Time for united action on depression: A Lancet-World Psychiatric Association Commission
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, focusing on “Section 2 — epidemiology and burden of depression”
Executive Summary:
by Joaquim Cardoso MSc
Chief Editor of “The Health Strategist” blog
Epidemiology
- About 4·7% (95% uncertainty interval 4·4–5·0) of the world’s population have an episode of depression in any 12-month time period. 134
- About half as many people have depression at any point in time given that average episode duration is about 6 months, although there is wide variation around this average. 135
- Higher estimates have been reported for 12-month and 30-day prevalence of depressive episodes, which include those due to bipolar disorder; 136 up to 20–33% of depressive episodes at any point in time are associated with a history of bipolar spectrum disorder.
Course and outcome
- Epidemiological estimates of lifetime prevalence are higher than those of 12-month prevalence, suggesting that 33–50% of people with a lifetime history of depression experience a depressive episode in a year.
- In primary or secondary care settings, follow-up studies of 5 years or more suggest that recurrence can be as high as 71–85%.
Age on onset:
- In the World Mental Health surveys, median within-country depression age of onset was 26 years (IQR 17–37) in high-income countries and 24 years (17–35) in low-income and middle-income countries There was also a meaningful secondary peak for onset late in life.
Sub-threshold depressive symptoms
- Point prevalence of dysthymic disorder averages 1·5%, but prevalence of sub-threshold syndromes of depressive symptoms with shorter duration (typically 2 weeks) is as high as 17%.
Sub-threshold depressive symptoms
- Point prevalence of dysthymic disorder averages 1·5%, but prevalence of sub-threshold syndromes of depressive symptoms with shorter duration (typically 2 weeks) is as high as 17%.
Comorbidities with other mental disorders
- Comorbid anxiety or substance use disorders, or both, are found among most people diagnosed with depression, …
Comorbidities with physical disorders
- Depression is associated with a wide variety of chronic physical disorders, including arthritis, asthma, cancer, cardiovascular disease, diabetes, obesity, hypertension, cognitive impairment, chronic respiratory disorders, a variety of chronic pain conditions, and dementia.
Physical disorders are influenced by depression in at least two ways.
- First, to the extent that it is a causal risk factor, depression leads to an increased prevalence of these physical disorders.
- Second, even if depression is more a consequence than a cause of chronic physical disorders, as appears to be the case for some disorders, comorbid depression is often associated with a worse course of the physical disorder, with several mechanisms potentially involved. (e.g. non adherence to treatment regimens).
- Depression is a major source of morbidity and mortality in older people, with associated increases in public health burden, costs and use of services, and mortality; and reduced quality of life.
- The co-occurrence of depression and diabetes appears to magnify the risk of developing dementia beyond that of either condition alone.
- Depression often occurs at the early stages of dementia. Additionally, the depressive syndrome might be an early manifestation of an underlying neurodegenerative disease.
- Alternatively, depressive symptoms might be a psychological response: a reaction to a person’s growing awareness of the catastrophic consequences of their impending, irreversible, impairment.
- Global estimates of excess mortality indicate more than 2·2 million excess deaths in people with depression, with particularly high rates of death among older individuals with cardiovascular disease.
Suicidal behaviour
- Suicide is ranked as the second leading cause of death among those aged 15–29 years and as the 15th most common cause of death at all ages worldwide. 201
- However, the relative contribution of depression to suicide is smaller in low-income and middle-income countries, where a mood disorder was identified in 25% of people who died by suicide. Suicide attempts are also far more common in people with depression.
The impact of depression on functioning
- The burden associated with depression increases sharply in the second and third decades of life
- Depression and bipolar disorder were the mental disorders most often rated as severely impairing in all countries.
- Depression was associated with 5·1% of all days out of role …
- Depression was one of the three disorders associated with the highest decrements in perceived health, along with severe insomnia and a group of neurological disorders that included epilepsy, Parkinson’s disease, and multiple sclerosis.
Depression affects a range of specific areas of functioning with evidence summarised in the following sectors, with an emphasis on describing the effect of depression on life course outcomes (as opposed to the effect of life events on depression).
- The first sector is education and employment. Early-onset mental disorders are associated with premature termination of education.
- The second sector is economic consequences.
