Time for united action on depression

THE publication of The Lancet–World Psychiatric Association Commission on Depression on 15 February 2022 could not have happened at a more critical time.

Depression is one of the leading causes of avoidable suffering and disability in the world and is the leading edge of the global health crisis of mental ill-health.

Even before the COVID-19 pandemic, depression was projected to peak in 2030 as a cause or preventable death and disability. Yet communities, governments, the media, and even the health sector itself have failed to acknowledge this reality. Nowhere near enough is done anywhere in the world to avoid and alleviate the suffering and prevent the disability that flows from untreated or poorly treated depression.

Despite the facts being clear for a generation, no government, even in the richest countries, has understood or acknowledged the erosion of social and economic development that results. It is over 10 years since the World Economic Forum reported that mental illness was the dominant contributor – to the tune of USD$16.3 trillion – among non-communicable diseases, which gouge a staggering 5% every year from the global economy.

The COVID-19 pandemic has added real momentum to this trend by increasing the incidence of depression and anxiety by at least 25%.

Against this backdrop, the Commission aims to advance understanding of the nature of depression, laying to rest a series of all too familiar simplistic and nihilistic debates – such as the idea that depression is simply sadness, that it is a creation of biomedicine, or that its roots are either biological or social – and to provide evidence that depression can be prevented and treated if we move beyond a one-size-fits-all approach.

Recognising depression as a central yet neglected global health problem led to the creation of this Commission at The Lancet. It had a mandate to present a balanced view of the available evidence on these and other core questions, also indicating the grey areas and knowledge gaps requiring further research. It condensed a wealth of knowledge and experience into a new resource for the global community.

The key messages are:

• Depression is a common but poorly recognised and understood health condition. This is changing but progress is too slow.
• Depression is a heterogeneous condition. It is a syndrome with many contributing causes, which vary according to biological, personal, sociocultural and environmental conditions.
• Depression is universal, but culture and context matter.
• Prevention is essential to reducing the burden of depression. There are social determinants and risk factors that are well understood but largely ignored.
• The experiences of depression and recovery are unique for each individual. The voices of people who experience depression are an indispensable source of knowledge to guide all aspects of prevention and treatment.
• Closing the gap for access to quality care. Even in high income countries only 50% of people with depression and a need for care manage to access this, and even then the quality of care is only minimally adequate in around 10% of cases. Despite improved awareness and primary mental health care investment, this pattern remains similar in Australia.
• A formulation, beyond merely a diagnosis, is essential to personalise care. Diagnosis is a necessary shorthand, but it must have utility for treatment selection and a unique formulation that broadens the therapeutic mindset and tailors it to each person.
• A clinical staging approach to care is essential. This facilitates early intervention, allowing the benefits and risks of particular treatment to be carefully balanced and ensuring intervention is proportionate to the stage of illness, while taking a pre-emptive stance and not waiting until people are severely ill and disabled, or at risk of suicide or premature death.
• Collaborative delivery models are a cost-effective strategy to scale up depression interventions in routine care. Treating depression must be holistic in its approach and this typically means a team-based model of collaborative care.
• Increased investment with whole-of-society engagement is a priority to translate current knowledge into practice and policy and to upgrade the science agenda. Discovery, innovation within the framework of health, social and medical research are overdue for major investment growth.

A set of recommendations were also endorsed:

For health practitioners:

• Be proactive in recognising depression.
• Learn about the diverse presentations and lived experiences.
• Personalise your approach— “one size” does not “fit all”.
• Prioritise the therapeutic alliance.
• Practice collaborative care to achieve optimal outcomes.

For decision makers:

• Respond to the lived experiences and the science.
• Invest in tackling inequities across the life course.
• Invest in early intervention and sustained care.
• Support the scaling up of the task-sharing of psychosocial interventions.
• Invest in depression research.

For researchers:

• Understand the aetiology and nature of depression.
• Identify novel prevention targets from social determinants to individual vulnerabilities.
• Design and test therapies addressing early and novel interventions.
• Develop precision medicine approaches.
• Engage with people who have experience of depression, their families, practitioners and policymakers.

For the general community:

• Seek support and care early.
• Talk with families and friends.
• Always remain hopeful — most people will recover.
• Focus your care on supporting your own priorities.
• Become an ally — speak up for societal changes.

The Commission hopes that the state-of-the-art content in the report will progress discussions around mental health policy reform and advocacy on a global level. It is actively engaged with relevant organisations such as United for Global Mental Health, the World Health Organization, the World Organization of Family Doctors (WONCA), Orygen Australia, the University of Melbourne, Friendship Zimbabwe, and the Office of the Surgeon General of the United States.

