Time for united action on depression: A Lancet-World Psychiatric Association Commission
Depression frequently accompanies other multifactorial illnesses such as diabetes, heart disease, cancer, and dementia, and infectious diseases such as HIV and COVID-19, and is likely to complicate and prolong the course of these associated conditions.
The consequences of the pandemic emphasise the need to make the prevention, recognition, and treatment of depression an immediate global priority
Early detection and sustained care as needed for people experiencing depression are essential to reducing distress, disability, and death by suicide.
The Lancet
Prof Helen Herrman, MD *; Prof Vikram Patel, PhD *; Christian Kieling, MD *; Prof Michael Berk, PhD †; Claudia Buchweitz, MA †; Prof Pim Cuijpers, PhD †; et al.
February 15, 2022
This is an excerpt of the publication above, focused on the Executive Summary.
Executive Summary
Evidence has accumulated over decades that depression is a leading cause of avoidable suffering in the world.
Yet, too few people in communities, governments, and the health sector understand or acknowledge depression as distinct from the other troubles that people face.
Not enough is done to avoid and alleviate the suffering and disadvantages linked with depression, and few governments acknowledge the brake that depression places on social and economic development.
By aligning knowledge about depression from many fields, this Commission has synthesised evidence from diverse contexts and, in consultation with people with lived experience, generated action-oriented recommendations for a variety of stakeholders:
communities and those affected by depression and their families; clinicians and public health practitioners, and researchers who work to understand and address it; policy makers and financiers of health and long-term care; and those responsible for motivating decision makers and politicians to act on the evidence.
Our aim is to promote concerted and united action to reduce the burden of depression and ensure that greater attention is paid to the millions of people who live with it across the globe.
Our task has never felt more urgent. The potentiation by the COVID-19 pandemic of adverse societal factors such as deep-rooted structural inequalities and personal impacts such as social isolation, bereavement, sickness, uncertainty, impoverishment, and poor access to health care has had negative impacts on the mental health of millions of people.
It has generated a so-called perfect storm that requires responses at multiple levels.
The consequences of the pandemic thus emphasise the need to make the prevention, recognition, and treatment of depression an immediate global priority, which we address through a number of key messages and recommendations.
- First, depression is a common health condition.
- Second, depression is a heterogeneous entity experienced with various combinations of signs and symptoms, severity levels, and longitudinal trajectories.
- Third, core features of the condition have been described over thousands of years
- Fourth, depression is the result of a unique combination of factors for each person affected.
- Fifth, at the individual level, detecting and diagnosing depression early in its course …
- Sixth, most individuals with depression recover from an episode if they obtain adequate support and treatment …
- Seventh, a public health approach to depression is needed, …
First, depression is a common health condition.
It is distinct from the sadness experienced by most people from time to time and from the misery or despair experienced by people in adversity.
It brings profound suffering to individuals and families, impairs social functioning and economic productivity, and is associated with premature mortality from suicide and physical illnesses.
Depression brings profound suffering to individuals and families, impairs social functioning and economic productivity, and is associated with premature mortality from suicide and physical illnesses.
Second, depression is a heterogeneous entity experienced with various combinations of signs and symptoms, severity levels, and longitudinal trajectories.
The term depression is used broadly in this Commission and does not relate to any one diagnostic system or category: we use the terms “major depression” and “depressive disorder” when referring to specific classifications.
We cover depression in this Commission as well as symptoms of depression causing distress or social impairment.
However, we do not cover depression as occurring in the specific diagnostic context of bipolar disorder.
Third, core features of the condition have been described over thousands of years…
… long before the advent of contemporary classifications, and in diverse communities and cultures.
History thus belies the myth that depression is a modern condition, an invention of biomedicine, or is restricted to certain cultural groups.
Fourth, depression is the result of a unique combination of factors for each person affected.
Proximal adversities act as triggers for the onset of an episode.
They typically interact with genetic, environmental, social, and developmental vulnerabilities and resilience factors.
Embracing the complexity of the disorder involves recognising the human brain and mind as an interface connecting our conscious selves to the world around us.
Such recognition requires going beyond a brain-based or a social-environmental paradigm and recognising that biology is inseparable from environment across the human life course.
Fifth, at the individual level, detecting and diagnosing depression early in its course …
… on the basis of recognising the signs and symptoms of illness and functional impairment over time, is a crucial first step to recovery.
A clinical formulation co-designed by the person with lived experience, caregivers as appropriate, and clinicians, sets the foundation for person-centred care.
A formulation accommodates the heterogeneous presentations and unique personal stories, and will vary in complexity depending on the individual and family needs, the resources available, and the platform of care.
Adopting a staged approach to prevention and care is a pragmatic strategy for reaching clinical decisions about interventions that are evidence-based and proportional.
The staged approach encompasses low-intensity, early interventions aimed at interrupting an emerging episode of depression, long-term multi-modal care for people with recurrent or persistent depression, and a range of intermediate interventions.
Collaborative care models offer an evidence-based way for health systems to implement the staged approach to prevention and care, realising a vision of personalised interventions for delivery at scale.