- The third sector is intimate relationships.
- The fourth sector is intimate partner violence.
- Another sector is parental functioning and offspring outcomes.
- The final sector is caregiving.
SECTION 2: epidemiology and burden of depression
About 4·7% (95% uncertainty interval 4·4–5·0) of the world’s population have an episode of depression in any 12-month time period. 134
About half as many people have depression at any point in time given that average episode duration is about 6 months, although there is wide variation around this average. 135 Higher estimates have been reported for 12-month and 30-day prevalence of depressive episodes, which include those due to bipolar disorder; 136 up to 20–33% of depressive episodes at any point in time are associated with a history of bipolar spectrum disorder. 137
This high proportion of bipolar involvement in current depressive episodes exists despite lifetime prevalence of bipolar disorder being much lower than that of depression because depressive episodes are much more persistent and recurrent among people with bipolar disorder than among individuals with depression. 138
Estimates of depression prevalence within world regions pooled across available data sources were created by WHO for 2015. 139
These estimates suggest that 12-month prevalence among women was somewhat higher in Africa and the Americas (5·8%) and somewhat lower in the Western Pacific (4·2%) than in the remaining regions of the world (5·0%). Among men, estimated prevalence was highest in Africa (4·8%), lowest in the Western Pacific (2·8%), and intermediate in other regions (3·5–3·8%).
More recent estimates of depression point prevalence in differently defined world regions were created by the Institute for Health Metrics and Evaluation as part of their Global Burden of Disease Study 2019. 140
The estimated point prevalence among both women and men was highest in North America (4·4% for women and 2·5% for men) and lowest in the Western Pacific (2·3% for women and 1·3% for men); it was intermediate in other world regions both for women (2·8–3·6%) and men (1·9–2·0%).
The exact reasons for such variations are yet to be understood. They are probably attributed mostly to the varying distribution of risk or protective factors. Methodological aspects, such as differential response to questions assessing depressive symptoms, might also account for some of the variability.
Most estimates of lifetime prevalence of depression are based on retrospective reports and need to be interpreted with caution as they are likely to underestimate true lifetime prevalence. 141
Retrospectively reported lifetime prevalence of depression from community epidemiological surveys with adults aged 18–74 years in 28 countries 135 averaged 10·6% (IQR 6–14) across countries. A prospective epidemiological study reported a much higher lifetime prevalence of major depression in the range of 30–40%. 141
Course and outcome
Epidemiological estimates of lifetime prevalence are higher than those of 12-month prevalence, suggesting that 33–50% of people with a lifetime history of depression experience a depressive episode in a year.
These estimates are broadly consistent with follow-up studies in clinical and community samples. However, this naturalistic course is diverse. Most depressive episodes remit within 1 year.
The prevalence of persistent depression (ie, an episode lasting more than 12 months) is estimated to be as low as 12% in people meeting criteria for a diagnosis of depression in community surveys; but can be as high as 61% among those receiving treatment for depression in primary and secondary care settings (table 1). 145
Table 1: See the original publication
The diversity of the naturalistic course in depression is also apparent in rates of recurrence after recovery. Among individuals who seek treatment, depression is often an intermittent recurrent disorder over the life course, 160 commonly with partial remission between episodes. 161
In primary or secondary care settings, follow-up studies of 5 years or more suggest that recurrence can be as high as 71–85%.
However, recurrence rates are much lower for people ascertained as having depression in community samples; between 27% and 45% report experiencing a recurrent episode over 20 years (table 1)
Age of onset
Retrospective reports have been used to reconstruct the distribution of age of onset — an alternative to the estimation of incidence. 162
In the World Mental Health surveys, median within-country depression age of onset was 26 years (IQR 17–37) in high-income countries and 24 years (17–35) in low-income and middle-income countries (figure 3). There was also a meaningful secondary peak for onset late in life. 163
These age of onset distributions are later than for a number of other common mental disorders, such as anxiety disorders, and many cases of depression are comorbid with these other temporally primary disorders. 164
There is considerable interest in the possibility that age of onset might be relevant for identifying depression subtypes, although this line of investigation is still at an early stage of development. 165
Figure 3 — Age of depression onset among the projected proportion of the population developing the disorder before age 75 years
There is an important implication of depression having a later age of onset than many other common mental disorders.