Implications of this publication for Australia?

The past 20 years have seen a sea change in awareness and understanding of depression and mental ill health. This has been accompanied by a genuine expansion in access to federally funded primary care treatment options for depression, which nevertheless is poorly distributed within the population.

Populations in outer metropolitan areas and rural and regional Australia have much poorer access than those in urban centres, even to this tier of care.

Headspace has improved primary care level access for young people too, and offers an effective collaborative care model, which now needs to be strengthened financially to sustain and flourish.

However, at the same time, for the substantial proportion of people with more persistent, relapsing or complex forms of depression and indeed all other forms of more complex or sustained mental illness, the situation has actually worsened.

State government-funded care has retreated and lost its way in all jurisdictions due to the fundamental failure in the design and investment in mainstreamed mental health care at state level. In Victoria, this is being addressed following a Royal Commission. And as the Productivity Commission revealed, at least one million Australians, arguably many more, often with some form of depression, are lost in a no-man’s land between the GP and the emergency department, languishing on long waiting lists or merely lost and abandoned. We have labelled these forgotten people the “missing middle” (here and here). We all know who they are.

Beyond access, quality is the key issue. So much of the burden of disease flowing from depression is avertable if evidence-based treatments were delivered in a timely, holistic, sequenced and compassionate manner. Typically, they are just not.

Averting the remainder of the burden depends on prevention, and the discovery of new treatments, both biological and psychosocial in nature. This means affirmative action within medical research.

Mental health research remains the poor cousin within government funding schemes like the National Health and Medical Research Council and Medical Research Future Fund (here, and here) but also in philanthropy. This cannot be allowed to continue.

Funders need to aim for equity proportional to the burden of disease and can be inspired by the example of the Wellcome Trust, which has made mental health one of its top priorities alongside infectious diseases and climate and health for its mammoth investment of £16 billion in the coming years.

The frontier of prevention also depends in large part on whole of government action, engaging communities and leaders in civil society, including people with lived experience and their families, as well as professionals and decision makers, to improve equity and reduce discrimination of all types in Australia, and to integrate mental health considerations in public health responses to non-communicable and communicable diseases.

For now, we need to increase access to quality care for all Australians who need it, as soon as they need it, for as long as they need it. The priority must be the missing middle, those Australians who are currently locked out of care.

The federal government has in its possession the blueprint for how this can be rapidly achieved through community-based multidisciplinary hubs for older adults and also for young people, to back up GPs and headspace primary centres. These have been commenced for both age groups but need to be scaled up much more rapidly.

The other major issue that has not been addressed with any sense of urgency is workforce training, expansion and support. This failure is paralysing the reform effort. With a 25% rise in depression and anxiety around the globe flowing from the ravages of the COVID-19 pandemic and the measures employed to contain it, mental health reform and investment must be a central pillar of the recovery plan from COVID-19 and a major election priority for all sides of politics as we enter the election period.

There are many other worthy health causes; however, mental health, brushed aside by other priorities for so many years in terms of transformational reform, represents the linchpin and essential focus for our convalescence and robust recovery from the pandemic.

Patrick McGorry AO is a psychiatrist, Executive Director of Orygen, and Professor of Youth Mental Health at the University of Melbourne.

Helen Herrman AO is Professor Emeritus of Psychiatry at Orygen and the Centre for Youth Mental Health at the University of Melbourne, and Director of the WHO Collaborating Centre for Mental Health. She is a former President of the World Psychiatric Association.

Acknowledgements

The Commission is authored by 26 experts from 11 countries. It has been led over a period of 4 years by chair Helen Herrman, co-chairs Vikram Patel and Christian Kieling, and co-ordinating editor Claudia Buchweitz. Michael Berk is a fellow Australian Commissioner. The full list of commissioners and authors is as follows: Helen Herrman, Vikram Patel, Christian Kieling, Michael Berk, Claudia Buchweitz, Pim Cuijpers, Toshiaki A Furukawa, Ronald C Kessler, Mario Maj, Patrick McGorry, Charles F Reynolds, Myrna M Weissman, Dixon Chibanda, Christopher Dowrick, Louise M Howard, Christina W Hoven, Martin Knapp, Brandon A Kohrt, Helen S Mayberg, Brenda WJH Penninx, Shuiyuan Xiao, Madhukar Trivedi, Rudolf Uher, Lakshmi Vijayakumar, and Miranda Wolpert.