Sixth, most individuals with depression recover from an episode if they obtain adequate support and treatment …
… even though for a minority there are recurrences.
We call on communities and professionals to support the empowerment of people with lived experience of depression. The active role of people with this experience, alongside families, practitioners, policy makers, and civil society, is essential in ensuring that the unacceptably high amount of unmet need is addressed, through sharing their experiences to reduce stigma; supporting others with information about the condition and possibilities for help; and advocating for greater resources for evidence-based approaches.
Seventh, a public health approach to depression is needed, …
… considering both its social structural determinants and the severity, breadth, and for many people, durability and persistence of its consequences.
The consequences include the loss of lives and the diminution of educational and work opportunities and social connections, and harm to future generations, given the known impact of parental depression on the development of offspring.
Preventive and health promoting actions at the population level and individual level have a crucial role in lowering the prevalence of depression.
Early detection and sustained care as needed for people experiencing depression are essential to reducing distress, disability, and death by suicide.
Collectively, these interventions can substantially contribute towards promoting the health of individuals, families, and communities, and achieving the Sustainable Development Goals in each country around the world.
Early detection and sustained care as needed for people experiencing depression are essential to reducing distress, disability, and death by suicide.
We encourage health-care practitioners to consider depression as a condition that affects people of all ages in several different ways.
It frequently accompanies other multifactorial illnesses such as diabetes, heart disease, cancer, and dementia, and infectious diseases such as HIV and COVID-19, and is likely to complicate and prolong the course of these associated conditions.
Practitioners will be rewarded by efforts to integrate depression care with their practice, leading to better outcomes, giving priority to the therapeutic alliance, and addressing the rights and needs of people with depression and their families.
It frequently accompanies other multifactorial illnesses such as diabetes, heart disease, cancer, and dementia, and infectious diseases such as HIV and COVID-19, and is likely to complicate and prolong the course of these associated conditions.
Public health practitioners, policy makers, and researchers need to integrate depression prevention and care into their broader agendas.
The inclusion of mental health as a central aspect of universal health coverage, and recognition of the need for policies and interventions across sectors, beyond the health sector alone, are vital.
Researchers should be encouraged to adopt a life course perspective to understanding depression and devise novel methods to optimise prevention, care, and recovery, using approaches that are accessible in diverse resource contexts.
Decision makers must respond appropriately using the best available evidence and acting on the knowledge that depression has especially profound effects on people living in poverty and adversity.
All these stakeholders must also strive to actively engage people with lived experience of depression, including families and caregivers, in the design and implementation of services, policies, and research.
Public health practitioners, policy makers, and researchers need to integrate depression prevention and care into their broader agendas.
The multi-disciplinary contributions to this Commission and its synthesis of evidence across fields generate a new focus on several aspects of the experience of depression.
The heterogeneity of depression, the universality of the experience even while influenced by culture and context, the uniqueness of the experience for each person, the importance of intervening early, and the consequent need to stage and personalise care, are described and justified.
The Commission emphasises the need to move beyond health care to consider what is required across societies to reduce the burden of depression.
Economic arguments are presented alongside evidence derived from clinical, scientific, and lived experiences to reflect on and recommend actions across policy, research, and practice.
Although there remains much that we do not know about depression, for which we advocate a cutting-edge science agenda, there is much that we do know, and which is not used optimally.
Therefore, investing in translation of knowledge into practice is imperative. There is abundant evidence for the efficacy of preventive and therapeutic interventions for depression.
However, most communities do not benefit, and most people affected by this condition globally do not receive these interventions because of a range of demand and supply barriers.
An adequate response to depression will require whole-of-society and whole-of-government engagement, with united action to reduce exposure to adversity and enhance protective factors as well as engage with one of the most private of all human experiences in its diverse aspects, and to ensure that people needing help can find it.
Never has this ambitious agenda been as urgent or necessary.
An adequate response to depression will require whole-of-society and whole-of-government engagement, with united action
Never has this ambitious agenda been as urgent or necessary.
BOX: Key messages
1 Depression is a common but poorly recognised and understood health condition
2 Depression is a heterogeneous condition
3 Depression is universal, but culture and context matter
4 Prevention is essential to reducing the burden of depression globally
5 The experiences of depression and recovery are unique for each individual
6 Closing the care gap requires engagement of people with lived experience
7 A formulation is needed to personalise care
8 A staged approach to care addresses the heterogenous nature of depression and its impacts on individual, family, and community functioning
9 Collaborative delivery models are a cost-effective strategy to scale up depression interventions in routine care
10 Increased investment with whole-of-society engagement is a priority to translate current knowledge into practice and policy and to upgrade the science agenda
1 Depression is a common but poorly recognised and understood health condition
Depression can cause profound distress, impair social functioning and economic productivity, and lead to premature mortality; it has substantial impacts on families and on society.
However, these impacts are neither well understood nor acknowledged, and there is an insufficient response at local and international levels.
Many factors regarding the prevention and treatment of depression remain unknown — for example, what works for whom and why — and further scientific discovery is required as well as better implementation of current management strategies to transform the lives of the millions of people and their families and communities who face these challenges.
