A cross-sectional study on Depression awareness using the D-Lit

Background: We as a society do not discuss about mental health as much as we talk about other diseases. The WHO and NCHM in 2016 had declared India as the most depressed country(6.5%) in the world. 70% of India’s population is the youth and do we wish to leave this legacy behind? “Immunization by Information” is the key to deal with this calamity. The objective of the study was to determine the current level of depression literacy. Methodology: 2,102 subjects comprising of high school students, college students and teachers were assessed with depression literacy scale (D-lit, 2004) designed by Kathy Griffiths. Results: The key findings were: that female subjects had significantly higher depression literacy (MU=9.98, t=7.845, p=0.00) than male subjects. Both college (MU=10.35, t=8.083, p=0.00) as well school students (MU=11.09, F=38.390, p=0.00) from arts stream had the highest depression literacy. The college students obtained the lowest mean percentage score of 41.97% on the Depression literacy scale. It was further noted that the subjects had very poor literacy in psychotic (28.55%) and management (22.75%) aspects of depression. Conclusion: This study acts as a preamble to an awareness model that is to be implemented by the professionals targeting the youth and adults of our society who reflect poor depression literacy. The eyeopening findings of this study substantiate the need of a robust movement of mental health awareness.


INTRODUCTION
Clinical Depression disorder is rampant in India, with a mortality rate only behind diabetes and cardiovascular disease. According to the WHO, India is the most depressed country in the world, with One in Twenty Indians affected by depression [1]. As it turns out, clinical depression can be completely treated and very efficiently managed if individuals have all the correct information about their symptoms and treatment options, and all the myths about depression are clarified. The only immunity against depression is information. We need to deal with it at the mental, emotional, political, legal and socio-cultural levels. The Indian Government has played an important role in destigmatizing and sensitizing the public through its various agencies. An important landmark in the area of mental health is the Mental Healthcare Act, 2017, which was passed by the Rajya Sabha on August 2016 and the Lok Sabha in March 2017 [2]. For the first time in our country, the Act creates a justifiable right to mental healthcare. The right to mental healthcare is the core of the Act and represents the government's attempt to address the neglect of this aspect of healthcare for decades. This remains a drop in the ocean if we do not take away the social stigma and myths around mental disorders.
Ironically, in India, the current rate of Mental Health providers is 1.0 psychiatrists and 1.5 clinical psychologists for every 1,00,000 people (Ministry of Health and Family Welfare, 2017) [3]. This conveys the critical need for more practicing professionals in the field of mental health not only for treatment purposes but also for the establishment of mental health awareness amongst the masses. Author have stated, that personal experiences and anecdotal evidence from family and friends, internet sources, print media, books, cinema, and television are important sources that people acquire knowledge and beliefs about mental health. We as a society underplay our understanding of mental disorders as the stigma attached to it is far more over-bearing. We take an 'ostrich' like approach to it. There are consequences of this poor mental health literacy. First, it may place a limit on the implementation of evidence-based mental health care. Secondly, the task of preventing and helping mental disorders becomes largely confined to mental health professionals [4]. In this era, the human race has become vulnerable to the extremes of stress and is exposed to severe losses, be it economic or social in nature. This has resulted in an increase in the prevalence of disturbed mental health in a developing country like India. The word depression is a part of our everyday language, people use the term to describe the feelings of sadness and have attached their own meaning to it which is far from the clinical picture WHO has described Depression as a common mental disorder, characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks [5]. But as described by Sigmund Freud and Karl Abraham, "depression is a complex reaction to loss" [6]. It is a disorder that is characterized by negative mood (melancholia), cognitive-behavioral changes and even physical issues. It is much more profound and perilous than a feeling of sadness. It includes a spectrum of conditions with episodes, illnesses, and disorders that are often disabling in nature, varies in their severity (from mild to severe) and duration (from months to years) and often exhibits a chronic course that has a relapsing and recurring trajectory over time [7]. Depression literacy is a specific type of mental health literacy and is defined as the ability to recognize depression and make informed decisions about treatment [8]. Research by Jorm and associates [9] mentioned that in spite of significant developments in India's healthcare systems, studies have rarely focused on literacy about mental illness. Depression is a major public health problem in India, contributing to significant morbidity, disability as well as mortality, along with significant socioeconomic losses [10]. The high rates of depression among adolescents and young adults, their low rates of mental health related help-seeking, and evidence that a young person's mental health literacy is associated with their help-seeking practices, highlights the need for examining and improving the depression literacy of the youth. Every section of society possesses distinctive notions and beliefs about mental illness, particularly the young generation. The modern education system, westernization, and industrialization immensely influence this generation by establishing a very peculiar and biased way of perceiving situations, thus educating this group in a realistic method is necessary. The status of mental health awareness is built on the fundamentals of pseudo-knowledge and false information which has exposed the younger generation to poor mental health literacy. In a study by Judith Miti Ogorchukwu and colleagues [10] it was stated that out of 916 the percentage of mental health literacy among the respondents was very low, and depression was identified by only 29.04% of the students. The scenario is quite similar amongst college going students as well, implying that higher education does not necessarily lead to an increase in awareness which should occur in an ideal educational environment. This view supported by a study which concluded the prevalence of poor literacy status among university students [11]. In this regard, teachers who work very closely with society also have an active role in fighting against stigma about mental illnesses. Teachers are frontline professionals who have daily contact with the youth and are therefore most likely to have the biggest impact on their students. Initially, teachers need to be aware of their prejudices and labelling practices against people with mental disorders. A study by Gur and Sener [12] stated that only 16.3%participants could correctly identify and label the depression vignette and just 13.5%recommended professional help from a psychiatrist or psychologist. The young generation is on the frontline of our society and their mind-sets are the future of our country, whereas the teachers are one of the most influential professionals in our society whose beliefs and knowledge shape the norms and minds of the youth.
The core objective of this research is to determine the current level of mental health awareness, focusing on depression literacy with the target audience of high school students, college students and teachers. The research also highlights the existing stigmas attached to clinical depression and seeks to understand beliefs and perspectives related to mental health of the subject sample. It further aims to facilitate professionals to develop a new educational model in order to create a higher level of awareness regarding varied aspects of depression in the population.

