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| EDITORIAL |
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| Year : 2017 | Volume
: 22
| Issue : 1 | Page : 4-6 |
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Depression in India: Let's talk to physicians too
Rajesh Sagar, Raman Deep Pattanayak
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 14-Jul-2017 |
Correspondence Address:
Rajesh Sagar
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_37_17
How to cite this article:
Sagar R, Pattanayak RD. Depression in India: Let's talk to physicians too. J Mental Health Hum Behav 2017;22:4-6 |
The World Health Day, celebrated on April 7, has chosen a theme on depression for its year-long campaign for 2017, with a slogan of “Depression: Let's talk.”[1] On its own, it is a significant development, indicative of the wider recognition of the burden posed by depression. One in five individuals suffer from a depressive disorder in their lifetime.[2] In low- and middle-income countries, more than 80% of years lived with disability (i.e., nonfatal disease burden) is attributable to depression.[3] The overall goal of the campaign is to have more people with depression, everywhere in the world, seek for and receive help. At the core of the campaign is the importance of “talking” about depression as a vital component of recovery.
It is important to reflect on the Indian scenario pertaining to depression and to consider how and whom to talk? Of course, it is important to talk about depression (i) at an interpersonal level to encourage people to share their mental health issues with friends and families; (ii) at a patient-clinician level, encouraging people to seek help, seek consultation, and professional help; and (iii) at a societal level and on public platforms to spread awareness and cut down stigma. Extending it further, it is also rather important for psychiatrists to “talk” to the primary care (PC) physicians and general practitioners to effectively deal with depression.
Let's have a look at the prevalence of depression in India. Available literature indicates a wide range of prevalence, mostly attributable due to methodological heterogeneities and diverse sampling. A prevalence of 15.9% for depression was reported by a methodologically rigorous, large sample study, which is quite similar to the Western figures.[4] Indian youth has been reported to have several-fold higher rates for suicide than the global average, and depression is one of the well-known risk factors for suicidal attempts and completed suicides.[5] In India, more than one lakh persons commit suicide/year,[6] which, to a certain extent, may be potentially preventable. Studies done specifically in primary health care or medical settings in India have found depression in 21% to as high as 84% of the cases.[7],[8] A vast majority of patients being seen by general physicians and/or attended across medical specialties have a rather higher risk of co-occuring depression which remain under diagnosed.
Coming to the past-year (12 months) prevalence and treatment-seeking, 5.52% population in India suffer from a common mental disorder (mood disorder: 1.44%) as reported in a representative household sample (n = 24,371 adults) survey, as part of world mental health surveys initiative.[9] Unfortunately, only 1 in 20 persons with a depressive disorder in the past 12 months received any form of medical help (past-year treatment-seeking for depression: 5.54%).[9] These figures reveal a huge treatment gap. Among a host of other factors, a low degree of awareness and lack of accessible services closer to the place of residence are responsible for poor help-seeking.
The general physicians and PC practitioners have the potential to play a key role in raising the awareness, early detection as well as provision of basic medical care for depression closer to home, and may serve as a link for referral. Currently, the mental health services are mostly limited to secondary or tertiary care settings, and their integration with PC has begun to happen only recently and not yet in an effective manner. Average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 100,000 population), which is clearly inadequate to deal with the burden of depression.[10] Under the National Mental Health Program, as part of 11th 5 year plan, some initiatives have been taken to provide impetus to capacity building in mental health, with centers of excellence, workforce development scheme, etc.[11],[12] The medical college seats in India have now increased to nearly 65,000 per annum to add to the existing strength.[13] However, even with these enhanced numbers of mental health professionals, the treatment gap is expected to remain wide, and there is likely to be a continued need for involving the physicians/general practitioners to bridge the gap at a PC level and to provide the screening, treatment, and referral services.
The shortage of workforce and resources in psychiatry can be overcome by means of a greater integration with general health/medical services. At the same time, most physicians are presently not sufficiently equipped with knowledge or skills to treat common mental disorders such as depression. On a positive note, the number of registered practitioners/clinicians far outnumber the psychiatrists and provide a relatively better doctor: patient ratio and more coverage for health services in rural and remote areas. There are close to 7 medical practitioners (nonspecialists) per 10,000 population vis a vis psychiatrists 0.02/10,000 population.[14]
Some of the advantages of physicians playing a role in dealing with depression can be summarized as follows: (i) general physicians' far outnumber the psychiatrists and with a high burden of depression and huge treatment gap, may contribute at a PC level, (ii) better coverage in the rural and remote areas with easy accessibility, (iii) cost and logistics, (iv) relatively high risk and comorbidity rates for depression in medically ill patient-population which is routinely seen in a PC physician's practice, (v) contribution to stigma reduction and better services integration (especially for milder depressions), and (vi) early identification, better detection rates, and linkages/referral to psychiatrists, wherever indicated. Of course, to achieve the above objectives and gain from the listed advantages (and to avoid untoward consequences), there is a need to take optimal steps to adequately train the “current” and “future” physicians.