2 Depression is a heterogeneous condition *
*This term encompasses depressive disorders as well as symptoms of depression causing distress or social impairment; depression as experienced by people diagnosed with bipolar disorder is outside the scope of the Commission.
Although usually classified as a binary disorder, depression has a diversity of clinical presentations, severity levels, and longitudinal courses; it extends beyond the boundaries imposed by current classifications and commonly overlaps with other conditions.
3 Depression is universal, but culture and context matter
Depression has been described across the aeons of human civilisation.
Depressed mood, loss of interest, and fatigue are common features of the condition across populations.
However, there is also considerable variability in types and prevalence of depressive symptoms and signs among cultures and contexts.
4 Prevention is essential to reducing the burden of depression globally
Social and economic actions are needed across society to mitigate the effects of adversities and inequities early in life and across the life course.
Interventions are also needed at the individual level, focusing on current life habits and risk factors.
More efficient prevention of depression is likely to have powerful impacts on the Sustainable Development Goals for a country and the health of individuals and families.
5 The experiences of depression and recovery are unique for each individual
Depression is the result of a set of factors, typically the interaction of proximal adversities with genetic, social, environmental, and developmental risk and resilience factors.
A frequent and complex association exists between depression and physical health.
No two individuals share the same life story and constitution, which ultimately leads to a particular experience of depression and different requirements for help, support, and treatment in recovery.
6 Closing the care gap requires engagement of people with lived experience
Most people with depression globally do not receive effective care due to a range of demand and supply barriers.
Empowering individuals, families, and communities to work with professionals who can learn from their experiences and help demand the implementation of known preventive and therapeutic strategies and to hold health-care systems and decision makers accountable is vital.
7 A formulation is needed to personalise care
Detection and diagnosis of depression on the basis of symptoms, function, and duration should be accompanied by a clinical review or formulation for each person, which takes into account individual values and preferences, life stories, and circumstances.
Formulation identifies characteristics aiding personalised treatment.
The complexity and sophistication of the formulation can vary depending on the context of care and availability of resources.
8 A staged approach to care addresses the heterogenous nature of depression and its impacts on individual, family, and community functioning
A staged approach offers a pragmatic tool to translate the heterogenous clinical nature of depression for management and to ensure that interventions are comprehensive but proportional to the severity of the condition.
This approach facilitates a focus on intervening early in the course of the condition and graduating the intensity of interventions, tailored to the specific needs of the person and the stage of illness.
9 Collaborative delivery models are a cost-effective strategy to scale up depression interventions in routine care
Collaborative care offers an evidence-based approach for the delivery of interventions by diverse providers, tailored to the specific stage of the illness, and always including participatory decision making with patients and engagement with families and communities, greatly increasing the chances of quality rights-based care and remission and recovery.
10 Increased investment with whole-of-society engagement is a priority to translate current knowledge into practice and policy and to upgrade the science agenda
Although much remains unknown about depression, for which we advocate a cutting-edge science agenda, current knowledge and strategies are not optimally used; the most important immediate imperative is to invest in translation of this rich body of knowledge for practice and policy.
“Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self — to the mediating intellect — as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.”William Styron (Darkness Visible, 1990)
References
See the original publication
About the authors
Prof Helen Herrman, MD *;
Prof Vikram Patel, PhD *;
Christian Kieling, MD *;
Prof Michael Berk, PhD †;
Claudia Buchweitz, MA †;
Prof Pim Cuijpers, PhD †;
Prof Toshiaki A Furukawa, MD †
Prof Ronald C Kessler, PhD †
Prof Brandon A Kohrt, MD †
Prof Mario Maj, PhD †
Prof Patrick McGorry, MD †
Prof Charles F Reynolds III, MD †
Prof Myrna M Weissman, PhD †
Dixon Chibanda, PhD
Prof Christopher Dowrick, MD
Prof Louise M Howard, PhD
Prof Christina W Hoven, DrPH
Prof Martin Knapp, PhD
Prof Helen S Mayberg, MD
Prof Brenda W J H Penninx, PhD
Prof Shuiyuan Xiao, MD
Prof Madhukar Trivedi, MD
Prof Rudolf Uher, PhD
Lakshmi Vijayakumar, PhD
Prof Miranda Wolpert, PsychD
†Lead writing group Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia (Prof H Herrman MD, Prof P McGorry MD);
Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia (Prof H Herrman, Prof P McGorry);
Department of Global Health and Social Medicine (Prof V Patel PhD), Department of Health Care Policy (Prof R C Kessler PhD),
Harvard Medical School, Boston, MA, USA; Sangath, Goa, India (Prof V Patel);
Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA (Prof V Patel);
Department of Psychiatry, School of Medicine (C Kieling MD),
Graduate Program in Psychiatry (C Buchweitz MA), Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil;
Child & Adolescent Psychiatry Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil (C Kieling);
Deakin University, IMPACT Institute, Geelong, VIC,
Highlight to the Brazilian authors
Claudia Buchweitz, MA †;
Graduate Program in Psychiatry (C Buchweitz MA), Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil;
Christian Kieling, MD *;
Child & Adolescent Psychiatry Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil (C Kieling);
Originally published at https://www.thelancet.com.