Lifetime prevalence (ie, the proportion of the population who have experienced the disorder to date) is estimated directly from results of community epidemiological surveys.
When a high proportion of first onsets occurs at ages later than those of respondents in the surveys, this estimate of lifetime prevalence will be lower than that of lifetime morbid risk (ie, the projected proportion of the population who will experience the disorder at some time in their life), which is estimated using actuarial methods with life tables. 166
On the basis of data from the World Mental Health surveys, the average morbid risk of depression at age 75 years is projected to be 19·6% (ie, almost one in five individuals around the world will have experienced depression by 75 years of age). 135
This is nearly twice as high as the proportion of World Mental Health respondents with a lifetime history of depression at the time of survey.
Furthermore, the median age of onset of depression among survey respondents is significantly lower than the projected median age of onset according to lifetime morbid risk calculations. The first reason for this difference is that early-onset cases are over-represented among those with a lifetime history at the time of survey. For example, fewer than half the survey respondents aged 18 years who will at some time in their life experience depression will have had that experience as of age 18 years. The second reason is survey bias of two types: loss of survey participants through early mortality of people with a history of depression, and under-representation in surveys of people older than age 85 years.
Sub-threshold depressive symptoms
Interest in expanding the definition of the depressive spectrum to characterise clinically significant manifestations that do not meet criteria for depression among people who might profit from early intervention is long standing. 167
Point prevalence of dysthymic disorder averages 1·5%, 168 but prevalence of sub-threshold syndromes of depressive symptoms with shorter duration (typically 2 weeks) is as high as 17%. 61 , 169
These syndromes, sometimes labelled as minor depression, might also overlap with the construct of adjustment disorder with depressed mood. Unlike depression, the prevalence of minor depression is high among children 170 and adolescents, 171 and associated with substantial distress and impairment, and with considerable medical and non-medical costs. 172
These syndromes constitute a risk factor for subsequent onset of depression and might be the sequelae of partial remission of an episode of major depression. 173
Comorbidities with other mental disorders
Comorbid anxiety or substance use disorders, or both, are found among most people diagnosed with depression, both in community epidemiological surveys 174 and in studies of primary care 175 or specialised care settings. 176
Numerous researchers have documented bivariate associations among hierarchy-free anxiety, mood, behaviour, and substance disorders that can be accounted for by correlated latent predispositions to internalising and externalising disorders. The internalising disorders can also be divided into secondary dimensions of fear (eg, panic, phobia) and distress disorders (eg, major depressive episodes, generalised anxiety disorder, and post-traumatic stress disorder). This structure is quite stable cross-nationally. 177
Longitudinal data have been used to investigate temporal progression across lifetime comorbid mental disorders and whether risk factors for individual disorders are more accurately conceptualised as risk factors for the latent dimensions underlying these disorders. 178
For example, observed gender differences in depression prevalence became non-significant when controls were included for latent internalising and externalising dimensions. 179
A cross-national analysis of this type, albeit based on retrospective age of onset reports obtained in cross-sectional community epidemiological surveys, followed on from World Mental Health surveys across 14 countries. 164
Almost all temporally primary lifetime anxiety, mood, disruptive behaviour, and substance disorders predicted the subsequent first onset of later disorders.
Most time-lagged associations were explained by a model that assumed the existence of mediating latent internalising and externalising variables. Depression was no more important than were several other internalising disorders (generalised anxiety disorder, obsessive-compulsive disorder, or post-traumatic stress disorder) in defining these latent variables.
An ambitious population-based cohort study with similar logic used information about age of first treatment of common mental disorders in health registries for the 5·9 million residents of Denmark born in that country between 1990 and 2015. 180
As in the retrospective World Mental Health study, all temporally primary mental disorders included in this Danish study were associated with elevated risk of subsequent onset of all temporally secondary mental disorders.
The strength of these associations becomes weaker as the number of years since onset of the temporally primary disorder increases.
Early-onset mood disorders were associated with especially high absolute risks of subsequent neurotic disorders (anxiety disorders and depression) over the next 5 years among both men (30·6%) and women (38·4%).