METHODOLOGY
A total of 2102 sample size was selected which included 1000 high school students (10th, 11th and 12th grade), 726 undergraduate students from arts and commerce college and 376 school teachers. The subjects varied from 14 different educational institutes of Ahmedabad and Baroda (Gujarat, India). The subjects were to be well versed in either English or Gujarati (local language of the demographic area of the research). The study was conducted from July 2019 to September 2019. Initially, respondents were approached, consent was taken after explaining the study objectives and procedures, inclusion criteria included those students and teachers willing to give informed consent and those who were affiliated to the approached institutes. The focus of this study is to derive knowledge regarding depression literacy among the student and teacher population. The subjects were subsequently assessed with the following:

Depression Literacy Questionnaire (D-Lit)
It is a 22-item questionnaire designed by Kathy Griffiths [13], which was used to gather respondent's knowledge about depression including common symptoms, soliciting ''true'' or ''false'' responses to 22 items. Don't know response is classified as false responses. Each correct response was assigned 1 point and false responses were assigned 0 points, so that the higher the score the higher the respondent's depression health literacy. Its internal consistency is α = 0.70 (n = 40) and test-retest reliability is r = 0.71, p = 0.02 (n = 12). This scale was used in Indian population in English and local language (Gujarati). The study also focuses to aid the professionals in order develop an awareness model for which the items in D-lit questionnaire were categorised and differentiated in accordance to the varied symptoms, impact and management of depression, this model has been adopted from Yasir Arafat and others [11]. This was done to gain more profound and holistic understanding of the population awareness.

