Chapter 7
Depression in modern society
No age, gender, or social group is immune to depression and even when strict criteria are used to define clinical depression it is still a very common human experience. As such it is worthwhile considering the global impact of depression and how major international bodies such as the World Health Organization and World Bank have tried to estimate the real world impact of depression and the economic costs to society. The findings from this work are starting to influence government policies in many countries, as well as encouraging more proactive attempts to tackle depression internationally. Also, this has fostered new thinking on the problem of depression in the workforce, introducing concepts such as ‘mental capital’. One reason that members of the workforce may be reluctant to seek help is because of the stigma associated with depression and it is useful to consider how this may undermine a person’s willingness to access treatment and the lessons to be learned from campaigns that have tried to combat prejudice. Finally, we briefly examine the notion of genius and madness and whether there is any evidence for an association between creativity and mood disorders.
Measuring the global burden of disease
For many decades, the most common measure of the health status of a population was the rate of deaths per 1,000 individuals within a defined area (such as a region or country). However, from the 1980s onwards, it became increasingly obvious that mortality rates are not the most useful way to capture the true extent of the individual, personal, and economic burden that a particular illness places on society. For example, some disorders, although not immediately leading to death, might impair the day-to-day functioning of large numbers of individuals over many years, preventing them from participating in the job market. Also, their illness might significantly impact on family members who then have to take time off from their own employment in order to provide care and support. For this reason, the World Health Organization and World Bank jointly commissioned The Global Burden of Disease Study. The goal of this project was to make a more meaningful assessment of the burden on individuals and society associated with a range of physical and mental disorders and a new measure of health status was created, the Disability Adjusted Life Year (DALY). The idea was that DALYs would reflect the combined effects of the years of health that are lost due to the morbidity (a measure of the ongoing disability connected to a disorder) as well as the mortality (measured by the number of premature deaths) associated with a particular illness in a given population. The work has become extremely well known and publications by the research group have been widely quoted, including one by Murray and Lopez (listed in ‘References and further reading’). The latter publication is especially important because it demonstrated that the health problems placing the greatest burdens on society worldwide are substantially different from the leading causes of death.
Across all regions of the world, six mental health problems were ranked in the top ten most burdensome disorders and together they accounted for 28 per cent of DALYs for all physical and mental disorders across all age groups. As shown in Box 8, when the assessment of burden is restricted only to adults aged 19–45 years living in the developed world (which comprises 75 per cent of the world population), depression was ranked number one, above all other physical and mental disorders (and bipolar disorders ranked sixth). Furthermore, depression was the most important contributor to DALYs in all world regions except Sub-Saharan Africa.
Box 8 The ten leading causes of global burden of disease in adults aged 19–45 years
| Total Disability Adjusted Life Years (DALYs) in millions | % of Total DALYs | |
| All Causes | 472.7 | |
| Unipolar major depression | 50.8 | 10.7 |
| Iron deficiency anaemia | 22.0 | 4.7 |
| Falls | 22.0 | 4.6 |
| Alcohol use | 15.8 | 3.3 |
| Chronic respiratory disorders | 14.7 | 3.1 |
| Bipolar disorders | 14.1 | 3.0 |
| Birth abnormalities | 13.5 | 2.9 |
| Osteoarthritis | 13.3 | 2.8 |
| Schizophrenia | 12.1 | 2.6 |
| Obsessive compulsive disorders | 10.2 | 2.2 |
(Adapted from The Global Burden of Disease by Murray and Lopez, 1996)
The study also explored how the patterns of the burden associated with different disorders would change in the future. One of the amazing findings was that—as we begin to eradicate problems that claim the lives of children in Africa such as malaria—more and more people will survive into early adulthood, which means more and more people are alive at the peak age of onset of depression and bipolar disorders. As such, the prediction for 2020 is that the DALYs lost to depression will rise even further, to 15 per cent of the overall total, placing depression second only to heart disease in terms of worldwide ranking for global disease burden for all age groups across all continents. Furthermore, a recent publication in The Lancet, led by a researcher named Gore, has already indicated that depression is the most burdensome condition worldwide in young people aged less than 25 years (with bipolar disorders ranked fourth).
