would allow us to identify individuals at risk and modify the defect using gene therapy.

However, even if we have the technology to implement genetic screening, does this mean we should? There are a number of ethical considerations that would need to be debated. Some of the potential areas of contention are as follows:

Genetic screening for depression would only be justifiable if we have effective interventions in order to prevent it developing. Pharmacogenetics holds the potential of "turning off" the genes responsible for depression so as to avoid the illness completely. However, there is limited research into the effectiveness of drug treatment in the prevention of depression.

However, there is a growing evidence base for psychosocial interventions in terms of preventing depression in individuals at risk, such as pre-retirement programmes, cognitive behavioural techniques, social networks and healthy lifestyle programmes.

HOW CAN WE ENSURE A HAPPIER AND BRIGHTER FUTURE?

We all have an interest in working towards a happier and brighter future. How can we achieve this? While there is no straightforward answer to this question, it is important that we pursue a number of goals, both individually and at NHS board level. These are:

NHS Lothian

Individuals

References

1. American Psychiatric Society (1994) DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4th Ed., Washington: American Psychiatric Association

2. Practice Team Information (2004/2005), ISD, Scotland, www.isdscotland.org

3. World Health Organisation: Mental Health and Substance Abuse, Facts and Figures, Conquering Depression: Myths and Misconceptions about Depression. Available from URL http://www.searo.who.int/en/ Section1174/Section1199/Section1567/Section1826_8096.htm Last accessed 23 March 2007

4. The Centre for Economic Performance’s Mental Health Policy Group (2006) The Depression Report: A New Deal for Depression and Anxiety Disorders, London School of Economics

5. Duffy, A., Grof, P. Robertson, C., Alda, M. (2000) The Implications of Genetic Studies of Major Mood Disorders for Clinical Practice, Journal of Clinical Psychiatry, 61, 630-637

6. Kendler, K. S., Kessler, R. C. & Walters, E. E. (1995) Stressful Life Events, Genetic Liability and Onset of Major Depression in Women, Amercian Journal of Psychiatry, 152, 833-842

7. National Practice Guidline 23 (2004) Management of Depression in Primary and Secondary Care, National Collaborating Centre for Mental Health