Comorbidities with physical disorders
Depression is associated with a wide variety of chronic physical disorders, including arthritis, asthma, cancer, cardiovascular disease, diabetes, obesity, hypertension, cognitive impairment, chronic respiratory disorders, a variety of chronic pain conditions, and dementia. 181
These associations can reflect causal effects of physical disorders on depression, causal effects of depression on physical disorders, and effects of common antecedents, such as socioeconomic disadvantage or adverse lifestyle factors, which simultaneously affect both body and mind. There is also the problem of spurious association, often unrecognised, when the same set of symptoms is double counted to arrive at both a psychiatric and a physical diagnosis.
For example, in chronic obstructive pulmonary disease, somatic symptoms such as fatigue, decreased appetite, and weight loss might be simultaneously attributed to the physical and the psychiatric condition.
Equally important to spurious association in a clinical setting is the misattribution of depressive symptoms to physical illness, resulting in failure to recognise depression and under-estimating the influence of depression on the course of physical illness. 182
Physical disorders are influenced by depression in at least two ways.
First, to the extent that it is a causal risk factor, depression leads to an increased prevalence of these physical disorders.
Consistent with this possibility, meta-analyses of longitudinal studies show that depression is a consistent predictor of the subsequent first onset of coronary artery disease, stroke, diabetes, heart attacks, obesity, osteoporosis, and certain types of cancer. 183
A number of biologically plausible mechanisms have been proposed to explain the prospective associations of depression with these disorders, such as hypothalamic-pituitary-adrenal hyperactivity, autonomic dysregulation, and impaired immune function. 184
Additionally, a variety of unhealthy behaviours known to be linked to depression, such as an increased amount of smoking and drinking, 185 poor eating habits, 186 and unhealthy food intake, are simultaneous risk factors for physical disorders.
On the basis of these observations, there is good reason to believe that depression might be a causal risk factor for at least some chronic physical disorders.
Second, even if depression is more a consequence than a cause of chronic physical disorders, as appears to be the case for some disorders, comorbid depression is often associated with a worse course of the physical disorder, 187 , 188 , 189 , 190 with several mechanisms potentially involved. One of the most consistently documented mechanisms is the association of depression with non-adherence to treatment regimens. 191 , 192
Differential population-based clustering of depression with comorbid physical conditions on the basis of patterns of underlying negative social determinants of health is also now being modelled in the syndemics literature, built on the idea that comorbid conditions potentiate one another in certain social, economic, or cultural contexts. 193
Depression is a major source of morbidity and mortality in older people, with associated increases in public health burden, costs and use of services, and mortality; and reduced quality of life. In the case of dementia, depression could be a risk factor or a precursor; or dementia might be a risk factor or trigger for late-life depression; and the two conditions can be difficult to disentangle diagnostically.
In the Framingham Heart Study cohort 194 a 50% increased risk of dementia was observed over a 17-year period among those with a diagnosis of depression at baseline compared with those without that diagnosis.
Results were similar for those taking antidepressant medication.
Hypotheses to explain this increased risk include chronic inflammatory and neurobiological changes (eg, hippocampal damage due to glucocorticoid cascade); 195 the cholinergic effect of tricyclic antidepressants; 196 and lifestyle factors such as poor diet, smoking, and reduced physical activity or social engagement, which are known to be associated with depression. 197
The co-occurrence of depression and diabetes appears to magnify the risk of developing dementia beyond that of either condition alone. 198
Depression often occurs at the early stages of dementia. Additionally, the depressive syndrome might be an early manifestation of an underlying neurodegenerative disease. 199
Alternatively, depressive symptoms might be a psychological response: a reaction to a person’s growing awareness of the catastrophic consequences of their impending, irreversible, impairment.
Global estimates of excess mortality indicate more than 2·2 million excess deaths in people with depression, with particularly high rates of death among older individuals with cardiovascular disease. 200
A meta-analysis comprising data from more than 1·8 million individuals in 35 countries confirms the presence of a significant association between depression and excess all-cause mortality; although this association might have been overestimated because of publication bias and low study quality. 190
Suicidal behaviour
Suicide is ranked as the second leading cause of death among those aged 15–29 years and as the 15th most common cause of death at all ages worldwide. 201
A meta-review 202 reported an almost 20-fold risk of death by suicide for people with depression with a standardised mortality ratio of 19·7%.
