Can we help more?
Authors: Robin B. Jarrett
Journal: World Psychiatry (2020)

Before you read this essay, you need the benefit of informed consent. Reading it could make you anxious, somewhat uncomfortable, and perhaps a bit provoked – in the sense of activating your intellect and triggering your social conscience. If acceptable, please read on. If possible, ask someone to read this piece to you. Settle in to a relaxed, seated, upright position. If comfortable for you, close your eyes. Clear your mind. Focus on your breath… breathe in and out… breathe deeply. Settle down and get ready to imagine something important to the fields of medicine, psychiatry, behavioral and public health. Imagine that you suffer from a potentially fatal, often chronic, mostly recurrent disease that affects your health, interpersonal relationships, job, finances, and overall well-being, including your ability to identify, think through, and solve problems. Picture several of your family members and friends also suffering with this disease. Realize that 322 million people worldwide live with this disease1. Grasp that this illness is the most significant contributor to non-fatal loss of health worldwide1. Appreciate that annually the disease results in 50 million years of living with disability and contributes to 788 thousand deaths1. Envision that you engage in a treatment for three to four months with about a 50% chance of improving your symptoms and your functioning2. Imagine that, if this treatment worked well for you, the chance that your symptoms would recur is significantly reduced, compared to the alternative treatment most often prescribed to adults with your symptoms3. Note that, in fact, if most of your symptoms are absent (i.e., remitted) for the final six of the 12 to 14 weeks of therapy, then you are not likely to experience a recurrence for about a year4. Is this a treatment that you would seek and want readily available for others (like you) throughout your local community? If you fund research, would you want to understand the parameters of this treatment? If you work in the scientific industry, would you want to know how to “assay” this treatment, learn how to package it? If you are the lead executive of a university technology transfer office, would you be interested in working with a knowledgeable researcher on products with the potential to disseminate this resource? If you are chairperson of the board of a start-up company, would you be seeking investors to brand, market and disseminate this treatment based on what people will really use? If you run a health system, would you want to assure that this treatment was accessible to all your providers and patients? If you are responsible for educating the next generations of clinical providers, would you assure that your graduates could provide this therapy at an optimal level with the ability to personalize it for each individual in need? If you work in global health, would you be looking for technologies to improve access for such treatment? What is this disease? What is this therapy? The disease is major depressive disorder. The depression-specific treatment is cognitive-behavioral therapy (CBT). With your eyes closed, continue to breathe in and out, with repetition, as your visualization may become clearer, perhaps more embellished and full now that you have a context for your images. Appreciate that most depressed adults, especially those who are female or young, prefer psychotherapy to antidepressant medications5. Despite their preference, most adults instead receive prescriptions for those medications6. Not surprisingly, less than half of adults adhere to these prescriptions6. Even fewer adults seek any treatment for depression7. Those who prefer psychotherapy often have difficulty overcoming practical and perceived barriers to accessing CBT and other evidence-based psychotherapies7. As you continue to breathe deeply, understand that, current­ly, the mechanisms through which CBT achieves reductions in depressive symptoms and depressive relapse, and (perhaps) recurrence are not well understood. Consider that one possible mechanism is the extent to which patients comprehend and use the compensatory skills that they learn in therapy8. So, in order to achieve the full effect of CBT you will need to: have the critical skills presented, understand these skills, and use them whenever your mood becomes dysregulated and/or you have a significant problem or re-emergence of the symptoms comprising major depressive disorder. Realize that there are several related forms of CBT that have been shown to prevent relapse after antidepressants or CBT in combination or alone reduce symptoms9. Picture, in your mind's eye, that high quality CBT can be readily available to any person with or at risk for major depressive disorder and related syndromes. How many depressive episodes would be prevented? In doing so, how much human suffering would be alleviated? How much money would health systems and taxpayers save? Would suicides and other deaths be prevented alongside depressive relapse and recurrence, as well as the associated disease burden to families? What would happen if psychiatry, psychology, and related disciplines propelled a world-wide vision to recognize what is known today about psychological treatments that prevent depressive relapse, and ensure that the public (including patients, providers, and public health systems) could benefit? Picture a global vision to create new knowledge about mechanisms, parameters and dissemination that matches what is known and can be learned about effective psychological intervention to prevent first onset, relapse and recurrence using the approach that the people affected want. What if there is also access to such benefits? Suppose that we, as a field, have not only such a vision but, most importantly, also have the will to carry it forward. What are the next critical steps? Count backward in your mind from five to one. Open your eyes. Return to your daily work, perhaps more alert, open, and committed to new opportunities.