Statistical Analysis
The software used was SPSS and the statistical tests used for the computation included Independent Samples T-Test and One-Way ANOVA. The level of statistical significance was kept at p<0.05 for all tests.  Table 1 yielded a significant difference between female and male subject's depression literacy (t = 7.845, p<0.05). It was revealed that the average score of female subjects on the D-lit was 9.89, which was higher than male subjects with their average score of 8.96. This suggests that gender is a variable that influences depression literacy. Similar results have been revealed in another study conducted by Ram and others where female gender had statistically significant higher D-Lit score (p=0.025) than male [14].

RESULTS
There is a link between female and high depression literacy, this could be due to the fact that women are perceived to be more likely to have experience depression and thus are more aware about mental health. A study by Viren Swami concluded that respondents were more likely to indicate that a male vignette did not suffer from a mental health disorder compared to a female vignette [15]. However, it is noted that there isn't a significant difference in depression literacy among Gujarati and English-speaking subjects The following table shows the classification of the items:

Biological Symptoms
Q7-Sleeping too much or too little may be a sign of depression Q8-Eating too much or losing interest in food maybe a sign of depression Similar to the results of Table 1, it was noted that there is a significant difference among male and female students of high school (t =5.817, p<0.05) as well as college (t = 5.058, p<0.05). However, there was no significant difference revealed between male and female teachers. When the sample was bifurcated into high school students, college students and teachers in terms of language, specifically the English and Gujarati medium of education, significant difference was found in both high school (t=4.642, p<0.05) as well as college students (t= -2.401, p<0.05). It was found that high school students pursuing their education from an English medium school had a higher mean score of 10.05 as compared students studying in Guajarati medium school who had a mean score of 9.14. However, it was revealed that college students from Guajarati medium had a significantly higher mean score of 9.74 on the D-Lit as compared to English medium students with a mean score of 9.12. It was further revealed that college students from arts (t=8.083, p<0.05) background had higher depression literacy than commerce students. The results of our study however contradicts with the findings of a study by Arun Dev which stated that for identification of mental health problems students from management were well aware compared to students from other fields which included arts, philosophy and natural sciences [16]. There was significant difference between High school students and college students with regards to their depression literacy (t =2.765, p<0.05). High school students had a higher mean score of 9.46 than college students with a mean score of 9.24. As we know that awareness regarding mental health has increased in recent times with the portrayal of psychological disorders in mass media. Owing to fact that there is a sudden rise in the availability and accessibility of information on the internet and social media, the upcoming generation such as high school students are more curious and aware of aspects concerning mental health compared to the college going students who were not exposed to such information in their times. The score of three groups of high school students from arts, commerce and science stream were tested for significance of depression literacy. A significant difference was obtained between the three groups on ANOVA (F= 38.390, p<0.05) conducted on the D-Lit scores. It was discovered that the mean score of high school students from arts stream on the D-Lit was 11.09 which was higher than that of students from other streams. Science students had lower average score of 9.62 than arts students, however this score was higher than students from commerce stream who had the mean score of 8.89 on the D-Lit. Hence, one can notice that commerce students are least aware about depression as their course does not provide them any knowledge regarding mental health, however in streams such as arts and science which include subjects like psychology and biology where psychological aspects of humankind are taught, enables them to have a broader perspective of mental health. It is shocking to note such disparity of knowledge regarding depression between students from same age group (16-17yrs) and how the course of subjects selected by the students influences depression literacy.  As elucidated in Table 4 the lowest correct response percentage was for statement 17, 16 and 22 that were to do with management of depression. This reflects that the highest stigma is attached to the treatment of depression; pharmacological as well as non-pharmacological.   Table 3 reveals that the sample had least awareness regarding psychotic symptoms (28.55%) and management (22.75%) of depression. The results of this study is similar to the study from which this model is adopted which concluded that only a very small portion of the participants correctly knew about psychotic symptoms and different options for the management (treatment) of depression [11].
It was further analysed that college students had the lowest awareness of psychotic symptoms (23.31%) and management (20.85%). These results are disturbing because 70% of our country's population comprises of youth. The WHO states that clinical depression among many individuals has an early onset during young adulthood(1). Thus, lack of awareness in the youth allows depression to grow into a profound mental health disorder due to the negligence of treating it during its onset.

