Depression
Content
DEPRESSION
INTRODUCTION: Depression (the disorder of loss), a type of mood disorder in which a distinction is drawn between a feeling state of dejection, sadness, or unhappiness, which may be brief in duration, and a clinical syndrome characterized by persistent sadness, profound discouragement, or despair which persists two weeks or more and is associated with a change from previous functioning. This clinical syndrome invariably involves alterations in mood experienced by an individual as a feeling of sadness, irritability; dejection, despair, or loss of interest or pleasure. Associated neurovegetative or biological signs of depression include impairment in sleep, appetite, energy level, libido and psychomotor activity. Cognitive manifestations of the depressive syndrome include distortions about oneself, one’s experience in the world and the future, accompanied by self-blame and indecision.1 EPIDEMIOLOGY: Prevalence and Incidence: Epidemiological studies of depression often describe the combined rates for both depression and anxiety disorders (the ―common mental disorders‖). In India the point prevalence of serious mental disorders is about 10 to 20 per 1000 of the population. There have been a number of studies of the prevalence in community and primary or general health care settings in South Asia and the reported rates vary considerably: from 5% to over 50%. As might be expected, rates are generally higher in primary care settings and when these are reported for common mental disorders (CMD), rather than the narrower diagnostic construct of depression. A review of 8 epidemiological studies of CMD in South Asia has shown that the prevalence in primary care was 26.3% (95% confidence interval [CI] 25.3%-27.4%). The prevalence of depression and anxiety among vulnerable groups is much higher; for example, amongst persons displaced by the armed conflict in Nepal, the prevalence was found to be as high as 80%. One population based cohort study of 2,494 women aged 18 to 50 years in India reported a 12 month incidence rate of 1.8% (95% CI 1.3%-2.4%). There are no studies in the region of the course and outcome of depression; however, studies from other countries show that the age of onset is most common in young adulthood and the disorder often runs a relapsing or chronic course.
Epidemiological facts on depression globally and in South Asia Globally - Lifetime prevalence 12.1%. - It accounts for 5% of total burden of disease from all causes. -Suicide mortality rate of 16 per 100,000. South Asia -Prevalence of 26.3% in 1999 in South Asia. -14,582 thousand DALY’s due to depression which is 3.6% of DALY’s due to all causes. -Suicide mortality rate of 10.5 per 100,000 in 2006.
IMPACT OF DEPRESSION: Each year at least 800,000 people commit suicide, 86% in developing countries. The South Asian region has amongst the highest suicide rates in the world and suicide is one of the leading causes of death in young people. Mental disorder is overwhelmingly the most important preventable factor for suicide, and depression is by far the most important mental disorder which predicts suicide. A systematic review of psychological autopsy studies identified depression (along with other mental disorders) as important proximal risk factor for suicide, with a median prevalence of mental disorder of 91% in suicide completers, and a population-attributable
fraction of 47–74%. Findings from psychological autopsy studies in India were similar. Depression is also associated with an increase in non-suicide mortality, for example, by worsening the outcomes of co-morbid physical health problems. A meta-analysis reported that the diagnosis of depression is linked with a 70% increase in subsequent all-cause mortality for persons aged more than 65 years (pooled odds ratio: 1.7 95% CI 1.5-2.0). In South Asia, 11% of Disability Adjusted Life Years and 27% of Years Lived with Disability are attributed to neuro-psychiatric disease. Depression is the single most important neuro-psychiatric contributor to years lived with disability. Studies from India show that people with depression spend more days being unable to work as usual due to their illness. One recent study in India in primary care estimated the cost of an episode of CMD disorder to be equivalent to three weeks’ wages for agricultural workers. The adverse economic impacts of depression are further worsened by the high costs of health care due to the condition; a recent Indian population based study of the health care costs of three common conditions affecting women (reproductive tract infections, anaemia and depression) reported that only depression was associated with increased health care costs and markedly increased the risk of catastrophic health expenditure. BURDEN OF DEPRESSION: Even when successfully treated and remission is achieved, depressive disorders still impose a considerable burden on the patient. Remission is rarely accompanied by a total disappearance of all symptoms. Residual symptoms, especially cognitive impairment or social dysfunction, can continue to reduce performance and cause considerable distress. The ever-present risk of relapse and recurrence also weighs heavily generally reducing the quality of life. The rate of recurrence of major depressive disorder treated in specialized mental health settings was very high (60% after 5 years, 67% after 10 years, and 85% after 15 years) but was significantly lower in the primary care population (35% after 15 years). As found in other studies the number of previous episodes and subclinical residual symptoms were the most important predictors of relapse. Increased mortality risk: The burden of depressive disorder extends far beyond the disorder itself influencing the mortality risk of the patient. The standardized mortality ratio (SMR) for suicide in patients with unipolar depression is 20.9 in men and 27.0 in women. In other terms, depressed men and women are 20.9 and 27 times, respectively, more likely to commit suicide than the general population. A 2000 meta-analysis