Although most people can sympathise with those who suffer from depression, many of us still have misconceptions about this mental illness, says Associate Professor Daniel Fung, chairman of the Medical Board at the Institute of Mental Health.
This year, World Health Day on Apr 7 throws the spotlight on depression. The campaign - Depression: Let’s Talk - launched in 2016 implies that it is not well spoken about and indeed requires us to talk more about the topic.
According to the World Health Organization (WHO), it can affect 6.9 per cent of the population. A local study in 2010 showed that about 6 people out of a 100 in Singapore will develop this illness over their lifetimes.
Depression is a disorder society can sympathise with, compared to other mental illnesses. Although patients suffering from most chronic mental illnesses bear the same stigma, society’s understanding of depression is far better than, say, bipolar disorder or schizophrenia.
One of the reasons for this is that depression appears to most people as a plausible illness. It is acceptable to be sad and in the deep throes of melancholia unlike a psychotic illness in which the patient manifests behaviour that is inconceivable and even frightening. In charities that treat mental illnesses, it is much easier to raise funds for depression, in which greater sympathy can be obtained, than schizophrenia.
Pop culture usually portrays depression far better than schizophrenia. In movies, such as Shutter Island (2010), schizophrenia is sometimes mistaken for psychopathic behaviour that depicts the sufferer as potentially evil and a killer. Depression on the other hand, like in The Hours (2002), is seen as the result of unprovoked guilt and a victim of the circumstance.
Mental health literacy studies have also indicated much better understanding of depression compared to schizophrenia for the same reasons. The precursor of depression, though not always true, is a neurotic person who cannot help the situation that he has fallen into. The precursor of schizophrenia is an oddball who is hard to understand and may have chosen his or her path in falling into the depths of madness.
The key issue, as both illnesses are mental illnesses, lie in the fact that one presents as an extreme sadness, with a risk of self-destruction, while the other an extreme madness who may drag others into their violent catharsis.
For one, it is not a disease that one can snap out of just by talking about it. In some situations, the depths of melancholia are hardly different from the depths of madness.
Treatments for depression are among the most well studied, with what doctors term as evidence-based practice. For mild forms of depression, treatments involving talking, like cognitive behavioural therapy, are a good start but when the symptoms become severe and entrenched, more potent interventions are needed. Medications serve to modify serotonin in the brain, the happy chemical that can alter the emotional state of the sufferer.
Electro-convulsive therapy (ECT), so well described in the movie One Flew Over the Cuckoo’s Nest (1975) offers a devastatingly simple way of lifting the mood quickly: Six courses of passing a small current through the brain with the sufferer under general anaesthesia.
Treatment involving talking are useful adjuncts at this point, because feeling better needs additional skills that maintain the emotional lift that medications and ECT have achieved. The use of other lifestyle changes including diet and exercise and even intense light treatments are not standalone treatments but offer some help in specific situations.
The idea of a cure in mental illness is still seen as a lofty goal largely because the etiology of depression, like most mental illnesses, is not linear. It is a combination of the environment interacting with the person’s internal vulnerabilities, whether these are genetic, a neurotransmitter dysfunction, or both.
A simple cause-and-effect approach will not yield simple answers, unlike infections in which the ability to kill the responsible pathogen will likely cure the illness.
Another common myth is that depression is not a severe mental illness. The risk of suicide is high in depression and in our local study, almost half of those suffering from depression will contemplate suicide and more than 10 per cent actually make an attempt.
The key to managing depression is to understand the interactional factors between the environment and the individual living in that environment. A new approach to understanding depression and other mental illnesses may be helpful.
The National Institute of Mental Health in America made a bold statement in 2013. Tom Insel as its director introduced the Research Domain Criteria (RDoC), a new research framework for understanding mental illnesses. RDoC will approach every disorder by understanding the underlying pathophysiology to describe the illness along several domains, instead of using the traditional approach in medicine of grouping symptoms by their clusters, as was practised previously.
This can potentially identify what we call biomarkers - an indicator of an illness which is objectively obtained. Most of us understand that temperature is a biomarker of inflammation and blood pressure is a biomarker of hypertension. This requires careful study and understanding with research into the illness.
There is a crying need for more research, particularly since Singapore has a unique ecosystem - its ethnic mix and a high intensity social environment within the radius of a small microcosm a perfect blend for good long-term studies.
But the culture for participating in research is much to be desired. I often hear patients and their families say, please just treat us and don’t use us as guinea pigs. Indeed, there are ethical considerations for research and patients obviously have the right to say no to taking part in such research.
But without adequate research, there can be no new treatments or innovation.
Finally, there is a difference between the prevalence of depression and those that actually seek treatment. Locally, many studies have indicated that when people have mental illnesses, they may not seek medical help but choose various forms of interventions to help themselves. These could take the form of a religious or traditional healer or someone they trust.
One reason is stigma, a feeling that depression specifically (and mental illnesses in general) is disgraceful and a mark of personal, and even family, weakness. This, coupled with poor understanding of depression and its treatment, will result in a treatment gap.
One way of trying to bridge this gap is to provide different ways of getting help. This may include non-traditional means such as self-help. Online cognitive behavioural treatment has already been shown to have success in this arena. The key is making the delivery of such treatments available and population based.
Talking about depression is a good first step for this year’s World Health Day.
Beyond talking about depression, we need action. We need the people who have suffered and recovered to speak up and share their experiences.
We need to advocate for more research and funding to be channelled to looking at the biological and social interactions that cause and maintain depression.
Finally, we must allow for new evidence-based delivery systems to get people with depression to help.
Perhaps by embracing depression and reducing its stigma, we can also reduce the stigma of all the other mental illnesses and make Singapore a truly inclusive society. Those who suffer from depression deserve a chance to see the darkness lift and receive hope for the future.
Associate Professor Daniel Fung is chairman of the Medical Board at the Institute of Mental Health and a senior consultant with the hospital’s department of child and adolescent psychiatry. He is also the programme director for Response, Early Intervention and Assessment in Community Mental Health (REACH).