DISCUSSION
An awareness model has to be developed with regards to the results of this study. As revealed, poor depression literacy is noted in all the three groups, however, the college students are the least aware and their laid-back approach must be tackled progressively, increasing depression literacy as the first step in encouraging youths to seek treatment. As teachers are one of the most important socializing agents in a student's life, thus their understating and clarity of mental health can positively influence the mental health literacy of the students. Hence teachers must be one of the main target groups of workshops and initiatives.
It was further noted that students from the commerce stream had alarmingly low depression literacy as they are not exposed to that sort of discussion in their course, in school as well as college. This issue must be taken care of to establish equanimity amongst all the three streams.
There is a dire need to integrate mental health awareness as part of one core subjects in high school and college. The west has shown the way in doing so. Two of the most popular awareness models in the west are:

The Adolescent Depression Awareness Program [17]
ADAP is a school-based depression education program that educates high school students, teachers, counsellors, and parents about adolescent depression. Multiple teaching modalities are employed with interactive lectures, videos, film assignments, homework, and group activities to reinforce key concepts. The core components include identifying symptoms of depression, understanding the process of medical decision-making, seeing parallels between depression and other medical illnesses, recognizing suicide as a potential consequence of depression, and understanding that depression is a treatable medical illness.

School Peer-to-Peer Awareness Program Addressing Adolescent Depression [18]
Researchers led by Sagar V. Parikh looked at the effectiveness of the Peer-to-Peer Depression Awareness Program (P2P), a school-based program that aims to decrease depression and other mental illness and promote well-being among students. The program, developed by the University of Michigan Depression Centre and the Ann Arbor Public Schools, seeks to improve the school climate around mental health so students feel comfortable talking about mental health and feel it's okay to ask for help if they need it. One unique aspect of the program is that it actively involves students in the design and implementation of the outreach. "Tapping into youth voices is a huge part of the success of the P2P program," the authors note. The forte of this project is its structure that allows a fluid conversation about depression between lay audiences and experts with years of clinical experience in addressing mental issues. Reference material from the WHO regarding clinical depression is provided to all participants, along with an audited list of mental health professionals practicing in Ahmedabad. Yet there is a need to formalize our efforts and classify the general population according to their literacy about depression. The findings of this 2000 plus sample hold importance in designing more such programs to deal with the general ignorance on a grave topic of serious concern.
The study highlighted that teachers and adults are less informed about depression. And High school children had the best understanding of depression. Hence, the internet and social media have played a facilitating role in increasing the understanding of mental health. While teachers continue to live in denial lest they will have to deal with one more challenge in class. The Mental Health Care Act provides persons with mental illness protection from cruel, inhuman and degrading treatment, right to information about their illness and treatment, right to confidentiality of their medical condition and right to access their medical records, to list just a few rights. The government is explicitly made responsible for setting up programs for the promotion of mental health, prevention of mental illness and suicide prevention programs. Given the huge shortage of trained mental health professionals in the country, the Act requires the government to meet internationally accepted norms for the number of mental health professionals within 10 years of passing this law. It has also effectively decriminalized suicide attempts by 'reading down' the power of section 309 of the Indian Penal Code. The findings reflect that we are resorting to the 'denial to control' model and the 'ignorance is bliss' approach to depression which explains the findings of the study. We have been avoiding to bring up this topic of depression as a society and the more we resist the more will persists. We are the most depressed country in the world. The question is that -are we mental health practitioners ready to take a proactive role to immunize through awareness or are we going to wait for it to take a toll like a natural disaster and then respond to it. The choice is within each one of us.

Limitations and Future Directions
The study was an eye-opener and the first step towards opening our doors to education and sensitization of the youth and adults. The way forward -is to design workshops, seminars, talks, programs that work on the educational -awareness model. So that one knows symptoms of depression and is ready to seek help and help others to seek help as one would do for typhoid and diabetes. Our next step is in this direction to create a better model that reflects the notion of "Immunization by Information".