103

VIEW POINT

Application of the ecological framework in depression: an approach whose time has come
Ram Lakhan 1, Olúgbémiga T Ekúndayò 2

1
Doctoral candidate in Public Health (Epidemiology), School of Health Science, Jackson State University, Jackson,
MS, USA. 2 Associate Professor of Epidemiology and Biostatistics, School of Health Sciences, Jackson State
University, Jackson, MS, USA

ABSTRACT
Background: Depression is a common psychiatric disorder. It is a global health problem and a public health
concern. There is a need to explore and conceptualize a workable and comprehensive model that facilitates
the treatment and prevention of depression in the community. The ecological model that has been used in
several health issues may be viewed as an option.
Objective: This paper aims to propose an ecological model for depression; the model can describe a
comprehensive approach in treating and rehabilitating people with depression.
Discussion: Application of a community model in psychiatry was first recorded by Lambo. However, application
of the ecological model in treatment, rehabilitation, and prevention of depression has not been recorded. We
review and discuss the application of this model in this setting.
Conclusion: This ecological approach may be a useful approach in treating and rehabilitating individuals with
depression in the community. This may require some degree of community sensitization, empowerment and
mental health advocacy.
Keywords: ecological model; depression; mental health
Date of first submission: 13/10/13 Date of initial decision: 22/10/13 Date of acceptance: 1/12/13

INTRODUCTION 1990, depressive disorders were fourth leading cause

of disease burden worldwide.[9] First three preceding
According to the World Health Organization (WHO),
causes were lower respiratory infections, diarrheal
depression affects more than 350 million people of all
disease, and perinatal conditions. By 2000, depressive
ages globally with over 50% not receiving appropriate
disorders superseded perinatal conditions and became
or adequate care.[1-4] It is also a common psychiatric
third leading cause of global disease burden. [10] Ferrari
disorder among children across the world.[5] Depression
et al, [11] applied epidemiological modelling to estimate
may occur as early as age of 3 years.[6] Symptoms of
global burden of depressive disorder. According to their
depression include depressed mood, loss of interest
estimation, the prevalence of depressive disorders
or pleasure, feeling of guilt or low feeling, decreased
remains similar 4.4% in year 1990, 2005 and 2010.
energy, disturbed sleep or appetite, feeling of tiredness
Prevalence of depressive disorders estimated higher
and poor concentration. Depending on the severity, it
in female gender (5.5%) than male (3.2%). Region wise
is categorized as mild, moderate and severe. [7] Studies
low and middle income countries have higher
conducted in the past two decades on the global burden
prevalence than the developed and upper income
of disease have drawn international attention to
countries. North America 3.7%, South America 4.1%,
depressive disorders as a leading cause of death and
Western Europe 4.7%, Eastern/ Central Europe 5.1%,
disability. [7, 8] According to the global burden of disease
Australia 4.1%, Africa/Middle East 6.6%, East/South
Address for correspondence Mr Ram Lakhan. Doctoral candidate in East Asia 3.9%, Asia South 8.6%, and Asia Pacific have
Public Health (Epidemiology), School of Health Sciences, Jackson State
University, 350 West Woodrow Wilson drive, Jackson Medical Mall, 5.6% prevalence of depressive disorders. [11]
Suite # 320. Jackson, MS 39213. USA
Phone: 001-601-899-2599 Depressive disorders commonly coexist with anxiety.
Email: [email protected]
Other medical conditions such as cardiovascular,
pulmonary, neurological, endocrine, gastrointestinal,
How to cite this article: Lakhan R, Ekúndayò OT. metabolic and diabetes are often associated with
Application of the ecological framework in depression. [12] Some of the coexisting disorders may
depression: an approach whose time has come. AP be outcome of the depressive disorders. Coexisting
J Psychol Med 2013; 14(2):103-9. disorders and loss of productivity due to illness
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Lakhan and Ekúndayò: Ecological approach in depression
increases the cost of treatment and care. The treatment health outcomes result from interactions with the five
cost of depression is high and associated with huge ecological systems (Figure 1). [23, 24] This approach can
economic burden. [12, 13] Depression affects more health be applied in varieties of health issues. [25] Literature
outcomes negatively compared to other physical review demonstrates proxy application of ecological
diseases such as angina, arthritis, asthma and diabetes. model or its components in treatment and prevention
Coexisting disorders lead to additional burden for of depression in several countries around the world. [1,
recovery. [14] Hence, huge economic burden on 19, 26, 27]

