Mental health assignment (2)

Mental
Health:
Depression
A Critical Essay
WindowsUser

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MENTAL ILLNESS: DEPRESSION
The objective of this essay is to critically discuss and analyse mental health
services provided in both primary and secondary systems. Also, the facts,
problems, considerations, theories and practices will be discussed here. The
pathways of care and intervention options are also included. The context will
be including many different aspects such as ethical considerations, social,
stigma, the care and environment these people need etc as well. As the
World Health Organization states that the mental health is regarded as a
state of well-being in which a person is capable to get along with the day to
day stresses of life and can manage to work with productivity and creativity
and can contribute in the welfare of the society. (World Health Organization,
2018). Depression is one of the highlighted topic that is discussed by WHO.
WHO has introduced a programme for the issue of depression named as
“WHO’s mental health gap action programme (mhGAP). This programme
aims to treat people with mental, neurological and substance abuse
disorders with the contribution of people that are not specialist in mental
health services. (World Health Organization, 2018). According to a study,
depression is one of the most predominant disorder in the world, followed by
anxiety, schizophrenia, bipolar disorder. (Vos,Barber et.al,2013). According
to another source, in the year 2014 the people showing depression or
anxiety was 19.7% aged 16 year or older in the UK. This figure was 15%
increase from the year 2013. These statistics were higher in females
(22.5%) than in males (16.8%). (Evans,Macrory et.al 2016).
Primary healthcare is all about providing “essential care”. Mental health
services in primary healthcare includes Diagnosis, Management and
Prevention of the mental disorder (What is primary care mental health?
WHO and Wonca Working Party on Mental Health, 2008). This is new form of
healthcare introduced by World Health Organization (WHO), which involves
the first line of treatment given to the patients. This type of healthcare is
provided by primary healthcare workers who are able and skilled to provide
mental health services. Primary healthcare requires on time diagnosis of the
issue, timely management of the chronic illness. It requires team work for
the better management of the problem which involves the contribution and
understanding of a patient, extended primary healthcare team and local
community support networks and providers. (Guidance for commissioners of

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primary mental health care services, 2012). Many policies are made and are
being implemented for the clinical commissioning groups that will lead to
betterment of the provision of mental healthcare to the people. These
policies include:
 The care provided to the patient should be as close to the patient’s
home as possible.
 Special consideration should be given to what the patient feels and
thinks for a particular management or issue.
 The patients and their caretakers’ preference are to get treated in
primary health care setup because they or their illness won’t be
highlighted in a primary health care setup among people and they
won’t fell any disgrace due to their condition. (HM Government (2011).
In UK, the overall yearly expenditure on NHS for primary mental healthcare
was £109 billion in 2009.Out of this 8% is allocated for primary health care
services (Goodwin et.al 2011) and around 12% was reserved for secondary
and tertiary mental health care services. In England, most people with
mental health disorder don’t receive any treatment except for the patients of
psychosis. (Guidance for commissioners of primary mental health care
services, 2012)
When the situation cannot be handled by a primary health care worker then
the patient is referred to secondary health care services. Secondary health
care services include general hospital services. They treat people with severe
and weakening mental health issue. These types of diseases can be severe
or chronic depression, self-harm or suicidal thoughts, bipolar disorder,
severe anxiety, drug or alcohol misuse. Secondary mental health care
services are also provided for the patients of psychosis, or those who feel
some events differently like hallucinations, delusions or flight of ideas.
(Humberews.co.uk, 2018). In England, the NHS serves both primary,
secondary and tertiary services along with psychological therapy

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services(IAPT). Primary care services include mostly General Practitioners
consultations and prescription. The secondary healthcare services include
community services, acute illness, crisis and rehabilitation services. (NHS,
2017). Most of the secondary health services are provided by NHS trusts and
foundation trusts. There were 55 mental health trusts at the end of 2016, as
stated in the report by NHS CONFIDERATION. (NHS,2017). There were
1,217,879 people of working age in contact with mental health services in
England, at the end of 2016. Whereas, the NHS digital’s monthly figures
show that there were 252,987 less people in contact with mental health
services at the same time in 2015. There were 1,825,905 people in contact
with secondary mental health services by the end of September 2016.
Moreover, 5.6% of the people were admitted to the hospital and being
treated there.
Table: population receiving secondary health services in the year 2015/2016
(age wise)