Effective screening and early detection of depression are possibly one of crucial and basic goals for physician sensitization and training. It is possible that physicians may face an initial denial or resistance from patients on suggestion of a psychiatric screening; however, a gradual approach to the subject is advisable, beginning with questions pertaining to biological functions (sleep, appetite, and libido changes) followed by behavioral changes (social, interpersonal relations, academic, or occupational functioning) and mood changes.
Studies have suggested that even in busy medical settings, use of as little as two questions may be a reasonable alternative (with 85% sensitivity and 66% specificity) to detect depression.[15] Effective screening tools are available for use by physicians in primary or general medical care. Patient Health Questionnaire-depression module (PHQ-9) is a 9-item scale (each item rated between 0 and 3 based on frequency) with sensitivity and specificity of 88% at cutoff score of 10.[16] A brief 2-item version of PHQ, which enquires about the frequency of depressed mood and anhedonia over the past 2 weeks, has been shown to detect major depression with a sensitivity of 83% and a specificity of 92% (at a cutoff score of 3).[17] In medical settings, some of depressive symptoms may overlap with somatic or physical symptoms experienced in other medical illnesses, which can be overcome by use of Beck Depression Inventory-Primary Care (BDI-PC-7 item) which does not focus on the somatic or physical symptoms.[18]
Other than conducting the effective screening for depression, physicians can play a key role in several other clinical aspects and public health awareness. Adequately trained physicians may contribute in various aspects as follows: (i) effective screening and early detection, as already discussed above (ii) entertaining or making a clinical diagnosis, along with formal exclusion of other conditions which may resemble or present such as depression; the World Health Organization (WHO) is revising the classification of common mental disorders in primary care version for ICD-11, with some major changes proposed from the earlier version, which can further facilitate the diagnosis by PC physicians,[19] (iii) initiating the treatment, management of depression, other depressive syndromes such as dysthymia, (iv) provision of nonpharmacological therapies (supportive, stress management, relaxation training, reactivating social networks, structured physical activity etc.) as stand-alone or as adjunct with medication, (v) early identification of warning symptoms/signs (e.g., suicidality) and referral services to specialists as and when required, and (vi) public awareness and educational activities for depression in the community.
As far as physician's needs assessment is concerned, a recent survey [20] of found that 57% physicians did not feel competent to deal with suicidal patients, and majority felt they would greatly benefit from additional training to enhance their assessment and intervention skills. In Indian context, several isolated efforts have taken place to sensitize or train physicians; however, these have been mostly single-time, or 1 day programs, at a local/regional level, or as part of research initiative to generate evidence for effectiveness.[21],[22]
Under the National Mental Health Program, some steps have been taken to provide district-level medical officers with courses in psychiatry; however, there is often no follow-up assessment, and not much effort to look into whether program has actually translated into practice. In all likelihood, such programs would have contributed to sensitize and orient the physicians to common mental health conditions such as depression. Whether it has amounted to a gain in knowledge and skills remains an area which need to be focused in the future. Often there are several practical challenges and logistic aspects, for example, permissions for time to attend courses which need to be addressed for their wider acceptability. Therefore, there is a need to look into both the long-term sustainability as well as scalability aspects of physician training programs in India.
There is a need to go in a gradual, step-wise fashion with consistent and concerted efforts looking at the various possible long-term sustainable solutions (rather than brief, short-term efforts which are likely to back-fire). Giving a due emphasis on psychiatry training in the undergraduate curriculum to better equip the future physicians, adequate exposure to common psychiatric aspects in internships, continuing medical education credited physician courses in depression and its safe and effective management, capacity building/training-of-trainers and trainings/refresher courses through various mediums are only some of the many possible ways. Further, with family medicine PG courses coming up in India, the screening and management of depression may be integrated in their teaching/training. Similarly, the exposure to common mental aspects (e.g., postpartum depression) among gynecology trainees shall go a long way to detect and appropriately deal with the burden of depression. There is a need for more physician educational tools and ready-reference resources in depression. The WHO-mhGAP intervention guide is a carefully developed, evidence-based tool developed for use in nonspecialist health settings, which has a module for depression and protocols for clinical decision-making in depression.[23] Further, the efforts to disseminate the knowledge and necessary skills to physicians need to be coordinated at multiple levels, with involvement of Ministry of Health, Medical Council of India, national bodies and associations for psychiatrists, physicians, practitioners to achieve the greater coordination and facilitate the “talk” between the respective regional, state, and local bodies for psychiatrists and physicians maximizing the achievements.
From international experience, it is known that single interventions to sensitize physicians do not work, and their effectiveness do blur over time unless the program does continue.[24] It is pertinent that mental health professionals should “talk” to physicians more often, more regularly, more meaningfully and also help to create more efficient and innovative channels for dissemination of knowledge and skills to physicians for identifying and treating depression.
To conclude, there is an important role of physicians in managing the depression in community. There is a need to optimally utilize this otherwise trained, professional resource by means of appropriate sensitization, orientation, and imparting of specific training to both current as well as the future physicians in screening and managing depression. It is pertinent for psychiatrists to “talk” to physicians to beat the depression in Indian context.
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