of deaths by suicide concluded that there was a hierarchy in the lifetime prevalence of suicide among patients with affective disorders, with patients hospitalized for attempted suicide having an almost 20-fold greater prevalence than subjects who had never had any affective illness. The risk of cardiac mortality after an initial myocardial infarction is greater in patients with depression and this risk is related to the severity of the depressive episode. A study of 896 patients hospitalized for myocardial infarction found a direct relationship between the severity of the depressive symptoms as measured by the Beck Depression Inventory Score at hospitalization and the risk of cardiac death over the following 5 years. Similarly, a meta-analysis of 20 studies has shown that clinical depression is a significant risk factor for mortality in patients with coronary heart disease both short-term (3–6 months; adjusted odds ratio 2.07) and long-term (6–24 months; adjusted odds ratio 2.61). Another study evaluated longterm mortality risks measured at middle age among 12,866 men with a high risk for coronary heart disease. Greater depressive symptoms were found to be associated with significantly higher risk of all cause mortality and a higher risk of cardiovascular death and, more specifically, stroke mortality. Functional burden: An analysis of data from the National Co morbidity Survey Replication, a US nationally representative household survey, found that overall impairment was significantly higher for mental disorders than for chronic medical disorders. Severe functional impairment was reported by 42% persons with mental disorders and 24% with chronic medical disorders. Treatment, however, was provided for a significantly lower proportion of mental (21.4%) than chronic medical (58.2%) disorders. Whereas chronic medical disorders are most likely to
be associated with impairment in domains of work and home functioning, mental disorders are most commonly associated with problems of social interaction and close relationships. Psychosocial disability is related to depressive symptom severity during the long-term course of unipolar major depression (MD). In a study of 371 patients with unipolar MD in the National Institute of Mental Health Collaborative Depression Study, monthly ratings of impairment in life functions and social relationships over an average of 10 years’ follow-up were found to be associated with a degree of depressive symptom severity. Significant increases in disability occurred with each stepwise increment in depressive symptom severity (asymptomatic. sub threshold depressive symptoms. symptoms at the minor depression/ dysthymia level. symptoms at the MD level). Depression is also associated with decreased productivity in the workplace and an increased risk of absenteeism from work. One study followed 2334 participants, who were employed full or part time and who reported an annual family income of at least US$25,000, over 5 years. The presence of clinical depression, defined as a score $16 on the CES depression scale, was related to increased unemployment and decreased annual salary.16 Over the 5-year follow-up period 33% of depressed participants reported new unemployment compared with 21% of non depressed participants. After correction for confounding factors the association remained highly significant; 17% of participants with depressive symptoms and 7% of participants without substantial depressive symptoms at baseline reported that their family income had decreased below US$25,000 5 years later. This association remained significant after adjusting for potential confounding variables. The National Co morbidity Survey Replication found that taking into account both absenteeism and presenteeism (being physically present at work but functioning sub optimally) an average of over 27 workdays per year were lost per depressed employee representing an annual individual loss of US$4400. At a national level, this translates into a loss of US$36.6 billion per year in the US. Family burden: Problems of social dysfunction, decreased income resulting from workplace absenteeism, underperformance or unemployment are a burden for the patient and the patient’s partner and family. At a time when the depressed patient is at greatest need of social support, depression tends to disrupt family stability frequently leading to separation or divorce. The link between depression and divorce can be bi-directional. A study using the longitudinal component of the Canadian National Population Health Survey (1994/1995 through 2004/2005) examined the relationship between the dissolution of a marital or cohabiting relationship and subsequent depression among Canadians aged 20 to 64 years. For both sexes, dissolution of a marriage or cohabiting relationship was associated with higher odds of a new episode of depression, compared with those who remained with a spouse or partner over the 2-year period following the depressive episode. Marital dissolution was more strongly associated with depression among men than among women. Depression in women during pregnancy is common. Prevalence rates have been reported to be 7.4%, 12.8%, and 12.0% for the first, second, and third trimesters, respectively. Other studies have shown that 10% to 16% of pregnant women fulfil the diagnostic criteria for MD, and even more women experience subsyndromal depressive symptoms. DALY measurements and predictions: DALY, disability adjusted life-years, is the sum of life-years lost due to premature death and years lived with disability adjusted for severity. It integrates the notions of individual mortality and disability with global disease prevalence. Using the DALY, unipolar MD was classed in 1990, as the fourth leading burden of disease or injury cause worldwide for both sexes, behind lower respiratory infections, diarrheal diseases, and perinatal disorders. By 2004 it had moved up to third place and World Health Organization projections estimate that it will be the leading cause of disease burden worldwide by 2030.
