Suicide reports affect people everywhere and the impact is widespread. Following the deaths of designer Kate Spade and chef Anthony Bourdain, suicide, suicide prevention and depression are now topics of public interest, prompting everyone to look around and see if someone they know is going through depression.
The challenge is, nobody knows who can have depression. There is a genetic link to the illness – depression is known to run in families – but it is also brought on by low serotonin levels in the brain, deterioration of physical health, and major life events such as changes in relationships or stress at the workplace.
Most people “get the blues” for reasons like a romantic breakup, a kerfuffle at the office, or a death in the family. But these extremely sad feelings or emotions are temporary. It doesn’t work like that for people with depression.
“There are people who can’t get out of this state (of being depressed),” says Malaysian Mental Health Association president Datuk Dr Andrew Mohanraj.
“If someone displays a persistent low mood for two weeks, and shows a loss of interest in pleasurable activities, and displays symptoms like loss of appetite and weight, irritability, feelings of guilt or hopelessness, and the inability to concentrate, these are signs we have to watch out for.
“These are symptoms of clinical depression, which is a psychiatric morbidity that needs to be diagnosed early and treated,” he says.
The 2015 National Morbidity Survey reveals that 1 in 3 Malaysians struggle with mental health issues. That’s a threefold increase from just a decade ago when the figure was only 10.7%.
Depression is the most common form of mental health illness. And while there are clear cut symptoms for depression, which Dr Mohanraj describes as “a silent killer”, these aren’t immediately visible. So, they often go undiagnosed.
A person may see a primary care doctor because they can’t sleep or have psychosomatic symptoms like persistent headaches or backaches. They come away with sedatives to help them sleep, or painkillers and analgesics for pain management. But the root of the problem isn’t diagnosed,” he says.
The issue isn’t a lack of expertise in the medical fraternity but a lack of awareness about the pervasiveness of mental health illness, he adds, and the need to screen for depression when symptoms are present.
The medical profession needs to better address mental wellness, he stresses. Primary care doctors, who Dr Mohanraj calls “the gatekeepers”, must realise their roles in diagnosing mental health illness and redirecting patients to get specialist treatment, just as they would for a heart patient.
“Primary care doctors need to ask more questions,” says the consultant psychiatrist. “They need to probe in order to rule out depression or direct patients to psychiatric care. With early detection, mental health illness can be treated early and we could save lives.”
Mental health illness, specifically depression, is a main cause of suicides worldwide. In Malaysia, there’s been a 60% increase of death by suicide in the last 45 years. The Malaysian Psychiatric Association estimates that seven people attempt suicide every day.
Studies also indicate that 13 out of 100,000 people die from suicide annually, although health professionals believe that figure to be under-representation because many suicides go unreported.
Dr Mohanraj adds, “Severe cases of depression manifest in psychotic symptoms and suicidal thoughts, which may start from having death wishes. Of course, a lot of people have death wishes that don’t translate into active suicidal thoughts or a plan or the actual act.
“There are protective factors that keep people from acting on death wishes, such as cultural or religious factors that see suicide as taboo. But there are those who see suicide as the only way to end their pain.”
An illness, not a defect
One of the biggest challenges in addressing depression is the stigma surrounding mental health illness.
“People see depression as a personality defect rather than a clinical illness,” says Dr Mohanraj. “They view depression as a sign of weakness, or a person behaving badly, and expect them to ‘snap out of it’. But it is a real and serious clinical entity.”
Depression is the second biggest cause of disability worldwide, after cardiovascular disease. In Malaysia, depression is projected to be the leading cause of disability by 2030.
Society needs to view mental health illness like a heart disease or diabetes or even broken bones, because depression is manageable. Treatment, Dr Mohanraj says, is a combination of psycho-social therapy and medication that restores the chemical imbalance which causes the condition.
“Malaysia has very effective medications to restore serotonin levels in the brain, which makes a person with depression feel better. But our mental health treatments extend beyond medication,” he adds.
“For mild cases of depression, you don’t need medication. Bio-psycho-social treatment combines medicines with psycho-social interventions, helping the patient overcome negative thoughts or helping them get out of an environment in which they do not thrive.”
Dr Mohanraj shares one example of a suicidal patient who needed a very different type of intervention.
“He was brought to hospital and treated for depression because he had attempted suicide. He was distressed, disappointed and really wanted to die. He told me that whatever treatment he was on, he would still kill himself because there was no way out of his problem.
“He was in debt and had no way of getting over his financial woes. We engaged Bank Negara, which has a division that helps people restructure loans, and they paid him a visit at the hospital and helped him come up with a plan. That was the intervention he needed.”
Getting everyone on board
Beating depression has to be a concerted effort. People need to seek treatment, but for this to happen we need to change the way we look at mental health conditions. People with depression often fear they will be perceived as weak or, even worse, crazy.
Though cultural and societal norms are changing albeit slowly, Dr Mohanraj believes that everyone from governments to employers to society must act together.
“We need to have a more holistic approach to address mental health issues,” he says. “It’s not just about improving services. A great deal of advocacy must be done. There has to be preventive measures to deal with workplace depression and depression among students. This needs to be done urgently.”
One example, he adds, is that companies and businesses need to pick up on depression among their staff. Depression in the workplace can manifest as absentism, irritability, the inability to focus and low productivity.
“If an employee has repeated medical leave for non-specific complaints, employers need to find out more and intervene,” says Dr Mohanraj. “It will only benefit their workforce and productivity which is their concern anyway.”