The reason for examining this information in detail is to emphasize the staggering scale of the impact of depression and also to try to counter any lingering misperception that depression represents a minor ailment or some sort of personality flaw that can be easily dismissed. For far too long depression has been referred to as the ‘common cold of psychiatry’. The Global Burden of Disease study demonstrates that this analogy fails to reflect the reality of the experience of depression in the modern world and is dangerously naive. It is true that, like the common cold, depression is highly prevalent; however, unlike the common cold, depression is not a mild or self-limiting disorder that will somehow disappear from society if we ignore it.
The economics of depression: depression in the workplace
Research has demonstrated that employment may have a protective role against the development of depression in many people, whilst unemployment or socio-economic deprivation may be stress factors that increase rates of depression in others. However, this does not mean that full employment will prevent everyone from getting depressed and international reports highlight that depression can be a significant problem in any workforce. In the United Kingdom, at the turn of this century, the Health and Safety Executive estimated that the number of workdays lost by individuals reporting depression was about twenty-two days per year and that this exceeded the days lost by individuals with other mental or physical disorders (who lost an average of 4–6 workdays per year). Research also indicates that treatment is important and a study from the USA in 2005 showed that those who took the prescribed antidepressant medications had a 20 per cent lower rate of absenteeism than those who did not receive treatment for their depression.
Absence from work is only one half of the depression–employment equation. In recent times, a new concept ‘presenteeism’ has been introduced to try to describe the problem of individuals who are attending their place of work but have reduced efficiency (usually because their functioning is impaired by illness). As might be imagined, presenteeism is a common issue in depression and a study in the USA in 2007 estimated that a depressed person will lose 5–8 hours of productive work every week because the symptoms they experience directly or indirectly impair their ability to complete work-related tasks. For example, depression was associated with reduced productivity (due to lack of concentration, slowed physical and mental functioning, loss of confidence), and impaired social functioning (due to social withdrawal and reduced ability to communicate).
Tensions and problems may arise at work, particularly if colleagues do not understand that the depressed person is under-functioning because of ill health rather than ‘not pulling their weight’. Of course this can sometimes lead to a downward spiral because the depressed individual might not be able to retain their current employment, which can further damage their self-confidence and self-esteem. Not only can this reduce their chances of finding a new job, it can act as a further stress factor in their life and increase the chances that depression will persist or recur. A study from the USA in 2010 reported that individuals with depression are likely to have a 20 per cent reduction in their earning potential and are seven times more likely than the general population to be unemployed; a situation that worsens during economic downturns. According to the Mental Health Economics European Network, depression is the leading cause of long-term disability and early retirement.
Economic cost
In understanding the cost of depression, it is important to realize that the size of the economic burden will depend on how we set the boundaries for defining clinical depression and also what costs are included in the calculation.
The health care costs of treating clinical depression are frequently far greater than for other mental or chronic physical disorders. One of the first studies to compare the costs for different illnesses was undertaken in the England and Wales NHS in 1996. The cost of treating clinical depression was estimated at £887 million which exceeded the combined cost of treating both hypertension (£439 million) and diabetes (£300 million). A more recent Europe-wide study of 466 million people in 28 countries in 2013 demonstrated that depression was the most costly brain disorder in Europe (accounting for 33 per cent of costs for all disorders). The study estimated that at least 21 million Europeans were affected by depression at a total annual cost of €118 billion (corresponding to about €275 per inhabitant).
Health economists do not usually restrict their estimates of the cost of a disorder simply to the funds needed for treatment (i.e. the direct health and social care costs). A comprehensive economic assessment also takes into account the indirect costs. In depression these will include costs associated with employment issues (e.g. absenteeism and presenteeism; sickness benefits), costs incurred by the patient’s family or significant others (e.g. associated with time away from work to care for someone), and costs arising from premature death such as depression-related suicides (so-called mortality costs). When these aspects are all taken into account, a study in the USA in the year 2000 demonstrated that the total costs of depression were about $83 billion each year; a sum that exceeds the costs of the war in Afghanistan from 2001 until 2012.
Studies from around the world consistently demonstrate that the direct health care costs of depression are dwarfed by the indirect costs. For example, out of the $83 billion costs of depression in the USA study, treatment costs constituted less than a third of the total ($26 billion). A study of depression in England in 2005 showed that whilst the total health service costs over six months were about £425 per person, the indirect costs averaged £2,575 per person. Interestingly, absenteeism is usually estimated to be about one-quarter of the costs of presenteeism. For example, in the USA in 2007, the cost of lost productivity due to absenteeism in workers with depression was about $8.3 billion compared to $35.7 billion due to presenteeism. In total, the economic consequences of depression are estimated to be at least 1 per cent of the GDP of Europe.