Depression is the most common psychiatric disorder reported in people who die by suicide, and psychological autopsy studies 203 estimate that depression is responsible for the largest proportion of the burden of disease attributed to suicide (as measured in disability-adjusted life years: 46%, 95% CI 28–61). 204
However, the relative contribution of depression to suicide is smaller in low-income and middle-income countries, 205 , 206 where a mood disorder was identified in 25% of people who died by suicide. Suicide attempts are also far more common in people with depression. 207
A meta-analysis of suicide attempts in individuals with depression found a lifetime prevalence of 31% (95% CI 27–34) and confirmed that suicide attempts were common in individuals with depression across the world. 208
Meta-analytic evidence 209 indicates that the risk of suicidal behaviour in people with depression is significantly associated with previous suicide attempts, severe depression, anxiety, hopelessness, family history of psychiatric disorder, comorbid substance abuse disorder, personality disorder, 210 and sleep disorders (particularly nightmares and insomnia). 211
Deaths from suicide among those with a current depressive episode occur mostly (75%) during the first episode, 19% in the second episode, and 7% in people who have more than two depressive episodes. 212
The impact of depression on functioning
The burden associated with depression increases sharply in the second and third decades of life (figure 4).
This high score for the number of disability-adjusted life years is partly attributable to the high estimated disability weight ranging from 0·145 (mild) to 0·396 (moderate) and 0·658 (severe), with the highest of these weights equivalent to those of the most severe physical conditions (eg, 0·582 for people living with HIV not receiving antiretroviral therapy and 0·569 for terminal cancer). 214
Figure 4 — The burden of depression across the life course according to country income level
Although there are several criticisms regarding the accuracy of disability weights, 215 , 216 , 217 depression is a highly burdensome condition and other studies have confirmed that the disability is experienced as one of the most severe of all health conditions.
Community surveys examining the comparative effects of diverse diseases on various aspects of role functioning 218 , 219 typically show that musculoskeletal disorders and depression are associated with the highest levels of disability among all commonly occurring disorders.
The most compelling study of this sort was based on 15 national surveys done as part of the World Mental Health Study. 220
Disorder-specific self-reported role impairment scores were compared across people who experienced each of ten chronic physical disorders and ten mental disorders in the year before interview.
Depression and bipolar disorder were the mental disorders most often rated as severely impairing in all countries. None of the physical disorders considered, including cancer, diabetes, and heart disease, had impairment levels as high as those for depression or bipolar disorder.
Depression is also associated with the highest number of days out of role at the societal level of any physical or mental disorder. In the World Mental Health surveys, 62 971 respondents across 24 countries were assessed for a wide range of common disorders and for days out of role in the 30 days before interview. 221
Depression was associated with 5·1% of all days out of role, the fourth highest population-attributable risk proportion of all the disorders considered (exceeded only by headache or migraine, other chronic pain conditions, and cardiovascular disorders) and by far the highest proportion among the mental disorders.
Depression was associated with 5·1% of all days out of role
The WHO World Health Surveys of 245 404 respondents across 60 countries examined the comparative decrements in perceived health associated with different chronic disorders. 136
A consistent pattern was found across countries and socio-demographic subgroups within countries: the association between depression and the decrement in perceived health was larger than for any of the four physical disorders considered (angina, arthritis, asthma, and diabetes).
A related study in the World Mental Health surveys compared depression with 18 other disorders, physical (eg, cancer, cardiovascular disorders, diabetes) and mental (eg, bipolar disorder, panic disorder, post-traumatic stress disorder) in predicting a summary measure of perceived health. 222
Depression was one of the three disorders associated with the highest decrements in perceived health, along with severe insomnia and a group of neurological disorders that included epilepsy, Parkinson’s disease, and multiple sclerosis.
Depression affects a range of specific areas of functioning with evidence summarised in the following sectors, with an emphasis on describing the effect of depression on life course outcomes (as opposed to the effect of life events on depression).
- The first sector is education and employment. Early-onset mental disorders are associated with premature termination of education.
- The second sector is economic consequences.
- The third sector is intimate relationships.
- The fourth sector is intimate partner violence.
- Another sector is parental functioning and offspring outcomes.
- The final sector is caregiving.
