By Invitation

An enigma of sadness and fear

Depression afflicts many people worldwide and to mark World Health Day on Friday, the World Health Organisation wants people to talk more openly about this disorder which, as the writer explains, is treatable.


You have always thought of yourself as fairly resilient, fairly strong and able to cope with all the general hassles and vicissitudes of life. And then one day - but you can't quite recall when exactly because it started so insidiously - there was a subtle change in how you feel: Things that you'd enjoyed didn't seem that enjoyable, that zest that you had had evaporated.

There were times when you were seized by an inexplicable panic and anxiety. And later, everything began to seem like such an enormous, overwhelming effort that it was almost unthinkable that you could get through all that minutiae of daily existence - not that you cared very much; you just wanted to lie on the bed and not get up but sleep evaded you and you felt awash with this lingering restive exhaustion.

You found yourself doing less, going outside less, interacting with other people less, eating less: The smell and taste of food nauseated you and your weight started to slide. You couldn't shake off that oppressive sense of gloom and dread which was like a carapace where nothing good could get in - not even the concerns and exhortations of your bewildered loved ones.

It was such a torture that you wished not to wake from whatever little sleep you managed; and your thoughts turned to death - first of wanting to be dead, then of wanting to die, and finally of wanting to kill yourself, and you fantasised about the various ways to do it.

But you couldn't quite articulate nor describe that pain and distress you felt which made it all the more lonely and alienating. The American author William Styron wrote that if such distress "were readily describable most of the countless sufferers from this ancient affliction would have been able to confidently depict for their friends and loved ones (even their physicians) some of the actual dimensions of their torment, and perhaps elicit a comprehension that has been generally lacking; such incomprehension has usually been due not to a failure of sympathy but to the basic inability of healthy people to imagine a form of torment so alien to every experience".


That "ancient affliction" that Styron was referring to - and which he himself had suffered terribly later in life - is depression. More than two millennia ago, the Greek physician Hippocrates had observed an illness that afflicted his patients and the symptoms he described remain to this day the quintessential features of depression: "sadness, anxiety, moral dejection, tendency to suicide, aversion to food, despondency, sleeplessness, irritability and restlessness, accompanied by prolonged fear".


In so many aspects, depression as a disorder remains very much an enigma - so complex is the interplay of multiple factors, including genetic vulnerability, early childhood experiences, abnormal brain chemistry, personality, and precipitating and aggravating external stressors in various permutations.

As a psychiatrist, I've seen depression happening to some people after a very minor environmental trigger; while others who aren't that vulnerable require a really major and disastrous life event to plunge them into depression; still others would develop depression without any obvious external cause - just as there is no such thing as an average person, no two patients are identical in the aetiology and manifestation of their misery.

One of the greatest fears that my psychiatrist colleagues and I have is of suicide in our patients with depression. Our fear is always that those patients who in the grip of intolerable anguish can see no way out, and will not allow themselves the option of any help that can pull them away from that abyss. They often feel that family and friends will be better off without them and so they believe that their death will remove a burden from those who care for them - when, in fact, the opposite is true. What is saddening about such deaths is that they are preventable if these individuals had given themselves more time, and sought and received the proper psychiatric care or hospitalisation.


In the 2010 Singapore Mental Health Study (SMHS), we found that six out of a hundred adults in the general population had suffered from major depression at some point in their life; of whom 43 per cent had suicidal thoughts and 12 per cent had actually attempted suicide. Six out of 10 of those with major depression had never sought help - which is deeply troubling as this is an extremely treatable illness with an available array of proven medications and psychological treatments.

Reasons for this gap in treatment likely include a lack of awareness that these distressing and debilitating symptoms are indicative of an illness and, of course, the fear of stigma.

Following the 2010 SMHS, we did a subsequent study that examined the level of mental health literacy among the general population of Singapore. Of those who were presented with a vignette of a person with severe depressive symptoms, only half could correctly identify it as a depressive disorder; the majority see the person as "weak" rather than sick - and the corollary to this is that the person in question could get better by exercising some willpower and, if not, the person is perceived as lacking in fortitude and resilience.

These findings were consistent with an Australian study that found that one in four members of the public thought depression was a sign of weakness, and they further said that they would not employ a person with depression; around a third would not vote for a politician who had depression, and one in five said if they had depression they would keep it to themselves.


Worldwide, there are about 350 million people of all ages, all walks of life, all races, creeds and classes, who suffer from depression. Other than the individual personal costs, the societal impact of depression stems from its relative pervasiveness among the population; from its early onset (typically starting in adolescence or early adult life) coupled with its recurrent nature; to its multifarious impairments - which often lead to a loss of productivity, a poor quality of life, and even premature death.

So it seems quite fitting that the theme of this year's World Health Day - a day which commemorates the founding of the World Health Organisation which falls on April 7 - is Depression: Let's Talk.

And it's certainly important to continue to talk about depression - and at all times and in different settings. But we should understand that for those who suffer from depression, it is difficult to talk about something that's so deeply personal and carries with it the risk of exposing something about themselves that they don't necessarily want others to know about. Neither do they want to be talked about in whispers or judged behind their backs, or discriminated against.

We must be realistic about the enduring power of stigma that clings so tenaciously to mental health issues, but we should continue to face it down with a concerted political, social, medical effort and media will .

One of the most important places where alleviating stigma is much needed is the workplace - where most of us spend a significant part of our lives and where we feel useful. We have no laws here in Singapore that protect people with serious health problems (including depression) from being discriminated against by employers, unlike countries such as the US and Britain where employers are legally obligated to provide "reasonable" accommodations to support employees with mental health issues who can perform the essential function of the job.

I often have patients asking if they should disclose their illness to their employers. It's a tough call to make as it is potentially risky. It very much depends on what the patients hope to accomplish with such a disclosure - be it to ask for some adjustments to the working hours because the medications that I'd prescribed are making them drowsy; or their need to take a period of leave because they are still not well enough to cope with their work; or because they have been hauled up for not performing well and are in danger of being sacked. The culture at the workplace is also important: Some workplaces are more understanding and supportive than others. And I would also caution my patients that they would have to be prepared for any gossip about them.

Employers ought to be aware of the business case in investing in interventions that address depression in the workplace: Research has shown that such efforts reduce employee absenteeism, increase productivity and improve their bottom line.

But most employers would not know how to do this and would need expert help - such as that rendered by The Partnership for Workplace Mental Health, a programme of the American Psychiatric Foundation Association that helps employers look for strategies to address mental health issues and reduce stigma.

In January this year, British Prime Minister Theresa May described mental illness as having been for too long "a hidden injustice in our country, shrouded in a completely unacceptable stigma and dangerously disregarded as a secondary issue to physical health". She noted that if left unaddressed, mental illness "destroys lives, it separates people from each other and deepens the divisions within our society", and she announced that her government would take action to tackle the stigma attached to mental health problems.

Addressing the unmet needs of people with depression and other mental health problems is crucial, not only for decreasing disability and suicides, and increasing productivity, but it is also a moral and humanitarian imperative which - in Mrs May's words - "goes right to the heart of our humanity; to the heart of the kind of country we are, the values we share, the attitudes we hold and our determination to come together and support each other".

  • The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.

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A version of this article appeared in the print edition of The Straits Times on April 04, 2017, with the headline An enigma of sadness and fear. Subscribe