Resumen de La depresión y la salud de nuestros pueblos
- español
Este artículo propone que existe un riesgo atribuible a la depresión vinculado con los problemas más importantes de salud pública. Por lo tanto, si pudiéramos reducir la prevalencia de la depresión, podríamos mejorar en formas muy significativas la salud de nuestros pueblos.
Muchas de las causas de muerte que se podrían evitar se deben a la depresión. Por ejemplo, los estados de ánimo negativos tienen relación con el fumar y con el abuso del alcohol; de las muertes causadas por armas de fuego, 58% son suicidios. Las jovencitas que han sufrido un episodio de depresión mayor presentan más altas probabilidades de tener experiencias sexuales en la adolescencia, más compañeros sexuales; consecuentemente sufren más enfermedades venéreas y con frecuencia son madres adolescentes; los síntomas de depresión también elevan el riesgo de obesidad. Si pudiésemos disminuir el nivel de depresión en el mundo, podríamos reducir significativamente estos problemas, y contribuiríamos no solamente a mejorar la salud mental de nuestros pueblos, sino también la salud en general.
¿De qué manera se podría lograr reducir la depresión en nuestros pueblos? ¿Cómo llegar a los que más nos necesitan con intervenciones que han sido evaluadas en forma empírica, por ejemplo, en estudios aleatorios? Cuando existe una epidemia de este tipo, el tratamiento no es suficiente para reducir la prevalencia. Es necesario dedicar una parte sustancial de nuestros recursos a la prevención para disminuir la incidencia, mejor dicho, el número de casos nuevos.
Se presenta un marco que abarca tres niveles de intervención: la prevención, el tratamiento y el mantenimiento; y seis formas de brindar servicios de salud mental: profesionales licenciados, asistentes de profesionales, voluntarios, compañeros de ayuda mutua, avances tecnológicos de comunicación (que incluyen la radio, la televisión y el Internet), y materiales impresos.
Este marco le permite al profesional de salud mental considerar varias formas de contribuir profesionalmente:
1. Diseñar y proveer los servicios a cada nivel.
2. Vincular a los usuarios con los servicios apropiados.
3. Evaluar la efectividad de los distintos tipos de proveedores de servicio y comparar el costo de cada combinación de nivel de intervención y tipo de proveedor.
Se presentan estudios que demuestran que se puede enseñar a las personas cómo mejorar su estado de ánimo, por ejemplo, usando métodos cognitivo-conductuales. Estos métodos tienen efectos a nivel de tratamiento y de prevención de episodios clínicos de depresión. Los métodos nos ayudan a tallar una realidad personal saludable. Los manuales en español e inglés para enseñar estos métodos en forma preventiva o en forma de tratamiento se hallan disponibles en: http://www.medschool.ucsf.edu/latino/ Se presenta también un programa de estudios por medio de Internet (www.dejardefumar.ucsf.edu) enfocado en la depresión y el dejar de fumar. Los resultados hasta la fecha han alcanzado 26% de abstinencia a los seis meses, cifra comparable con el porcentaje que deja de fumar acudiendo a grupos reunidos con este propósito o empleando el parche de nicotina.
Se sugiere que se establezcan salas Internet en las clínicas de salud pública, en los pueblos alejados de las ciudades latinoamericanas. Con una conexión satelital, se podría hacer llegar cuestionarios de tamizaje a dichas clínicas para identificar a los pacientes que sufren de los problemas de salud más comunes, como depresión, tabaquismo, abuso del alcohol u otras drogas, etc. A los que sufren de estos problemas, se les podrían brindar las intervenciones Internet más avanzadas y evaluadas en estudios aleatorios.
Ya es hora de iniciar el camino que un día nos llevará hacia un mundo sin depresión
- English
This article proposes that depression has a major influence in the health of our communities. The attributable risk of depression on many public health problems is likely to be substantial. If so, reducing the prevalence of depression would produce a significant benefit on the overall health of our world.
For example, of the nine top causes of preventible deaths in the USA, depression is related to the use of tobacco (number one cause of death), alcohol (third), and illicit drugs (ninth); it is a risk factor for harmful eating patterns and activity levels (second greatest causes of death); 50% of deaths due to firearms (seventh cause of death) are suicides; girls with a history of major depression are more likely to engage in sex as teenagers, to have multiple partners, become teenage mothers, and, therefore, are at greater risk for sexually transmitted diseases (eighth cause of death). Determining the attributable risk of depression for these and other major public health problems will be helpful in reducing their burden.
