World Mental Health Day, which falls each October, was conceived 28 years ago, not so long ago when you consider that the earliest descriptions of depression, for example, appeared 4,000 years ago in Mesopotamia, West Asia. Back then depression was considered a spiritual rather than a physical condition, and was thought to be caused by demonic possession. Instead of doctors, priests were called, and treatments ranged from beatings to physical restraint and starvation in an effort to drive the devil out. Things improved under the Greeks and Romans, who viewed depression through a more sympathetic lens; they believed its root was in the biological and psychological, and adopted therapies that included gymnastics, massage, diet, music, baths, bloodletting and a medication composed of poppy extract and donkey’s milk. While the “medicine” might not hold today, a healthy diet, relaxation and exercise are still seen as effective components of a treatment approach. A Persian doctor, Rhazes (865–925CE), was light years ahead of his time. He believed mental illness had its roots in neurology and advocated a form of behaviour therapy – not unlike today’s cognitive behavioural therapy which helps patients to challenge and change unhelpful thoughts and behaviour, regulate their emotions, and develop coping strategies to solve current problems. The Middle Ages and the Renaissance saw deeply unsympathetic approaches to mental illness. The devils were back, and with them came exorcisms, drowning, burning at the stake, witch hunts – and even executions. Free mental health support amid Covid-19 offered via Mind HK In 1621, Robert Burton outlined the primary causes of depression – lack of occupation and loneliness – in his seminal The Anatomy of Melancholy . “Be not solitary, be not idle,” he urged, and encouraged the use of diet, herbs, exercise, purgatives – to rid the body of toxins – and music therapy in its treatment. The 19th and 20th centuries brought psychoanalysis and Sigmund Freud, who believed that melancholia – depression – was a response to loss, either real (a death) or symbolic (a failure to achieve a goal). My mother, who became ill with clinical depression in the 1970s, would have agreed on the loss front. She was prescribed high doses of imipramine, one of the first drugs to emerge for the treatment of depression, a tricyclic antidepressant (TCA), which helped but was countered by serious side effects that included weight gain, fatigue, and the potential for overdose. When that did not work, Mum was admitted to hospital and subjected to electroconvulsive therapy, or ECT, which, at the time, had connotations of One Flew Over the Cuckoo’s Nest . She tried psychoanalysis, which she found unhelpful. “Raking over the old coals of my childhood, I had a perfectly happy one,” she would protest. We tried many treatments over the years – a cocktail of antidepressants, acupuncture, disastrous nutritional advice when she gave up all her medications and collapsed into a dreadful depression; the nutritionist suggested coffee enemas, which seemed laughable in the face of Mum’s desolation. For those who live with depression – in themselves or in a loved one – it can seem as if treatment is too slow to take effect, to take shape, to come onto the market. But in fact, the treatment of depression has seen great strides even since my mother’s diagnosis 40 years ago. New antidepressants have been developed – and are in development. Because only 40 per cent of patients respond to the first drug they are prescribed, these treatments are constantly being fine-tuned. Recent research suggests a particular protein, GPR56, is involved in the biology of depression and consequent effect of antidepressants. Of the study, Professor Gustavo Turecki of McGill University said: “Identifying new therapeutic strategies is a major challenge, and GPR56 is an excellent target for the development of new treatments of depression.” Mike Shooter, one-time president of the Royal College of Psychiatrists in London, says “the refining of current drugs and the search for new ones proceeds apace”. Shooter himself, though, is much more interested in other factors. “GPs [family physicians] are being encouraged to prescribe things like exercise and social activities, that help in themselves, offer support to those who are miserable, and show them that they are not alone in their distress,” Shooter says. “This is particularly important in the Covid crisis , in which sufferers of existing depression may feel lonely in their misery and the long-term psychological effects of lockdown, unemployment and a general feeling of uselessness are beginning to be appreciated.” Dr Vanessa Wong, a Hong Kong-based psychiatrist, says she is hopeful of other recent interventions. One is neuromodulation, which alters nerve activity by applying an electric charge or chemical agent to stimulate the nervous tissue, such as in vagal nerve stimulation (the vagus nerve monitors our bodily sensations and orchestrates our parasympathetic responses). Another is repetitive transcranial magnetic stimulation (brain stimulation therapy that uses magnets on the scalp to treat serious mental disorders that have failed to respond to medication) and also esketamine nasal spray – recently approved by the United States’ Federal Drug Administration – used in conjunction with an oral antidepressant. Ketamine, known as a party drug, has been used for decades as a safe and effective anaesthetic. But recent clinical evidence suggests it is a powerful treatment for severe depression, post-traumatic stress disorder, or PTSD , and suicidal ideation. Many prominent psychiatrists consider ketamine as fast and effective, with results in a matter of days or hours – rather than the weeks or months it takes for oral medication to kick in. A patient in the US who had battled severe depression for two decades and had been admitted to a psychiatric clinic after a suicide attempt was treated with ketamine through an intravenous drip administered for four hours a day over five days. The patient’s Hamilton depression index score – the measurement used to gauge levels of depression – went from a 36 (out of 50, with anything greater than 23 considered severe) to a zero within a month. The effect lasted for five months. The greatest advances, though, must be in our global attitudes to mental illness. Dr May Lam, a Hong Kong-based specialist in psychiatry, says even the past decade has seen more public awareness of mental illness and that means sufferers are seeking help earlier – and achieving better outcomes. Lam says there is much more engagement between mental health professionals and schools and other sectors. Writer and psychiatrist Linda Gask says: “We have much more evidence now for what works than we did in the past. We know people can be helped – if we can make that treatment available.” With greater awareness, stigma lessens. As Shooter says: “Young men, especially, seem far more willing to express their distress and seek treatment. This is a huge advance, helped by campaigns involving celebrities talking about their own experiences.” Wong says people are increasingly aware that “healthy lifestyle practices such as eating a balanced nutritious diet, having good quality sleep, exercise , stress management and social connections are important aspects of mental health. Meditation and mindfulness practices are also helpful in relieving depressive symptoms and improving overall well-being.” Mental health care has come such a long way, even in the decades since World Mental Health Day was recognised in 1992. People who battle must believe that, and step forward to seek help when they need it.