Lancet–World Psychiatric Association Commission on depression

A neglected global health crisis

The burden of disability due to depression is highest in young adults and in low and middle-income countries

The burden of disability due to depression is highest in young adults in their second and third decades of life and in low and middle-income countries,¹ said Professor Helen Herrman, Centre for Youth Mental Health, University of Melbourne, Australia. This burden affecting young adults leads to impaired work performance, income, and personal relationships.¹

Yet, the burden of depression in terms of age-adjusted disability life years/100,000 population has remained unchanged over the past 30 years.¹ This contrasts with the appreciable reduction in the global burden of cardiovascular disease over the same time.¹

In high- and low-income countries only 14% and 6% of patients, respectively, receive adequate pharmacotherapy, and 17% and 8% of patients, respectively, receive adequate psychotherapy

Only 52% of patients in high-income countries and 27% in low-income countries have any contact with services, only 14% and 6%, respectively, receive adequate pharmacotherapy, only 17% and 8%, respectively, receive adequate psychotherapy.¹

Interventions are needed at multiple levels to reduce the global burden of depression, said Professor Herrman. These need to address public understanding and political will, to drive prevention at societal and individual levels, and to enable access to effective care.¹

Key messages on diagnosis and management

Each patient needs a personalized management plan that addresses their unique combination of symptoms and experience

Depression is a common, heterogeneous condition associated with a clinically recognizable set of symptoms that cause distress and interfere with normal function in everyday life,¹ said Professor Mario Maj, Department of Psychiatry, University of Campania L Vanvitelli, Naples, Italy. It occurs worldwide with the most prevalent symptoms varying from region to region, reflecting culture and context.²

Every individual with depression has their own unique personal combination of symptoms and experience, so each patient needs a personalized management plan.³ This plan also needs to take into account the clinical stage of the depression, whether it is at an early intervention stage or recurrent and persistent,¹ explained Professor Maj.

Whole-of-society engagement is needed to translate current knowledge into practice and policy

Collaborative care delivery models involving the primary care team, the mental health specialist team, families, lay counsellors and cross-sector providers are advocated by the commission,¹ said Professor Maj. In addition, the commission advocates for increased investment with whole-of-society engagement involving families, schools, workplaces, neighborhoods, and health services, to translate current knowledge into practice and policy and to upgrade the science agenda.¹

Recommendations for action by four primary stakeholders

Prevention and investment strategies are needed to address inequities

Professor Vikram Patel, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, provided an overview of the commission’s recommendations for action to reduce the burden of depression by the four primary stakeholders as follows:¹

• For healthcare practitioners, especially these in primary care — To increase their understanding of the diverse heterogeneous presentations of depression, manage the whole person (not the diagnosis), and to provide personalized care using a collaborative care model
• For policy makers — To respond to the evidence and implement prevention and investment strategies to address inequities across the life course, especially for those in the second and third decades of life

Most people with depression will recover with the right support and treatment

• For researchers — To further investigate the multifactorial causation of depression and who will respond to which treatment to provide evidence for precision medicine management
• For the general community and people with the lived experience of depression — To recognize the importance of seeking help early to increase the chance of recovery and to remain hopeful, because most people with depression will recover with the right support and treatment