Depression is prime cause of disability

THE WORLD is ending the millennium disabled by sadness and facing a growing epidemic of mental disorder, according to a new report.

Depression was the number one cause of disability in the United States last year and the third biggest cause, after heart disease and strokes, in Europe. Worldwide, depression was the leading cause of disability in 1990 among those aged 15 to 44.

It is the first time that the global scale of the suffering caused by depression has been uncovered. As mortality rates have halved over the past century and countries as disparate as Chile and the United Kingdom now enjoy similar life expectancy, attention has switched from the causes of death to causes of disability.

Using a new measure called the DALY (Disability Adjusted Life Year) the World Health Organisation has for the first time ranked diseases according to the restrictions they impose on normal life, rather than on their propensity to cause death. On that basis, depression, which can confine people to their homes in a state of misery, unable to perform normal everyday activities, leaps to the head of the rankings, although it features nowhere in the mortality tables.

David Nabarro, senior project manager with WHO, said depression was universal, affecting peasants in rural China as well as the economically prosperous United Kingdom, and WHO was conducting a multi-centre study to compare levels of depression in different countries.

"Depression has been systematically neglected in international health partly because of the stigma associated with it," he said. "It is becoming clear that, together with injuries, it is a very important cause of disability. I think something has been missed."

Dr Nabarro was speaking at the launch of the annual World Health Report, published by WHO yesterday. The report says that a quarter of the disability suffered by people in high-income countries is attributable to depression and other psychiatric disorders while in low and middle- income countries it accounts for a tenth. "The disease burden resulting from depression is estimated to be increasing both in developing and developed regions," it says.

The report highlights the avoidable burden of death and disease caused by the perils of malaria and tobacco and calls for a "new universalism" to direct limited resources at providing universal access to basic health care, such as immunisation and safer childbirth, rather than in building expensive hospitals, which are used mainly by the better off.

This marks a transformation in WHO's objectives, which only two decades ago spelt out its vision of health as a state of "complete mental and physical wellbeing" to be brought to all people by the end of the millennium.

That has been replaced by an economic realism, which recognises the inevitability of rationing across the globe. Dr Nabarro said: "Rationing is seen as a pejorative term but it is the truth. Choices have to be made."