Mental health and wealth: the concept of mental capital
In the last thirty years, many societies have shifted towards more knowledge- and service-based economies. A number of international groups such as the Foresight government think tank in the United Kingdom and the Trimbos Institute in the Netherlands that have published reports comment that people increasingly work with their heads rather than their hands. The Foresight Report drew attention to the importance of developing both mental capital and mental well-being in the wider population as well as the possible threats posed by changes in working practices that will occur over the next twenty years (see Box 9). For example, the report identified that rates of depression might increase in some individuals because they have difficulties in adapting to new employment demands. The report concluded that how a nation develops its mental capital affects its economic competitiveness and prosperity and its mental well-being, social cohesion, and inclusion. Given that depression is the biggest cause of absenteeism and presenteeism, the work on mental capital extends interest in the global impact of depression beyond its economic cost to its economic significance.
Box 9 What is mental capital?
According to the Foresight Report in the United Kingdom, the term mental capital refers to a person’s cognitive and emotional resources. It combines
It gives a snapshot of how well an individual is able to contribute effectively to society, and also to experience a high personal quality of life.
The report stated that:
the idea of mental capital naturally sparks associations with ideas of financial capital and it is both challenging and natural to think of the mind in this way.
In her thesis on mental capital, the Dutch academic Rifka Weehuizen comments that whilst in the past, physical health was crucial for performance at a job, today, it is mental health. Also, she draws attention to evidence that new types of working practice and the pressure to be ever more productive may actually lead to higher levels of stress and depression and argues that this may explain the ‘happiness paradox’ where increasing numbers of individuals in the leading economies worldwide appear to be more unhappy despite being better off than their predecessors. Weehuizen points out that what drives economic growth is not necessarily good for mental health, but mental health is essential for further growth.
Work in the United Kingdom, the Netherlands, and elsewhere emphasizes the need for governments to develop policies to maximize mental capital and to engage in mental health promotion. It also advocates the need for private and public investment in the mental health of the workforce. This has led to several initiatives such as workplace screening programmes to try and detect depression and schemes offering ‘in-house’ counselling and treatment services. Some initiatives have also been developed to try to raise awareness of depression. These have attempted to increase the uptake of treatment by individuals with depression, but also to increase the knowledge of senior managers about the nature of the problem in the hope of making it easier for individuals to discuss depression without fear of prejudice or stigmatization.
In 2005 in the United Kingdom, Lord Layard, a renowned economist, published The Depression Report which specifically used data about the economic costs and economic significance of depression to successfully argue for investment in the treatment of depression and anxiety to try to reduce the long-term economic burden. Layard estimated that the cost of providing psychological therapies to individuals with depression would be entirely offset by the savings accrued by the Department of Work and Pensions as a result of reduced incapacity benefits payments and gains made by the Exchequer through increased tax revenues (as individuals returned to employment after treatment). He provided data to show that the incapacity benefit paid to an individual with anxiety or depression during the course of one month equated to the cost of providing them with about ten sessions of CBT (estimated at about £750). Although some of the assumptions he employed in making the calculations have been questioned, Layard’s arguments proved to be persuasive and, on the basis of the programme being ‘cost-neutral’, up to 10,000 new therapists have been trained and hired to treat patients with depression and anxiety in primary care in the United Kingdom.
Stigma and depression
One of the by-products of the increasing understanding of the economic cost and global significance of depression is an emerging commitment to providing early treatment. Sadly, history tells us that depression often remains a ‘hidden disability’, because people fear the consequences of disclosure to their employer. For example, in 2009, a survey in the United Kingdom by the Time to Change organization (a group trying to combat stigma) revealed that 92 per cent of the public believed that admitting to having a mental health problem such as depression would damage someone’s career. A study in the USA in 2005 produced similar findings and showed that 25 per cent of people with depression believed that admitting to being depressed also had a negative effect on their friendships.
Fear of rejection by work colleagues or friends is compounded by the fact that many people with depression also believe they will be stigmatized by the health care system. In this century, Anthony Jorm and his colleagues in Australia have repeatedly shown that a major barrier to help-seeking is that individuals with depression feel embarrassed and ashamed to talk about their problems with health professionals and also believe that many professionals will react negatively to them. Similar findings are reported around the globe.