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Age People in contact
with services
Percent of
population in contact
with services
Total 1,825,905 3.4%
15 or under 13,631 0.2%
16-17 22,042 1.7%
18-19 54,564 4.0%
20-29 283,524 3.8%
30-39 253,607 3.6%
40-49 264,411 3.5%
50-59 223,015 3.2%
60-69 153,259 2.5%
70-79 200,893 5.0%
80-89 271,786 13.2%
90 or older 85,172 20.0%
Table 1 shows us the population that received secondary mental health
services in the year 2015 to 2016 classified according to age. It is Evident
from the data that the people of the age group 20-29 received the services
most, accounting 283,524. This is followed by the age group 80-89 years old
which accounts 271,786 people. (NHS, 2017)
Currently, there is no standardized model of primary mental health care
service in the UK. The primary mental health care system is not working up
to the mark which is evident from some of the facts.
The interface between primary-secondary mental health services don’t fulfil
the criteria which results in slowing down of the access to the healthcare,
the difference between the people facing the illness and the number being

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treated, difficulties in receiving care, gaps in services being provided. There
is a difference in the number of people being diagnosed with problem and
the people receiving proper management which shows the systemic
weakness for assigning particular pathway of care for a specific patient.
There is inconsistency in patient being properly assessed, diagnosed with the
disease and the treatment being given. There is lack of knowledge that how
collective care works, people are unaware of responsibilities of specialists
working in primary health care system and they don’t understand the
interface between psychiatrist and general practitioner. Many patients get
good consultations with the general practitioners but sometimes they are not
diagnosed properly and that many people don’t get proper explanation of
their diagnosis and treatment. Sometimes patients overuse the drugs
because of no alternate drugs are provided when they should be given.
Majority people feel it useless to receive primary mental healthcare because
they think they are wasting their time and money. There is a difference of
view between the general practitioner and the patient. The patient wants to
be listened and they want a personalized treatment plan for themselves and
the general practitioner uses the techniques that are suitable for everyone.
General practitioner lacks the confidence to provide better services. As a
result the patient has to be seen in specialist out-patient clinics.{Guidance
for commissioners of primary mental health care services. (2012)}
Providing a good healthcare to patient means that keeping the patient’s
interest at first so that healthcare services are easily accessible to them. A
good health care system should include the following points:
 All the treatment being provided to the patients should be evidence
based as stated in NICE guidelines.
 Every patient should have a different and customised treatment plan
according to his/her needs. They should be given their time to talk, to
be listened and should engaged in every decision.

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 Mental Healthcare services should be provided on the basis of their
needs.
 Proper and on time health care services should be given to the people
so that mental illness that is preventive in its early years doesn’t
intensify.
 The personnel should be well trained and educated enough to handle
such patients and deal with the illness.
 There should be easy accessibility of care and should be treated on
time rather than waiting for the situation to get worse.
 The healthcare systems should have sufficient capacity to treat large
number of patients having different mental illnesses.
 The treatment being carried out should be systemic and be
continuously monitored through a set of measures designed according
to the patient’s problems. For the patients with anxiety or depression
disorder this can be easily achieved as the condition of patient is being
monitored session to session.
 The patient should be ensured that their recovery is possible and they
will be working fine with the routine and social networks soon by
having someone to talk and giving them hopes about the future.
 The primary health care should be community linked and linked to
volunteer services as well. These community or volunteer services in
turn should work in collaboration with primary health systems.
 Services should be targeted for people whom the general practitioner
refers labels as at risk for mental health problems.
There are many evidence based mental health care pathways on the account
of NHS. These pathways of care have the objective to guide the
commissioners and providers to follow the NICE guidelines and upgrade the
support and care for people seeking mental health care. The College Centre
for Quality Improvement (CCQI) has established a self-assessment tool to

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assess the services in England with the aim of providing good quality care
delivery to people. The College Centre of Quality Improvement is divided
into groups that work for this cause. These groups consist of clinicians’,
mental health professionals and experts by experience. The self-assessment
tool is created by College Accreditation and Review System(CARS). The
CARS is a web-based platform hosted by Royal College of Psychiatrists. All
the service providers offering mental health services are required to
successfully complete this self-assessment tool. (Royal College of
Psychiatrists, 2018)
(Nice.org.uk, 2018)
Personwithsuspecteddepression.
Adults
Service organization
and training
Principlesof care Principlesof care Patientand
service user
experience.
Care foradults.Care forchildrenand
youngpeople.