Burden of depression Classical burden Residual symptoms • Cognitive impairment • Relapse and recurrence • Decreased quality of life • Suicide • Cardio- and cerebrovascular diseases
Mortality burden
Disability burden • Psychosocial • Work days lost Family burden Economic burden
PREVENTION OF DEPRESSION The evidence to support the efficacy of primary prevention interventions is weak, mainly because few if any interventions have been tried and/or evaluated in terms of their impact on depression. However, based on the evidence of risk factors, it is likely that programs aimed to reduce poverty, enhance educational achievement, combat gender related discrimination and violence, reduce the impact of natural disasters and build social cohesion to eliminate the risk of conflict would all have an impact in reducing the population burden of depression. Being in debt is a major cause of depression and anxiety, particularly to the poorest and the illiterate who do not have access to bank credit. This is perhaps most vividly illustrated by the suicides of farmers in central regions of India. Microfinance and rural banking initiatives which extend credit to vulnerable populations may be a primary preventive strategy for depression and suicide. Health promotion activities can have substantial impact of development of depression in future. In China, a depression prevention programme that educated schoolchildren in positive thinking, conflict management, and decision-making skills was effective for reduction of depressive symptoms. A structured school-based physical activity programme, over 1 year reduced anxiety levels in adolescents in Chile. One-semester programme of educational counselling every week reduced anxiety in the long term in Iranian nursing students .Mental health promotion in schools could be integrated into general school health programs and may include greater awareness about mental health problems amongst teachers and parents to reduce the risk of depression in young people and provision of counselling interventions for at risk adolescents. There some evidence to support the use of psychological interventions, for example group therapy to enhance resilience and self-esteem, as an indicated prevention strategy; however, this evidence is from high resourced countries and its generalisability to the South Asian region is uncertain. MANAGEMENT OF DEPRESSION A substantial evidence base testifies to the efficacy and cost-effectiveness of treatments for depression. Though much of this evidence is derived from high-income countries, there is now a growing evidence base from developing countries, including in South Asia. Based on these reviews, evidence based package of care—a combination of treatments aimed at improving the recognition and management of depression to achieve optimal outcomes has been proposed for low and high resourced settings (Panel 3). Although evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression, the majority of patients, particularly in developing countries, either do not seek help from biomedical services or, when they do, do not receive such evidence based treatments. It is important, therefore, to increase demand and access to such treatments. In order to achieve these goals, treatments need to be adapted to increase their acceptability,
accessibility, and affordability. The delivery of these treatments should ideally be carried out through an integration of depression programs into existing health services or community settings with task-shifting to non-specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers. CONCLUSION: Depression has a high prevalence worldwide in both developed and developing countries. In addition to the profound effects on the quality of life of the patient, depression has a major impact on mortality risk by suicide, and on cardiovascular and other diseases as well as death by all causes. Depression impairs cognitive and social functioning leading to decreased performance in the workplace and elsewhere. This dysfunction has considerable economic impact on the individual, his or her family, his or her employer, and on society at large. Depression, especially maternal depression, affects the health and development of the baby with possible longterm consequences for the mental health of future generations. REFERENCES: 1. Jerald Kay, Allan Tasman. Essentials of Psychiatry. England: John Wiley & Sons; 2006. 533-54. 2. Jean-Pierre Lépine, Mike Briley. The increasing burden of depression. Neuropsychiatric Disease and Treatment 2011:7(1)3–7 3. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R Packages of Care for Depression in Low- and Middle-Income Countries. PLoS Medicine, 2009 6 (10): e1000159. 4. Patel, V, Sumathipala, A, Khan M. South Asia. In: Culture and Mental Health: a comprehensive textbook 2007 (eds Bhui, K. & Bhugra, D.) Edward Arnold, London. 212224 5. Prince, M et al. "No health without mental health." Lancet 2007, 370(9590): 859-77