An example of attributable risk is helpful in clarifying this important epidemiological concept. We know that smoking causes lung cancer. But not all cases of lung cancer are due to smoking. If 85% of lung cancers were due to smoking, and if people stopped smoking altogether, then eventually, we would avoid 85% of deaths due to lung cancer. This percentage would be the risk attributable to smoking. Similarly, if the risk attributable to depression is large, by preventing or treating depression we would eventually reduce the number of deaths from public health problems that have a large attributable risk due to depression.
Depression is a highly prevalent disorder. It has been identified as the leading cause of disability worldwide. Taking into account both disability and mortality, it was ranked fourth in terms of producing the greatest burden of disease worldwide in the year 2000, and will reach second place by the year 2020. Because it is so prevalent, treatment is not enough. Learning to prevent depression will be one of the greatest challenges for the health field in the 21st Century.
The scarce number of professionals will be a major obstacle in the provision of adequate treatment and preventive services to our communities. In order to increase our ability to reach as many people as possible, a framework for expanding mental health services is reviewed. This framework consists of three levels of service (prevention, treatment, and maintenance) and six levels of intervention agents: professionals, paraprofessionals (paid health workers who are not licensed to practice independently), partners (volunteers who implement or support the implementation of interventions), peers (individuals who provide mutual help to others suffering from the same risk factors or health problems), paraphernalia (electronic media and other gadgets that can be used to teach interventions techniques or support self-change plans), and print. This framework highlights options beyond traditional services (treatment by professionals) such as the development and implementation of services at each level, creation of screening methods for linking users to appropriate services, and comparative evaluation of effectiveness and cost-effectiveness of each cell when compared to other cells in the framework. For example, professionals could be involved in determining whether an Internet-based depression prevention intervention has greater impact than a depression treatment group conducted by professionals: does the prevention intervention reach more people? How many days of depression-related disability are associated with one or the other service delivery method? Are there specific subgroups in the community that respond better to one or the other method? A table with examples of empirical studies using many of these methods is included in this article.
Evidence is presented regarding the ability to teach methods that will lead to regulate one’s mood and their empirically supported efficacy at both prevention and treatment levels. Manuals designed fot this purpose are available for download in Spanish and English from: http://www.medschool.ucsf.edu/latino/ The approach used in the manuals is based on the idea that people can learn the healthy management of their personal reality by learning to manage their internal (mental) reality with cognitive methods, and their external (physical) reality with behavioral methods (see: http://www.medschool.ucsf.edu/latino/pdf/ healthy_management.pdf).
One of the latest manuals developed, is the “Mothers and Babies Course” that was designed to prevent depression during pregnancy and postpartum. It is important that women be explicitly included in depression prevention programs because the prevalence of depression is twice as high in women as in men, and because the transgenerational trasmission of depression can be exacerbated if the mother is depressed when taking care of very young children.
A research program focused on the role of depression on smoking cessation is presented. A Spanish-language smoking cessation study conducted via surface mail found encouraging results. This approach (“Taking Control of Your Life”) was then adapted to Internet (http://www.stopsmoking.ucsf.edu). A series of studies conducted in Spanish and English have yielded as high as 26% abstinence rates at six months, which are comparable to those found for smoking cessation groups and the nicotine patch. Moreover, over 34,000 Spanish- and English-speaking people from 89 countries have visited our site, and 12,000 have signed consent and taken part in our clinical trials.
This experience suggests that web-based interventions can be effective for major public health problems, and that they can reach large numbers of people worldwide. Therefore we recommend that a systematic effort be undertaken to develop Internet resource rooms that would eventually become routinary part of public health clinics just as pharmacies, by means of which screening programs for the most common health problems should be made available in as many languages as possible. Individuals who screen positive for these problems should be interviewed by their health care providers, and, if appropriate, be “prescribed” evidence-based Internet interventions addressing their problems (such as smoking cessation, depression, pain, and so on). These interventions should be developed using sound and graphics so that reading ability is not necessary to use the websites.
The development of methods to prevent and treat depression and other health problems at a worldwide scale should be made a high priority by international health organizations. It is time we begin to build the road to a world without depression
