23 Mar 2015
Depression is the commonest mental illness in the world yet only a few can tell you what exactly it is. Most people can well enough to recognise signs and symptoms of heart attack, diabetes, breast cancer and many more medical conditions. This statement is not only true for the general population, medical practitioner are no exclusion.
Many different impression, perception and thought about depression from one person to another person, from one culture to another culture and from one place to another place. For me what is common throughout the world about this mental illness is ignorant. No wonder why John Kirwan, former New Zealand All Black rugby player, now rugby coach, recently said about his depression:
"Beating that was the hardest thing I had to do in my life. I didn't have a clue what was wrong with me, nor did lots of the doctors I saw. I finally found a doctor who really got it, understood. That's what you need. There are so many preconceptions out there about mental illness".
Before I learn this psychiatry module about a year ago, I like many of my friends thought that depression is not so common and it is actually not an illness of any kind. However after knowing that approximately about 20% of women and 12% of men worldwide suffer from depression1, which is higher than prevalence of other common disease such as diabetes where worldwide prevalence is about 2.8% in year 20002, it changes my perspectives on depression. Interestingly even though depression is very common I rarely encounter any patient who was diagnosed with depression during my medical and surgical attachment. I only saw one patient with depression for the whole attachment. This totally contradicts with what I learn where prevalence for depression among patient in hospital is about 10%1.
This makes me think why such a gap occurs between what I learn and what I encounter in a real world. I began to question myself in lots of different ways in order to answer this question. I start looking back to myself first how my perception toward depression before I learn about this mental illness. I was clueless about depression. I used to have perception that depression has the same meaning to sadness. Depression is a normal thing to happen to someone that encounter unfortunate event in their life. I never knew depression is a mental illness that needs to be diagnosed and treated accordingly. I never heard people went to a doctor because they feel their life miserable and I also never heard a doctor prescribing a medication to patient because of depression. That was me before I learn this psychiatry module.
Majority people in my country, Malaysia, have the same perception like me. There never knew that depression is a mental illness where it has specific criteria to diagnose and need to be treated accordingly like other disease. Why it is like this? In my opinion this is very much related to how culture in my country which is eastern culture where a lot of people believe in mysticism. Even though majority of them will seek medical practitioner when they get other physical illness but when it come to the illness related to mood, feeling or behaviour where there is no obvious physical pain, they prefer to go to shaman or spiritual healer. They believe some other spirit are harming and controlling their inner self. Although many of them are Muslim where they shouldn't believe in such away but a very long history of mysticism in that part of the world has made it hard to be washed away from people perception. This is the perception about depression in this part of the world.
Here in Ireland or in the western culture, I find people's perception toward depression is quite different. Many of people here know the depression is part of mental illness. However a lot of them as other place in the world don't know what exactly we called depression as a mental illness. If they do get depression they don't know to whom they should consult, how to deal with it and what the treatment option are available. Not many advertisements about the illness can be found out there in the public. Apart from that depression as other mental illness carry some stigma in the community here. Stigma that there is no cure for the depression, the depressed person will never come back to normal and they are dangerous to public.
It seems clear to me that many factors why people are less likely to seek medical attention when they have depression. As many as two thirds of the people with depression do not realize that they have a treatable illness and do not seek treatment3. Lack of knowledge together with misconception what exactly the depression is unable people to distinguish and determine whether they are having depression or something else. As bad as ignorant about the disease itself, people don't know what to do when they know they have depression. Stigma that surrounding the depression also contribute to this phenomenon. The evidence for this is clearly stated in the conclusion of the research done by Lisa J. Barney et al where they wrote "self- and perceived-stigmatizing responses to help-seeking for depression are prevalent in the community and are associated with reluctance to seek professional help"4.
Then I start to question myself it is only because of the public that do not seek medical treatment that contribute to the under diagnose of depression or there are others factor determine it. When I read an article title Depression over and under diagnosed in primary care4, it make me realise that most GPs have difficulty in diagnosing depression. According to the article "a meta-analysis of more than 50,000 patients has shown that general practitioners (GPs) have great difficulty separating those with and without depression, with substantial numbers of missed and misidentified cases of depression"5. Doctors in the primary care is the first medical person that patient will come and complaint about their depression symptoms. However if most of these doctors fail to recognise and diagnose it, this will bring the number of undiagnosed depression further up.
Why is this happen? Why depression is so common to be unrecognised even by a doctor? I don't know the exact reason but for me may be because of the symptom of depression is a lot and varies from one person to another person make it harder to diagnose. According to the DSM-IV-TR diagnostic criteria for a major depressive episode includes at least 5 of the symptoms which are low mood, anhedonia, significant weight loss, insomnia, loss of energy, psychomotor agitation, feeling worthlessness, low concentration and recurrent thoughts of death for the same 2-week period, representing a change from previous functioning, must include either low mood or anhedonia1.
Apart from this criteria patient also present with atypical presentation where major depressive disorder may not initially present. In primary setting patient with depression often come with symptoms such as fatigue, headache, abdominal discomfort or change in weight1. Patients can become more irritable rather than low mood or sad. Initial symptoms of depression in children is harder to recognise and can be misleading as the children may present with irritability, decline in school performance or social withdrawal1. Misdiagnose depression in patients in primary care will lead to inappropriate treatment and poorer outcomes6.
In term of treatment of depression, I learnt about biopsychosocial approach which is for me is very unique module of treatment. This type of treatment helps to tackle each aspect of the depression including brain pathophysiology, psychological state and social circumstances of the patient. For most patients with mild to moderate depression psychotherapy (cognitive behavioural therapy, interpersonal therapy) is the treatment of choice. However, the combined approach with medication generally provides the patient with the quickest and most sustained response1. Usually, antidepressant medication such as SSRIs is used for severe depression.
In conclusion, learning psychiatry module has change a lot of my perspective toward depression and mental illness generally. It has exposed me to a different and new perception in this topic. Before this I see depression as something that not important to diagnose and treat but now I see depression as a very serious illness that can lead to fatality if left untreated. I will make sure that in the future, I always put depression as part of my differential diagnosis for most medical or surgical cases that I encounter as a doctor.
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