The first sector is education and employment. Early-onset mental disorders are associated with premature termination of education. 223 , 224 , 225
Depression is significantly associated, at least in studies done in high-income countries and after adjusting for comorbid conditions, with about a 60% increased odds of not completing secondary school. Several prospective studies document the effect of depression on occupational difficulties. For example, an analysis of World Mental Health data showed that a history of depression as of the age of completing schooling (regardless of the exact age) predicted current (at the time of interview) unemployment and work disability. 226
The fact that these findings were significant only in high-income countries raises the possibility that the impairments associated with depression are influenced by contextual factors such as the complexity of work and the eligibility of depression for sickness-benefits or disability benefits.
The second sector is economic consequences. The personal earnings and household income of people with depression are substantially lower than those of people without depression. 227 , 228 However, as with unemployment, depression could be a cause, a consequence, or both. 229
Several prospective studies suggest that the onset of depression before the completion of education predicts substantially reduced income-earnings in adulthood after adjusting for level of educational attainment. 230 , 231
Epidemiological surveys have estimated the workplace costs of depression related to low work performance while on the job; 232 in the USA, the annual salary-equivalent human capital value of these losses has been estimated to range from USD$30·1 billion 233 to $51·5 billion. 234
The third sector is intimate relationships. Although most of the literature on intimate relationships refers specifically to marriage, this evidence might generalise to other types of intimate relationships. Early-onset mental disorders predict a low probability of marriage. For people who marry, these disorders might be positively associated with early (before age 18 years) marriage, 235 which is known to be associated with several adverse life course outcomes. These associations are largely the same for men and women and across countries. Depression is one of the most important premarital mental disorders. A premarital history of mental disorders also appears to predict divorce, 236 again with associations quite similar for husbands and wives across all countries and depression among the most important disorders in this regard. 237
Marital dissatisfaction and discord are strongly related to depressive symptoms, 238 , 239 with an average correlation between marital dissatisfaction and depressive symptoms of approximately r=0·4 across studies and very similar patterns for men and women. 240 Longitudinal studies show that this association is bidirectional, 241 , 242 but with a stronger time-lagged association of marital discord predicting depressive symptoms rather than depressive symptoms predicting marital discord. 243
Few studies have considered the effects of clinical depression on marital functioning, 244 , 245 but consistently document significant adverse effects.
The fourth sector is intimate partner violence. This type of violence is partly a consequence of pre-existing mental disorders. 246 The World Mental Health surveys 247 found that the association between premarital history of depression and subsequent intimate partner violence disappears after controls are introduced for disruptive behavioural disorders and substance use disorders, suggesting that depression might be a risk marker rather than a causal risk factor. However, a large sibling control study 248 reported that men with depressive disorder had a higher risk of perpetrating intimate partner violence against women than did their unaffected full siblings, although absolute rates were low. The risk was further elevated when there was comorbidity with alcohol use disorders, drug use disorders, or personality disorders.
Another sector is parental functioning and offspring outcomes. Both maternal and paternal depression have an effect on the offspring, but the effect of maternal depression might be greater than the effect of paternal depression. 249
The negative effects can include low birth weight, poor school performance, relatively high rates of physical health complications, depression, anxiety, substance abuse, and suicidal behaviour, with substantial, persistent, and wide-ranging economic effects. 250
Effects on their offspring are sustained when parents experience persistent depression, live in poverty, or both. 251 These adverse effects can be mediated by the association of both maternal 252 and paternal 253 depression with negative parenting behaviours. These associations are found throughout the age range of children, but are most pronounced for the parents of young children. Both laboratory and naturalistic studies of parent–infant micro-interactions have documented subtle ways in which depression in a parent leads to maladaptive interactions that hinder affect regulation in infants, hamper later child development, and increase risk of subsequent psychopathology. 254
The final sector is caregiving. For family members, the experience of caring for a child or older adult with depression is usually demanding and frequently an isolating experience. Most informal mental health carers are female family members. They frequently have a double role caring for children and an older person living with depression. They might lose employment and contact with friends and outside activity, and even other members of the family. Family carers have a heightened risk of becoming depressed or anxious themselves. 255
Section 3: the roots of depression
See original publication
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,
Originally published at https://www.thelancet.com