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NICE guidelines
Special care provided for people with depression
When working with people with depression and dealing with their
caretakers:
 A healthy and trustworthy environment should be built which should
be purely non-judgemental
 People should be provided with all treatment options in the
atmosphere of hope and positivity.
 The workers should realise the social stigma of depression.
 The privacy and honour of every patient should be maintained.
 The carers or the families should be explained about each and every
fact of the disease, treatment and intervention.
 Avoid using clinical language.
 If it is written information, make sure that it is clear to the patient and
the carers.
 Inform the patients about the help and support groups and other local
& national groups available that they can reach out easily.
 An informed consent should be taken from the patient especially if the
patient is suffering from severe mental health disease or is subject to
Mental Health Act.
 Make sure that the information is well explained and a written consent
for the treatment is signed by the patient which should contain that
what the particular treatment will contain, what is expected from the
patients and what will be the outcomes.
Decisions and statements
 This guideline is especially for people with severe depression and
people with depression with psychotic symptoms and for those being

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cured in the laws of Mental Health Act. It says that they should
consider for advance decisions and advance statements working
together with the person. The copies of the record and other
documents should be attached in patients care plan in primary or
secondary care. The copies of these documents should also be given to
the caretakers and the patient.
Support the families and the caretakers
 Complete guidelines shall be given to the carers the mental illness and
how is it treatable and the contribution of the carers towards it.
 Offering a complete check-up for the care with regards to mental and
physical health if needed.
 Discussing the importance of privacy and confidentiality terms with the
person and the carers.
Assessment, care and treatment decision
 When dealing with a person with depression, a brief assessment
should be carried out. Focus on the degree of functional loss and
duration of the episodes.
 When going through such a patient with functional impairment
consider some points and how they may have contributed to the
development, course and severity of the disease: history of
depression or any other mental or physical illness, any past history
of mood swings, the experience and response to treatments in past,
information on the inter personal relationships and the social
background with sliving conditions.
 Respect and honour when dealing with the patents with a particular
religious and cultural values.
 Ask about any suicidal intentions or self-harm thoughts from such
people.
Treatment and interventions

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 It is better to provide the management and intervention to the
people in their own native language so that they can easily
understand.
 Treatment should be given by competent practitioners to such
people. The intervention should be supervised thoroughly,
monitored regularly and evaluated periodically.
(Nice.org.uk, 2018)
There is a 4-step model as advised by National Institute of Health
and Clinical Evidence(NICE):
1. Step 1 consists of identification, evaluation and initial
management
2. Step 2 consists continuous weak symptoms of depression or
mild to moderate depression/anxiety disorder
3. Step consists persistent weak symptoms of depression or mild
to moderate depression/anxiety disorder with negligible
response to initial intervention or moderate to severe
depression.
4. Step 4 consists of severe depression or anxiety disorder, it
may be life threatening or at risk to self-neglect
NICE proposes a couple of therapies that should be provided for the
patients. Cognitive Behavioural Therapy(CBT), couples therapy, counselling
for depression and brief dynamic therapy are few therapies being given to
the patients:
 As estimated about a half of all the mental illness consist of anxiety
disorder. These anxiety disorders include social phobia, health anxiety,
Obsessive compulsive disorder(OCD), Post traumatic stress

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disorder(PTSD), Panic disorder and generalised anxiety. All these
conditions if left untreated, can turn into long-term disease.
 At an average, after taking about 10 session of CBT which costs
around £750 many patients get well within 4 months. The chances of
getting back to the worse condition are lessened for depression. The
success rate for CBT is good for the mental illness and th effect are
longer lasting than the drugs.
 The recovery rate expected from successfully running services that is
being approached by Improving access to Psychological Therapies
(IAPT) services is 50%.
 The reliable rates being 65% and those with no change are 28% with
deteoriation rates being 7%.
There are still many patients with poor results to initial interventions,
continuous moderate depression, complex and severe depression.
Majority of patients are being treated in primary health care system, by
mental health teams or are psychiatric outpatients.
Mild to moderate problems:
Psychosis, bipolar and emotional difficulties are regarded as mild to
moderate disorders.
The proof for the effectiveness of the intervention is limited to opinion of
the experts and the service user and carer priorities.
The services that are evidence based that should be available in any setting
as specified by NICE:
 Support for drugs and treatment
 Physical health monitoring
 Cognitive behaviour therapy(CBT) for common mental health
disorders.
 Support from the work, education and work

