Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health Mr. Dainius Pūras

The World Health Day - 7 April 2017

Depression: Let's talk about how we address mental health

On the occasion of World Health Day, I welcome the opportunity to address its theme: depression. 

It is fitting that depression has been chosen as this year's theme. Mental health more broadly has begun to enjoy increasing attention as a new global health priority, now recognized in the 2030 Agenda as a human development imperative.

The human right to health is understood to inclusively guarantee the right to the highest attainable standard of physical and mental health. There can be no health without mental health and everyone is entitled to an environment that promotes health, well-being, and dignity.

As a global community, we have now accepted that people experiencing poor mental health, including depression, should receive treatment and support. There is growing international recognition that increased investment and political attention is necessary to achieve parity between physical and mental health. Concurrently, civil society and other actors are increasingly using a human rights lens to scrutinize legal, policy, and service level responses to mental health.

Millions of people across the globe, from all walks of life, are affected by depression and other mental health conditions and cannot access appropriate treatment or support.  Consensus has been reached that this situation is not acceptable and that this gap must be seriously addressed and reduced. However, hard talk is needed to discuss and decide about the "how" - which interventions should be prioritized.

Evidence and the experience of rights-holders now tells us that the dominant biomedical narrative of depression as a "burden" on individuals and societies is shortsighted and insufficient for developing appropriate responses in policy and in practice. This is a widespread and systemic public health and human rights issue which demands urgent reconsideration of how we invest in mental health and how we manage conditions such as depression.

The right to health includes entitlements to both healthcare services and certain pre-conditions which support mental health—social and underlying determinants. The longstanding biomedical tradition of medicalizing various forms of psychosocial distress and human suffering has cast a long shadow over the importance of addressing the social and underlying determinants of health.  This not only undermines the right to health, it also ignores a rapidly growing evidence base.

For example, there exists compelling evidence that higher prevalence of depression is strongly linked to early childhood adversities, including toxic stress and sexual, physical and emotional child abuse, as well as to inequalities and violence, including gender based inequalities and gender based violence, and many other adverse conditions which people, especially those in vulnerable situations such as poverty or social exclusion, face when their basic needs are not met and their rights are not protected.

Integrating this evidence and securing human rights entitlements requires a new approach that balances population-based interventions with individual care and support.

For example, at the population level, an effective and rights-based approach to address depression requires scaling mental health across policies and services in general health, education, poverty reduction, violence prevention, etc. so that major risk factors are reduced, while protective factors and the resilience of individuals, families and communities is strengthened.

At the individual level, rights-based mental health services must secure a wide range of cost–effective, psychosocial interventions available in the community for anyone who may be facing emotional and social distress.  Importantly, delivering these interventions in most cases does not require psychiatric specialization.  For example, in lower income countries, where a specialized mental health workforce is scarce, cost-effective psychosocial interventions may be provided by general care workers – family doctors, community nurses, home visitors. For a large proportion of people with mild and moderate depression, cost-effective specialized or non-specialized interventions based on human interaction and on talking and listening, starting from "watchful waiting",  may be all that is required and must be understood as frontline treatment interventions.

Regrettably, recent decades have been marked with excessive medicalization of mental health and the overuse of biomedical interventions, including in the treatment of depression and suicide prevention. The biased and selective use of research outcomes has negatively influenced mental health policies and services. Important stakeholders, including the general public, rights holders using mental health services, policymakers, medical students, and medical doctors have been misinformed.  The use of psychotropic medications as the first line treatment for depression and other conditions is, quite simply, unsupported by the evidence. The excessive use of medications and other biomedical interventions, based on a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned.

Biomedical interventions will remain as an important treatment option for severe depression and other mental health conditions.  However, we should not accept that medications and other biomedical interventions be commonly used  to address issues which are closely related  to   social problems, unequal power relationships, violence and other  adversities that determine our social and emotional environment. There is a need of a shift in investments in mental health, from focusing on "chemical imbalances" to focusing on "power imbalances" and inequalities.

"Let us talk" – is a very good slogan chosen for this World Health Day of 2017. People need to talk about their depression, about what they think might be behind feeling sad or happy. Those who make policy decisions need to talk about what went wrong with addressing mental health of individuals and societies, and how things need to be different now. It may be a hard talk – but even more so it is important that we need to talk.