INTRODUCTION: Depression (the disorder of loss), a type of mood disorder in which a distinction is drawn between a feeling state of dejection, sadness, or unhappiness, which may be brief in duration, and a clinical syndrome characterized by persistent sadness, profound discouragement, or despair which persists two weeks or more and is associated with a change from previous functioning. This clinical syndrome invariably involves alterations in mood experienced by an individual as a feeling of sadness, irritability; dejection, despair, or loss of interest or pleasure. Associated neurovegetative or biological signs of depression include impairment in sleep, appetite, energy level, libido and psychomotor activity. Cognitive manifestations of the depressive syndrome include distortions about oneself, one’s experience in the world and the future, accompanied by self-blame and indecision.1 EPIDEMIOLOGY: Prevalence and Incidence: Epidemiological studies of depression often describe the combined rates for both depression and anxiety disorders (the ―common mental disorders‖). In India the point prevalence of serious mental disorders is about 10 to 20 per 1000 of the population. There have been a number of studies of the prevalence in community and primary or general health care settings in South Asia and the reported rates vary considerably: from 5% to over 50%. As might be expected, rates are generally higher in primary care settings and when these are reported for common mental disorders (CMD), rather than the narrower diagnostic construct of depression. A review of 8 epidemiological studies of CMD in South Asia has shown that the prevalence in primary care was 26.3% (95% confidence interval [CI] 25.3%-27.4%). The prevalence of depression and anxiety among vulnerable groups is much higher; for example, amongst persons displaced by the armed conflict in Nepal, the prevalence was found to be as high as 80%. One population based cohort study of 2,494 women aged 18 to 50 years in India reported a 12 month incidence rate of 1.8% (95% CI 1.3%-2.4%). There are no studies in the region of the course and outcome of depression; however, studies from other countries show that the age of onset is most common in young adulthood and the disorder often runs a relapsing or chronic course.
Epidemiological facts on depression globally and in South Asia Globally - Lifetime prevalence 12.1%. - It accounts for 5% of total burden of disease from all causes. -Suicide mortality rate of 16 per 100,000. South Asia -Prevalence of 26.3% in 1999 in South Asia. -14,582 thousand DALY’s due to depression which is 3.6% of DALY’s due to all causes. -Suicide mortality rate of 10.5 per 100,000 in 2006.
IMPACT OF DEPRESSION: Each year at least 800,000 people commit suicide, 86% in developing countries. The South Asian region has amongst the highest suicide rates in the world and suicide is one of the leading causes of death in young people. Mental disorder is overwhelmingly the most important preventable factor for suicide, and depression is by far the most important mental disorder which predicts suicide. A systematic review of psychological autopsy studies identified depression (along with other mental disorders) as important proximal risk factor for suicide, with a median prevalence of mental disorder of 91% in suicide completers, and a population-attributable
fraction of 47–74%. Findings from psychological autopsy studies in India were similar. Depression is also associated with an increase in non-suicide mortality, for example, by worsening the outcomes of co-morbid physical health problems. A meta-analysis reported that the diagnosis of depression is linked with a 70% increase in subsequent all-cause mortality for persons aged more than 65 years (pooled odds ratio: 1.7 95% CI 1.5-2.0). In South Asia, 11% of Disability Adjusted Life Years and 27% of Years Lived with Disability are attributed to neuro-psychiatric disease. Depression is the single most important neuro-psychiatric contributor to years lived with disability. Studies from India show that people with depression spend more days being unable to work as usual due to their illness. One recent study in India in primary care estimated the cost of an episode of CMD disorder to be equivalent to three weeks’ wages for agricultural workers. The adverse economic impacts of depression are further worsened by the high costs of health care due to the condition; a recent Indian population based study of the health care costs of three common conditions affecting women (reproductive tract infections, anaemia and depression) reported that only depression was associated with increased health care costs and markedly increased the risk of catastrophic health expenditure. BURDEN OF DEPRESSION: Even when successfully treated and remission is achieved, depressive disorders still impose a considerable burden on the patient. Remission is rarely accompanied by a total disappearance of all symptoms. Residual symptoms, especially cognitive impairment or social dysfunction, can continue to reduce performance and cause considerable distress. The ever-present risk of relapse and recurrence also weighs heavily generally reducing the quality of life. The rate of recurrence of major depressive disorder treated in specialized mental health settings was very high (60% after 5 years, 67% after 10 years, and 85% after 15 years) but was significantly lower in the primary care population (35% after 15 years). As found in other studies the number of previous episodes and subclinical residual symptoms were the most important predictors of relapse. Increased mortality risk: The burden of depressive disorder extends far beyond the disorder itself influencing the mortality risk of the patient. The standardized mortality ratio (SMR) for suicide in patients with unipolar depression is 20.9 in men and 27.0 in women. In other terms, depressed men and women are 20.9 and 27 times, respectively, more likely to commit suicide than the general population. A 2000 meta-analysis of deaths by suicide concluded that there was a hierarchy in the lifetime prevalence of suicide among patients with affective disorders, with patients hospitalized for attempted suicide having an almost 20-fold greater prevalence than subjects who had never had any affective illness. The risk of cardiac mortality after an initial myocardial infarction is greater in patients