Depression: The Fault Lies In Classification

The World Health Organization estimates that more than 300 million people across the world are living with depression. “But that does not mean that all the 300 million people would need medical intervention,” says Vikram Patel from Harvard Medical School and the Delhi-based Public Health Foundation of India. The reason: the current binary classification of depression that distinguishes people as either “well” or “sick” is fundamentally flawed. The binary model is “unsuitable” for depression as there is no clear line that differentiates the miseries of daily life from the disorder that can be treated through medical intervention.

Levels of depression

In the absence of a biomarker that neatly distinguishes healthy and depressed people, the binary model relies on symptoms of emotional well-being — feeling miserable, losing interest in things, unable to sleep, idea of self-harm and feeling profoundly fatigued — and assesses the duration and impact of these symptoms to arrive at a diagnosis.

“The binary model uses the answers to a list of questions and then applies a complicated set of rules to arrive at a diagnosis for depression,” says Prof. Patel. “It uses a set of symptoms without recognising that there might be stages through which the symptoms graduate to a full medical disorder.”

In an essay published in PLOS Medicine on April 4, Prof. Patel proposes a continuum of stages to define depression. At one end of the spectrum are people who are well and do not have any distressing emotional experiences. “But many people have depression-like symptoms in reaction to the trials of everyday life, for example when there is the death of a dear one,” he says. A significant proportion of people now diagnosed as suffering from depression have only mild to moderate symptoms and most often do not need clinical intervention. What such people need is advice on how to help themselves recover and support from friends, community-based workers or the Internet.


When to step in

The next stage is when the distressing experience lasts longer — at least two to four weeks — and severely impacts day-to-day social functioning. This condition needs medical intervention — antidepressants, brief psychological treatments or both, though most of this can be provided through primary care physicians and community health workers. At the extreme stage are the recurrent or refractory depressive episodes where patients do not respond to existing treatments or suffer from relapse. “This constitutes only a small fraction and they need to see a psychiatrist or clinical psychologist,” he says.

Since the model of various stages would dramatically reduce the number of people with depressive symptoms who need medical intervention, the focus of specialists can be to treat severe cases.

Staged model in India

There is a body of evidence to show that with appropriate training and supervision, front-line community health workers can effectively deliver psychological treatments for moderately severe to severe depression, such as the Healthy Activity Program, a six- to eight-session treatment; the results of the study were published in December 2016 in The Lancet.

In the VISHRAM (the Vidarbha Stress and Health ProgRAM) programme in 30 villages in the Amravati district in Vidarbha, central India, the staged model was implemented by providing care for mild stages by community agents, while more severe stages were treated by lay counsellors working in collaboration with primary care physicians and visiting psychiatrists. This led to a huge reduction in treatment gap for depression, according to a paper published in January this year in The Lancet Psychiatry.

Following the study, all the 30 villages have a community health worker “who is trained to detect depression, provide low-intensity psychosocial interventions, and refer the patient to the public health system for further management”.

The above article was originally posted in The Hindu, on 8th April, 2017, and was adopted from the blog Science Chronicle.

From The Cosmogasmic Person:

Cases of depression have been increasing since long, and especially among the working class, and teenagers. With the increased competition for jobs, and the pressure for educational institutes, we can no more ignore the effects of depression on the victims, and can no more classify it as just a ‘mood’. Students need to be educated of the ill-effects of a bad mental health, and should be encouraged to talk about their issues. A friendly environment should be set up to facilitate victims to open up, and depression should be a valid reason for someone to take a day or two off just as in the case of other health issues.


Mental health is just as important as physical health. If your brain isn’t fit, all your body functions are affected, it is the control house of your body, and when the guiding system fails, the whole machinery fails too. We recently saw the sad incident of a student, filming his last few minutes on a facebook live video, and then finally jumping off his hotel room. He was depressed. Many people are of the opinion that he was at fault, he was rich, spoilt and a drug-addict. But why does one do drugs? Because they seek comfort. They find a way to escape from reality through drugs, it is an alternative for them, because they don’t talk about their issues. “Everyone is depressed, and if they can deal with it, you can too”, this is not the right response to a victim. Everyone has different endurance levels. Why should not discussing about your issues be a positive thing? We should stop laughing off at ‘small issues’, because these small issues are what build up and end up destroying us. Parents and guardians should not pressurize the children and make them feel that bad marks will destroy their lives, there is a fine line between encouraging and pressurizing. Spot the victims around you, and talk to them, listen to them, and treat them just like other patients. Depression isn’t a joke. Many people are falling in the darkness of this disease, and its high time we take some serious steps to help  people cope with depression. Some of these methods can include adopting pets in educational institutes (studies have shown that interacting with dogs reduces anxiety and depression in students greatly), students should be motivated to have a life beyond the educational boundaries of the colleges and schools, offices should have dedicated group of experts to help the victims, awareness should be made in the society about depression, and failure should be treated as a new learning rather than an end.

PET scans shows how depression makes the brain unhealthy which reduces the performance and activity of the brain(shown as yellow-orange areas).

Please come forward. If you are depressed talk to someone, an expert, a close friend, or a family member, know how you can deal with it. Consult experts for required medicines. Medicine in depression cases should not be viewed as odd, depression is a serious ailment, and requires the assistance of medicine, that intervenes with the brain activity to release chemicals that calm you down and make you feel better. Drugs are not the way out but only a temporary escape. Once again, if you know someone who might be depressed, be the friend they need, we can all bring a change in this scenario if we all want to. Stay Strong, and Happy Reading.

-The Cosmogasmic Person


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