A study in China in 2010 suggested that the overwhelming majority of depressed patients presenting to primary care talked only about their physical symptoms. The researchers commented that the Chinese patients probably suppressed or disguised their psychological problems because of their fear of the powerful stigma attached to depression in their culture. One of the potential consequences of the reluctance of depressed people to present to clinical services or to downplay the mental health elements of their problem is illustrated vividly in the Layard report. This identified that in people with long-term depression (even when the symptoms prevented them from working) less than 50 per cent were receiving effective treatments. Again, this finding has been replicated for cases of depression in the developing as well as in the developed world.
Numerous studies confirm that there is still a social stigma associated with depression. According to the English social psychiatrist Graham Thornicroft, to tackle stigma we need to consider its three key elements, namely: problems of knowledge (ignorance), problems of attitudes (prejudice), and problems of behaviour (discrimination). There have been a number of national campaigns such as ‘Defeat Depression’ in the United Kingdom, ‘beyondblue’ in Australia, and ‘Depression Awareness, Recognition and Treatment’ (DART) in the USA. The programmes all combined attempts to raise awareness in the general public alongside interventions targeting clinicians. Beyondblue also developed an internet website to educate young people about depression and to provide advice about how to access help.
In New Zealand, before embarking on a national campaign of their own, the Ministry of Health carried out a fascinating review of what had or had not proved effective in such campaigns elsewhere. Their report highlights that an 11 per cent improvement in depressive symptoms can be achieved through depression prevention programmes. The benefits of engaging with the media (such as the popular press and television) were more difficult to assess, but it was noted that advertisements featuring high-profile sportsmen and women or well-known celebrities who talked about their experiences of depression did produce some shifts in public attitudes (although this was not found in all countries). The document provided useful insights into the most important elements of a successful anti-stigma campaign (see Box 10).
Box 10 A review of depression campaigns undertaken to inform a public health campaign in New Zealand in 2005
A review of the evidence about how people change their health attitudes and behaviours, and which behaviours lead to better depression outcomes, identified the following knowledge, beliefs, and attitudes that relate to the motivation to act on depression:
The final issue to consider when examining how stigma may affect a person with depression is to also realize that having a depressive episode does not prevent a person from holding negative views about depression that reflect those of their community, culture, or the population at large. Prior to experiencing depression, a person may believe that depression is a sign of personal weakness, etc. This can fuel self-prejudice and lead the person to feel ashamed, to avoid acknowledgement of their problem, and to reject offers of potentially beneficial treatments.
Depression and creativity
The possible link between depression and creativity has been discussed since ancient times and in the 4th century bc Aristotle is said to have commented, ‘Why is it that all men who are outstanding in philosophy, poetry or the arts are melancholics?’ In modern times, Kay Jamison, an eminent researcher in the field of mood disorders, has written extensively on this topic and has published a book entitled Touched with Fire. Notably, Jamison makes the point that although some people romanticize and exaggerate the links between artists, composers, or writers and mood disorders, it would be wrong to dismiss out of hand this potentially positive aspect of mental disorders.
The roll call of creative artists throughout history who are reported to have experienced periods of depression or bipolar disorders is long and impressive. For example, poets and writers include William Blake, Lord Byron, John Keats, Robert Lowell, Sylvia Plath, Edgar Allan Poe, Mary Shelley, Robert Louis Stevenson, Leo Tolstoy, Mark Twain, and Virginia Woolf; artists include Michelangelo, Edvard Munch, Georgia O’Keeffe, Vincent van Gogh; and musicians range from Mozart, Handel, and Schumann to Charlie Mingus. The possible links between creativity and mood disorders have led a number of researchers to try to study the links, such as Joseph Schildkraut of Harvard, who tried to piece together the personal histories of mental health problems in a group of American painters known as the New York School of Abstract Expressionists. The study, called Creativity’s Melancholy Canvas, was published in the American Journal of Psychiatry and showed that between six and eight of the fifteen artists probably had a history of depression or manic depression. Some also used drugs or drank alcohol to excess at the same time. Also, four of the group died prematurely. Gorky and Rothko committed suicide, whilst Jackson Pollock and David Smith died whilst driving cars recklessly (which some observers hypothesized might indicate suicidal intent).