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 Timely management of the disorder to avoid deteoriation of the
disease.
 Urgent access to services available 24 hours.

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Mental Health Legislation and Policies in UK:
Mental health issues are one of the most common health issue prevailing in
United Kingdom. It is witnessed that out of four people, one individual is
facing some sort of mental health issue. Many of these individuals remain
untreated for longer period of time and hence the number of suicides or self-
harms increases. The budget for mental health issues in UK is not sufficient
and mainly lacks the coverage of potential areas. As stated by NHS, only
13% of total budget goes to mental health services. The aim of NHS is to
provide mental health services to people of all class, race, income or age
and fight against all odds in the society causing mental health issues. For
such purpose, a policy was launched by NHS known as “parity of esteem”.
The main aim of this policy was to allocate resources equally in mental
health services sector, provide quality care and provision to services to
every individual in the society. As this goal was concerned as a long-term
goal, it has been included in the UK government policy, legislation and policy
statement of NHS. To support the cause of parity of esteem, s strategy
regarding mental health services in England was formulated by Coalition
Government (Gov.uk, 2011). The strategy was named as “No Health Without
Mental Health”. The main objective of this policy was to create equality
among physical and mental health problems and gave equal important to
both. The purpose was to provide best services to mental health patients
and work for their wellbeing. The strategy had six main key points: (Parkins
and Powell, 2017).
1) Greater number of people will have better mental health.
2) Greater number of people will improve and recover from mental health
issues
3) Greater number of people will have both better physical and mental
health.

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4) A positive experience of mental health services will be provided to
patients.
5) Lesser number of people will encounter any sort of harm
6) Lesser number of people will face the issue of discrimination or
dishonor.
In order to successfully implement the strategy, a framework was also
formulated. The framework prescribed the plan through which different
bodies including employers, schools or hospitals could strive to fulfill the
cause of proper mental health services provision to the society. Furthermore,
there was an act passed in 2012 regarding social and health care. The act
was named as the “Health and Social Care Act”. This act paved way for
mental health awareness and also provided recognition to importance of
both physical and mental health. The act strongly supported the point that
NHS is aimed to work for betterment of both physical and mental health and
equal attention and care will be provided to patients with either health issue.
Later in 2015, this agenda was further supported by the Government and
clearly stated that “NHS England is aimed to provide par importance to
mental health issues along with physical health problems. The support and
mandate provided by the government had specific essentials including giving
equal attention to the importance of mental and physical health. Hence,
encouraging the case and purpose of parity esteem. Later in 2014, further
steps were taken to strengthen the cause of parity of esteem. A publication
was introduced by Deputy Prime Minister along with the Care Services
Ministers known as the “Priorities for Essential Change in Mental Health”.
The report primarily focused on areas that require immediate improvement
in the area of mental health care. Moreover, the necessity of the cause of
esteem parity was also discussed including 4 main themes:
1) Easy and greater availability of mental health services
2) The combined approach of mental and physical health

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3) Early prevention of mental health problems and to work for the
wellbeing of mental health patients.
4) Striving to improve the quality of life of patients with mental illness
Furthermore, NHS England along with other concerned bodies published a
five-year view regarding mental health wellbeing in 2014 known as the “NHS
Five Year Forward View”. This publication aimed to contribute towards the
cause of equality between physical and mental health. It also aimed to fully
achieve the cause of parity of esteem and work equally treat physical as well
as mental health by 2020 (Hilton, 2016).

