Background and Main Ideas

Recession, health and mental health

Evidence supporting the association of economic insecurity with both psychological distress and health services use is strong, as is the evidence supporting the association of economic insecurity with MDD and suicide (1). Recent data from 29 European countries suggest a strong correlation between suicide rates and economic indices in men but only a correlation with unemployment in women (2). Meta-analyses of longitudinal studies concluded that unemployment is not only correlated to psychological distress and depression but is also a cause of it (3). Economic crisis variably affects specific vulnerable groups, with women being probably more exposed to the consequences of a crisis, although official unemployment rates are usually higher for men, even though the rate of job loss is usually higher for women (4).

The impact of the current social and financial crisis upon health and mental health in Greece

Conducting a nationwide prospective telephone survey in Greece, Economou et al (5) found that the one-month prevalence of MDD increased from 3.3% in 2008 to 8.2% in 2011, and a significant association was identified between MDD and economic hardship. Preliminary data suggest an increase in suicides in Greece during the current crisis (6). There are signs that health outcomes have worsened, especially in vulnerable groups (7) [70], and a recent systematic review showed that this trend was greater in patients with LTCs (8). Preliminary findings of our research team showed a link between greater perceived impact of the current recession and MDD and suicidality in patients with LTCs seeking urgent care in our hospital’s Accident and Emergency Department (AED) (9,10).

Psychological morbidity in long term conditions

Studies of the Scientific Supervisor [53,55,56,61,66,74,87] and of colleagues participating in our research team have shown that a quarter of all patients with LTCs have co-existing anxiety and depression which are associated with increased health service utilisation (11,12) and poorer health outcomes (13). We have also shown that the prevalence of MDD in Greek patients with rheumatologic disorders attending a follow-up clinic is estimated at 25.4% [53], while the prevalence of MDD in patients with LTCs attending our AED was 28.0% [87]. These findings indicate that patients with LTCs tend to be vulnerable to MDD, but whether this vulnerability and its association with the current crisis varies across subgroups of patients remains to be established.

Psychological morbidity and impaired health

Patients with LTCs and associated psychological problems have a range of unmet needs. In diabetes, depression is associated with more diabetes-related complications, impaired physical and mental health status and more emergency department visits (14). We have previously found that several psychological parameters are associated with delayed engagement to treatment in diabetes [14] and that depression is strongly independently associated with more severe self-reported dyspnoea in COPD [52]. Frequent scheduled care is associated with marked worry about the illness, fears that treatment will be ineffective and impaired coping (15). Our recent findings have also shown that illness perceptions of patients with LTCs are associated with frequent unscheduled care (16) and qualitative studies have demonstrated overwhelming anxiety at times of crisis leading to use of unscheduled care (17). A multivariable model is required to address the specific crisis-linked factors associated with the development of MDD in this patient group and to identify the most vulnerable to the rising social and income inequalities patients. A multimodal intervention targeting risk factors and enhancing resilience to MDD is also warranted to meet the patients’ unmet needs, if we are to maintain and improve their health status and well being during the current crisis in Greece.

Risk and resilience factors for Major Depressive Disorder

A number of factors have been found to increase the risk for MDD or to enhance resilience to MDD and high consensus indicates that vulnerability to depression has been linked to the interaction among genetic predisposition, stressful life events and psychosocial parameters including personality traits (18-20). Convergent evidence poses the contributory role of genes in MDD but their mechanism of action has not yet clearly defined (20-23). Our previous findings have shown that gene polymorphisms combined with personality traits act as risk factors to the development of mental illness [68,79]; inclusion of non-genetic variables and their link to the genetic background is considered fundamental in the study of mental disorder development, including MDD.

A great amount of clinical and preclinical evidence have shown that serotonergic (5-HT) neurotransmission, hypothalamico-adrenal axis (HPA) function and neurotrophins or heat shock proteins (HSPs), dedicated to housekeeping genes and stress-induced cellular activities, are implicated in regulation of mood, reactivity to psychological stress, self-control, motivation, drive, and cognitive performance (19,22,24-26). Genetic studies have hypothesized that a proportion of the risk of MDD is due to polymorphisms within genes related to the 5-HT neurotransmission, the HPA function and BDNF or HSPs expression (27-28).

On the other hand, a number of psychosocial and personality factors are considered to promote resilience to or increase the risk for MDD, including positive emotions and active coping style, humour and optimism, cognitive flexibility and events with positive meaning (29). People and elderly patients who deal with religious activities and spirituality have more positive attitude towards illness and fewer depressive symptoms (30). Enhanced social support has been also associated with low levels of depression and stress, especially in patients with LTCs such as rheumatoid arthritis, cardiac illness, or cancer and comorbid depression (29). Lower socio-economic status (31), female sex (32), ceasing to cohabit with a partner (31), childhood trauma (33) and alcohol use/abuse (34) have been also associated with increased risk for MDD. Moreover, our previous research showed that adverse illness perceptions are also associated with depression and health outcomes in medical illness [56,67,81], and that the role of the patients' coping with stressors capacities and sense of coherence (SOC) should not be underestimated with regard to its contribution to depression development/alleviation [21,50,89].

No studies, however, have investigated which resilience/risk factors are of particular importance during a social and financial crisis and whether a biological and/or psychosocial element acts as mediator or moderator in MDD development/alleviation in high-risk populations such as people with LTCs with medium (routine care) or high (urgent care) levels of illness-related stress in a high-risk environment, such as the current Greek recession. Therefore, we plan to investigate a set of polymorphisms, including 5-HT1A and 5-HT2A receptors, 5HTT, MAOA, COMT; CRH1 (corticotropin releasing hormone) and GR (glycocorticoid) receptors, BDNF and HSP70/HSP90 genes, and to test their interactions with psychosocial factors in promoting or preventing MDD development during the current Greek recession in the above mentioned samples.

Improving Quality of Care

The US Preventive Services Task Force has recommended that there is evidence for the efficacy of integrated care for depression in medical illness, when screening is coupled with system changes that help ensure adequate treatment and follow-up for depression (35,36). It is reasonable to assume that this is particularly true when people with LTCs experience additional difficulties during recession times. Furthermore, the following documents highlight the need to detect and treat psychosocial problems in physical disease: NICE Clinical Guideline 15 Type I Diabetes; NICE Clinical Guideline 12 COPD; DOH Report on Psychological Therapies 2004; NICE guidelines on “treatment of depression in people with chronic physical health problems” 2008. In addition, Edward (37) pointed out that resilience can be improved through low intensity interventions aiming to enhance the patient's self-righting and self-management factors in the context of comorbid mental and chronic medical conditions.