with depression and this risk is related to the severity of the depressive episode. A study of 896 patients hospitalized for myocardial infarction found a direct relationship between the severity of the depressive symptoms as measured by the Beck Depression Inventory Score at hospitalization and the risk of cardiac death over the following 5 years. Similarly, a meta-analysis of 20 studies has shown that clinical depression is a significant risk factor for mortality in patients with coronary heart disease both short-term (3–6 months; adjusted odds ratio 2.07) and long-term (6–24 months; adjusted odds ratio 2.61). Another study evaluated longterm mortality risks measured at middle age among 12,866 men with a high risk for coronary heart disease. Greater depressive symptoms were found to be associated with significantly higher risk of all cause mortality and a higher risk of cardiovascular death and, more specifically, stroke mortality. Functional burden: An analysis of data from the National Co morbidity Survey Replication, a US nationally representative household survey, found that overall impairment was significantly higher for mental disorders than for chronic medical disorders. Severe functional impairment was reported by 42% persons with mental disorders and 24% with chronic medical disorders. Treatment, however, was provided for a significantly lower proportion of mental (21.4%) than chronic medical (58.2%) disorders. Whereas chronic medical disorders are most likely to
be associated with impairment in domains of work and home functioning, mental disorders are most commonly associated with problems of social interaction and close relationships. Psychosocial disability is related to depressive symptom severity during the long-term course of unipolar major depression (MD). In a study of 371 patients with unipolar MD in the National Institute of Mental Health Collaborative Depression Study, monthly ratings of impairment in life functions and social relationships over an average of 10 years’ follow-up were found to be associated with a degree of depressive symptom severity. Significant increases in disability occurred with each stepwise increment in depressive symptom severity (asymptomatic. sub threshold depressive symptoms. symptoms at the minor depression/ dysthymia level. symptoms at the MD level). Depression is also associated with decreased productivity in the workplace and an increased risk of absenteeism from work. One study followed 2334 participants, who were employed full or part time and who reported an annual family income of at least US$25,000, over 5 years. The presence of clinical depression, defined as a score $16 on the CES depression scale, was related to increased unemployment and decreased annual salary.16 Over the 5-year follow-up period 33% of depressed participants reported new unemployment compared with 21% of non depressed participants. After correction for confounding factors the association remained highly significant; 17% of participants with depressive symptoms and 7% of participants without substantial depressive symptoms at baseline reported that their family income had decreased below US$25,000 5 years later. This association remained significant after adjusting for potential confounding variables. The National Co morbidity Survey Replication found that taking into account both absenteeism and presenteeism (being physically present at work but functioning sub optimally) an average of over 27 workdays per year were lost per depressed employee representing an annual individual loss of US$4400. At a national level, this translates into a loss of US$36.6 billion per year in the US. Family burden: Problems of social dysfunction, decreased income resulting from workplace absenteeism, underperformance or unemployment are a burden for the patient and the patient’s partner and family. At a time when the depressed patient is at greatest need of social support, depression tends to disrupt family stability frequently leading to separation or divorce. The link between depression and divorce can be bi-directional. A study using the longitudinal component of the Canadian National Population Health Survey (1994/1995 through 2004/2005) examined the relationship between the dissolution of a marital or cohabiting relationship and subsequent depression among Canadians aged 20 to 64 years. For both sexes, dissolution of a marriage or cohabiting relationship was associated with higher odds of a new episode of depression, compared with those who remained with a spouse or partner over the 2-year period following the depressive episode. Marital dissolution was more strongly associated with depression among men than among women. Depression in women during pregnancy is common. Prevalence rates have been reported to be 7.4%, 12.8%, and 12.0% for the first, second, and third trimesters, respectively. Other studies have shown that 10% to 16% of pregnant women fulfil the diagnostic criteria for MD, and even more women experience subsyndromal depressive symptoms. DALY measurements and predictions: DALY, disability adjusted life-years, is the sum of life-years lost due to premature death and years lived with disability adjusted for severity. It integrates the notions of individual mortality and disability with global disease prevalence. Using the DALY, unipolar MD was classed in 1990, as the fourth leading burden of disease or injury cause worldwide for both sexes, behind lower respiratory infections, diarrheal diseases, and perinatal disorders. By 2004 it had moved up to third place and World Health Organization projections estimate that it will be the leading cause of disease burden worldwide by 2030.