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Mental Health disorders are given high importance in law. It is especially
important for does who are involved in criminal justice system. In such case,
statutory agencies play a major role in supporting the people facing serious
mental health issues. The statutory agencies include all the bodies that
created by the government. The first body under statutory agency includes
the role of Police. The police play a major role in identifying the suspects
going through mental health disorders and provide sufficient help to them. It
is known that the police is always considered the first authority to be called
when any such criminal with mental health disorder is identified. It is stated
in Mental Health Act 2007 that around 11000 people with mental health
disorder are rescued and sent to police station for safety purpose (UK
Legislation, 2007). All such patients are given the chance to interact with
various other individuals and overcome their mental health disorders. It is
permissible to the police to take an individual with mental health disorder in
custody and transfer to a safe place for certain prescribed time as per
Section 136 of Mental Health Act 2007. The police should also seek legal
advice in such case. The section 136 does not allows the police or law to
detain the individual without his/her consent (Bowcott, 2012). The statutory
agencies are mainly focused towards advocacy and employment related
work (Newbigging et al, 2012). The statutory agencies have played a
dominant role in field of service delivery. Other than that, the statutory
agencies have also contributed majorly towards other roles including
development of new strategies in the area of care and support, involving
people with mental health disorder in commissioning and service
development (Curry et al, 2011).
The non-statutory agencies mainly include two types of bodies. Firstly,
government funded non statutory agencies and voluntary non statutory
agencies. The main purpose of non-statutory agencies to help fill all the gaps
that are not fulfilled by statutory agencies. The non-statutory agencies

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majorly cater three broad service areas. Firstly, community support like
home support, schemes for employment and day cares. Secondly, support
services like access to valid information and advocacy. Lastly, providing
services at the individuals respective accommodation including nursing and
home care. It is quoted by NHS that around quarter budget of NHS goes
directly to the improvement and welfare of non-statutory agencies
exclusively catering provision of psychological therapies (Mental health
strategies, 2012). One of the biggest benefit of non-statutory service
agencies is the provision of mental health services at low cost or for free.
There services are easily available around the community, online or on the
phone. These services include personal development, online support,
consoling, training, group and family support and many other (Miller, 2013).
Since many decades, service users have been deeply involved in mental
health services. There are various areas in mental health services in which
the user involvement has been widely noticed. These areas include care
management and individual assessment, stages of research, hiring of mental
health professionals, planning, developing and evaluation etc. A research
was conducted by three famous professionals, Miller, Chambers and Giles in
2016 for deeper understanding of the concept of user involvement in mental
health services. With the help of the research, 5 attributes were identified
regarding involvement of service user. These include working in partnership,
gathering view point and feedback of service users, person centered
approach, advocacy and informed decision making. Several benefits of
service user involvement were identified in the research including a positive
image of staff, personal development, knowledge, social inclusion,
improvement in communication and increased confidence (Miller, Chambers
& Giles, 2016).
Depression is known as one of the most common mental disorder prevailing
all over the world. Depression is a feeling of sadness and isolated from the

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world that is triggered due to certain event, hardships, loss, or
disappointment. There are several ethical considerations attached with
depression due to its nature of becoming common these days (Rehm, 2010).
There are several cases reported such as patients are prescribed to take
medication at the early stage or simply due to feeling of sadness. These
symptoms can be improved with the help of psychotherapy and consoling.
The pharmaceutical companies also face severe ethical consideration in this
matter. The way of marketing the medication and types of research
published on this topic are greatly criticized in the society. For example, pills
for treating depression are becoming highly common among the society
where individuals are in search of instant happiness and excitement. It is
also reported that people with mental health disorder and usage of
substances face disability later in life. Ethical questions related to anatomy
of patients are also witnessed on rise. These questions mainly include: How
to deal with difficult mental health issues and take the correct decision on
time specially when the primary disease symptom is the insight and reality
testing failure (Schneider, 2016).
Mental Health Illness is considered as one of the most common illness all
over the world and requires huge budget for its proper management. As
reported by WEF and WHO, it is considered one of the biggest burden on the
economy in terms of budget resulting in $2.5 trillion cost in 2010. The
economic budget is estimated to increase in 2030 by $6 trillion (Bloom et al,
2011). There are several researches conducted on the stigma of depression
within the society. The people with mental health issues face negative
behavior and stereotypes from society. Being called as weird or crazy are
the most likely used words by teenagers as well as adults. Furthermore,
people facing any sort of mental health issues are also considered a danger
to the overall society and hence are isolated from every gathering and
events. This negative perception regarding mental health illness if more