Small-scale studies, whilst intriguing, do not offer proof of a robust link between creativity and depression. To do a scientific study of the association between creativity and depression, we would first need to define creativity (e.g. the dictionary refers to ‘creative ability, resulting from originality of thought or expression’). We would then have to find a way to select a sample of creative people, and to use established criteria for recognizing depression or bipolar disorders in order to assess what proportion of the creative sample had experienced a mood disorder. Finally, to truly understand whether the rates of mood disorder are increased in our creative sample, we would also need to recruit a control group. For example, members of the general population who are not regarded as creative (but who ideally have the same average age, similar educational experiences, and show the same gender distribution as the creative group). Interestingly, there are published studies that apply some of these methods and try to answer the question ‘do mood disorders occur in creative people more often than we would expect by chance?’
Two of the best-known studies on creativity and mood disorders were undertaken in the USA by Nancy Andreasen in the 1980s and Arnold Ludwig in the 1990s. Andreasen studied thirty writers (both male and female) and thirty control subjects (matched according to age and gender). Ludwig’s study compared fifty-nine female writers (who were all attending the same conference) and fifty-nine female ‘non-writers’ in a matched control group. Although the size of these two studies is relatively small, they both showed that about 20–50 per cent of the writers surveyed had some form of mood disorder. Furthermore, depression was three times more likely and bipolar disorders were four times more likely to occur in writers than in the comparison groups. Andreasen also noted that the families of the writers had more relatives who were creative and had a history of mood disorders.
What we do not learn from these studies is whether the same factors that may make some people vulnerable to developing a mood disorder also predict that a person will be more creative than the average person. To explore this scientists have tried to determine what the most likely components are that would enable someone to be more creative and then to see if these are also characteristics of people who experience mood disorders. According to Goodwin and Jamison’s textbook on Manic-Depressive Illness, the most common overlapping factors found in creativity and mood disorders are temperament (or personality style), thinking style (cognitive factors), and cyclical changes in mood. For example, when someone is hypomanic, their thinking may be speeded up and they may start to make more frequent and far-reaching links between different ideas, they may show a degree of disinhibition (meaning they may become more aware of things in their environment), and they have more energy and less need for sleep. All these things occurring together could allow someone to achieve a higher level of creativity than other people. Whilst it is easy to see how the experience of hypomania could facilitate creativity, it is less clear how the experience of depression can be helpful and it is widely reported that some literary figures, such as Virginia Woolf, were unable to write when they were depressed. Interestingly, this does not appear to be a universal experience and one survey of writers reported that 30 per cent noted that their mood actually worsened in the time immediately preceding a period of increased creativity. What most artists and writers seemed to acknowledge is that it is the depth and intensity of their feelings and moods that are important in helping them extend their creativity beyond their innate level. As Kay Jamison observes, it seems that the experience of depression or hypomania ‘can allow for certain insights or changes in energy levels that may further enhance the creativity of naturally creative people’.
The next issue to consider is whether more severe episodes of mood disorders are associated with more creativity or if they render people unable to express their creativity. Sadly, writings over many centuries suggest that the latter is more often the case. For example, even during the Renaissance, there was a distinction made between ‘sane melancholics’ who were high achievers and those with an insanity that prevented them using their creative talents. It seems that when people are severely depressed their physical and mental activity may be so slowed down that they are unable to write, paint, or compose, In contrast, a severe manic episode may render an individual so chaotic that their creative ideas are so disorganized as to be incomprehensible.
The information we have described may mean that moderate but not extreme periods of mood disturbance can facilitate the creative process. As such, it is also important to try to determine if treatment is a help or a hindrance to creative people. A study of Irish and British writers by Kay Jamison found that a significant number had been treated for their mood problems and that more had been to therapy than taken medication. This tends to support the notion that writers and artists worry that medications may impair the creative process. To examine this, Morgen Schou (a psychiatrist who is famous for his influential role in introducing lithium into day-to-day treatment) undertook a small study of twenty-four artists and writers and compared their creative output before and after they were prescribed lithium in the late 1970s. His study found that twelve individuals (50 per cent) actually reported increased productivity, whilst a further six individuals reported no change. The other six individuals (25 per cent) reported that lithium treatment decreased their creativity to the extent that four of them declined to carry on taking it. Obviously, such a small study cannot provide a definitive answer, but it is interesting that treatment did not undermine the creative processes of the majority.
To summarize what is known to date, we can say that the majority of people with a mood disorder are not more creative than their peers. Furthermore, most creative people do not have a mood disorder. However, in those creative individuals who do have mood disorders, some of the symptoms of the disorder, such as intense emotional states and changes in thinking processes, may raise their creativity to a new level. We will leave you to decide whether Figure 11 is an accurate representation of what treatment has to offer these individuals.
11. More lithium.