Burden of depression Classical burden Residual symptoms • Cognitive impairment • Relapse and recurrence • Decreased quality of life • Suicide • Cardio- and cerebrovascular diseases
Mortality burden
Disability burden • Psychosocial • Work days lost Family burden Economic burden
PREVENTION OF DEPRESSION The evidence to support the efficacy of primary prevention interventions is weak, mainly because few if any interventions have been tried and/or evaluated in terms of their impact on depression. However, based on the evidence of risk factors, it is likely that programs aimed to reduce poverty, enhance educational achievement, combat gender related discrimination and violence, reduce the impact of natural disasters and build social cohesion to eliminate the risk of conflict would all have an impact in reducing the population burden of depression. Being in debt is a major cause of depression and anxiety, particularly to the poorest and the illiterate who do not have access to bank credit. This is perhaps most vividly illustrated by the suicides of farmers in central regions of India. Microfinance and rural banking initiatives which extend credit to vulnerable populations may be a primary preventive strategy for depression and suicide. Health promotion activities can have substantial impact of development of depression in future. In China, a depression prevention programme that educated schoolchildren in positive thinking, conflict management, and decision-making skills was effective for reduction of depressive symptoms. A structured school-based physical activity programme, over 1 year reduced anxiety levels in adolescents in Chile. One-semester programme of educational counselling every week reduced anxiety in the long term in Iranian nursing students .Mental health promotion in schools could be integrated into general school health programs and may include greater awareness about mental health problems amongst teachers and parents to reduce the risk of depression in young people and provision of counselling interventions for at risk adolescents. There some evidence to support the use of psychological interventions, for example group therapy to enhance resilience and self-esteem, as an indicated prevention strategy; however, this evidence is from high resourced countries and its generalisability to the South Asian region is uncertain. MANAGEMENT OF DEPRESSION A substantial evidence base testifies to the efficacy and cost-effectiveness of treatments for depression. Though much of this evidence is derived from high-income countries, there is now a growing evidence base from developing countries, including in South Asia. Based on these reviews, evidence based package of care—a combination of treatments aimed at improving the recognition and management of depression to achieve optimal outcomes has been proposed for low and high resourced settings (Panel 3). Although evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression, the majority of patients, particularly in developing countries, either do not seek help from biomedical services or, when they do, do not receive such evidence based treatments. It is important, therefore, to increase demand and access to such treatments. In order to achieve these goals, treatments need to be adapted to increase their acceptability,
accessibility, and affordability. The delivery of these treatments should ideally be carried out through an integration of depression programs into existing health services or community settings with task-shifting to non-specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers. CONCLUSION: Depression has a high prevalence worldwide in both developed and developing countries. In addition to the profound effects on the quality of life of the patient, depression has a major impact on mortality risk by suicide, and on cardiovascular and other diseases as well as death by all causes. Depression impairs cognitive and social functioning leading to decreased performance in the workplace and elsewhere. This dysfunction has considerable economic impact on the individual, his or her family, his or her employer, and on society at large. Depression, especially maternal depression, affects the health and development of the baby with possible longterm consequences for the mental health of future generations. REFERENCES: 1. Jerald Kay, Allan Tasman. Essentials of Psychiatry. England: John Wiley & Sons; 2006. 533-54. 2. Jean-Pierre Lépine, Mike Briley. The increasing burden of depression. Neuropsychiatric Disease and Treatment 2011:7(1)3–7 3. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R Packages of Care for Depression in Low- and Middle-Income Countries. PLoS Medicine, 2009 6 (10): e1000159. 4. Patel, V, Sumathipala, A, Khan M. South Asia. In: Culture and Mental Health: a comprehensive textbook 2007 (eds Bhui, K. & Bhugra, D.) Edward Arnold, London. 212224 5. Prince, M et al. "No health without mental health." Lancet 2007, 370(9590): 859-77