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fueled up by the role of media. Publishing stories and creating films that
portray a negative and dangerous image of mental health patients is
becoming quite common these days. Due to the impact of these societal
stigma’s, mental health patients soon develop stigma inside their own minds
known as self-stigma. The self-efficacy of the patient is badly destroyed and
the feeling of loser or unsuccessful being develops. Hence, the patients
never try to move a step forward towards the path of recovery and
betterment (Gulliver, Griffiths & Christensen, 2010).
Depression is considered as one of the most severe health problem that
leads to critical consequences. In year 1990, it was ranked as 4th most
common disease among the world population and is expected to reach 2nd
most common disease by 2020. A research was conducted to analyze the
quality of life of people with depression. The Research named as FINDER
(The factors influencing depression endpoint research) was a observational
study conducted to analyze the quality of life of depression patient before
and after medication. The research clearly demonstrated that the quality of
life of depression patient is significantly affected and reduced in comparison
with rest of the population. The antidepressants play a major role in
improving the quality of life of patients within 3 months (Lenox-Smith,
Macdonald, Reed, Tylee, Peyeler, Quail & Wildgust, 2013). The effect of
depression on an individual life is regarded as an intangible burden. Apart
from FINDER study, there were several more studies conducted that clearly
demonstrated that depression affected social, work and physical functioning.
The severity of depression determines the level of disturbance and effect on
quality of life. The intangible elements of quality of life that are influenced
due to depression includes stress, pain and suffering on the loved ones,
friends and family and the impact on these elements is difficult to measure
(Niel, 2008).

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The carers of depression patients play a vital role supporting the patient and
helping to move towards recovery. It is clearly witnessed that family of
individual with depression are highly influenced. The family provides all sort
of support to the patient with depression including financial, emotional and
practical help. The patient is directly reliant on the carer and seeks all sort of
help from them. The carer’s time and quality of life is greatly affected as the
patient takes most of the time and attention. The increased community care
and less reliance on psychiatric help has lead increase in responsibility of
carers. In order to cater the needs of the carers’, they should be regularly
screened to look for any sort of depression symptoms. A research was
conducted by Royal College of General Practitioners regarding the needs of
carers of depression patients. It was stated that about 40% of carers of
depression patients face some sort of depression due to their role of caring.
The Royal College of General Practitioners provided a list of measure to be
taken to provide early support to carers.
1) The carers should be provided access to GP’s on time.
2) In order to properly look after the carer, a champion should be
appointed with all GPs’.
3) A register should also be maintained stating all the information of
carers and checkups.
4) Timely audits should be conducted to keep check on services provided
to carers.
The carers usually ignore their own health while caring for the depression
patient. The carers of depression patients are usually in state of struggle.
They are greatly affected by the condition and symptoms of the depression
patient as reported by chairwomen of RCGP, Dr Clare Gerada. In such
regard, the role of GP’s is highly crucial role in identifying early symptoms of

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depression in the carers. The carers are a critical asset of the society and
hence the commissioners should invest in providing them care and support
on time (BBC New, 2013).
Similarly, social inclusion also is one of the most important aspect linked
with depression. The word social inclusion is defined as to participate,
contribute or involve in the society and work for its welfare. The opposite of
social inclusion is social exclusion which is the disconnection from the society
and unfair treatment. Social exclusion has a close relation with mental illness
and leads to deprivation from society. In order to deal with these issues, the
overall society play a major role. The support from peer and family helps the
patient to move towards recovery and leads to social inclusion.

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References:

 Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S.,
Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya,
A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A., & Weinstein, C.
(2011). The Global Economic Burden of Non-communicable Diseases.
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 Bowcott, O. (2012). UK fined over mentally ill man's 'inhuman
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(2012). 2nd ed. Raffertys.

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 Gulliver, A., Griffiths, K.M. and Christensen, H., 2010. Perceived
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 Hilton, C., 2016. Parity of esteem for mental and physical healthcare in
England: a hundred years war?. Journal of the Royal Society of
Medicine, 109(4), pp.133-136.
 HM Government (2011). No health without mental health: a cross-
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