treatment and care, and disease burden of depression

Component system levels of ecological model
is a public health priority. [14-18] A survey conducted by
Smokowsky, [19] in 17 countries, estimated that on an Micro:
average 1 in 20 people is affected with depression. This This is the central level of the system which encloses
survey demonstrates the need for public health call to the individual. The person interacts with objects and
address depression more widely. The 2012 World people in their intimate and immediate world. The
Health Assembly called for the WHO and its member individual’s micro-system includes parents, siblings,
organizations to act on this issue. [7] spouse, friends, children and significant others involving
Our understanding of bio-psycho-social medical model very dynamic and active engagement and interactions.
has improved in past few decades. [20] Understanding Mezzo:
of social determinates of health (SDH) has been playing
This includes different micro-systems and the various
a significant role in designing and planning health
systems that serve the Microsystems, formal and
programs. According to the U.S. Institute of Medicine,
informal. They include, family/families, group/groups
social determinants are contributing risk factors for
health, thus they should be incorporated into care (peers organizations, local facilities and services.
planning.[21] Considering the magnitude of problem, cost Individuals are at higher risk of developing psychological
of treatment, affordability and accessibility, the current stress, if communication is poor between various
research has been focusing towards psycho-social and Microsystems and if there is disconnection or disruption
community based approach. Such approach has been of the micro- and mezzo systems, creating a social
promoted and recognized by WHO. [7] According to the disorientation which can mimic, or manifest as, anomie.
WHO, depression can be treated at primary level by Similar to the micro-system, the individual is not simply
incorporating psychotherapy with antidepressant observing or passive, they play an active role in creating
medications. Several approaches around the concept a supportive ecology, using past experiences and
of psycho-social prevention and treatment of depressive knowledge. This system includes institutions, formal and
disorders have been tried out at community level in past informal bodies, religious institution (church, temple,
few decades. Many of the community intervention mosque etc), school, club, office, work, union, informal
programs highly correlate with ecological approach. The support group, and volunteer organization etc, with
ecological approach has been widely used in a variety which the person is in close contact.
of health promotion programs.[22] Because the ecological Exo level:
model already encompasses the various existing
community programs; using the ecological model This includes specific social structures and
should provide a more holistic approach to, and a better organizations that does not contain individual. However,
understanding of the treatment and prevention of it affects an individual’s immediate environment and
depressive disorders. their microsystem. The individual does not play any role
in constructing the Exo system, but they experience
OBJECTIVE direct impact on their mood and affect. For example: a
This paper discusses the applicability of the ecological sole earner in the family being laid off from their job
model as an approach to the management of with their unemployment having direct negative impact
depression on them and their family. Loss of income creates
DISCUSSION psychological, social and economic stress to the
individual and their family. Stress can affect their
Ecological model:
activities of daily living. Prolonged stress poses
Urie Bronfenbrenner theorized a model around child significant risk of producing mental illness in the
development. This model covers five environmental individual and their family.
systems that impact an individual’s growth and
development: a) Micro, b) Mezzo, c) Exo, d) Macro, Macro level:
and e) Chrono. This model found relevance in several This covers the larger society and culture in which an
health issues. However, it applies across all health individual lives and interacts. Macrosytem plays a
concerns. [22] According to this model, an individual’s ubiquitous role including in developing and
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Lakhan and Ekúndayò: Ecological approach in depression
industrialized countries, across all socioeconomic Treatment pathway for depression
status, ethnicity, and immigrant status. This system Ecological theory indicates that a positive and
deals with the perception of general community that supportive functional relationship with microsystems
affects individual, family, school, and institutions. For (e.g. family, peer, parents, teachers, schools) increases
example: historically black colleges and universities chances of healthy social functioning and decreases
receive less research funding. Certain minor ethnic depressive symptoms, their severity and number of
groups are considered lazy and because of that episodes. [19] This effect may result from the natural
perception, they don’t get equal opportunities for process social cohesion and function that occur without
employment. any external intervention. The whole idea of applying
Chrono level: ecological approach for depression depends on
strengthening this system. The macro and exo- systems
This system considers cumulative experiences on a can play a supportive role by creating the appropriate
person, what they experience over the course of their ecology for the micro and mezzo systems to function
lifetime. These experiences include environmental appropriately.
events, as well as major transitions in life. Policies, rules As explained in Figure 1, the person with depressive
and regulations, political parties in action impact the symptoms is given psycho-social support by family
individual and their micro system. This goes across time members of micro system. [30] Lay counsellors of
and across all levels. implementing organization (mezzo-) approach to the
Psychosocial pathophysiology of depression: family members and educate them about depression.
They also convey the importance of healthy and
An individual may stress out due to a negative event or
supportive communication of family members with the
a physical illness. [12, 28] Taking a hypothetical situation,
individual.
a person who is unable to report to their work/job will
eventually not have financial resources, lose their health Units of mezzo system such as schools, clubs, offices,
insurance, and thus access to medical care. Due to churches, temples are targeted with programs for
the ensuing lack of appropriate support, this person education and awareness of depression. Educational
feels stressed, and helpless. If the person had some and informational activities can sensitize members of
empathetic communication, and psycho-social support this system and provide them with some level of
at this stage, their stress might have not become chronic appropriate cognitive, emotional and social
and severe chronic. Thus depression may be avoided competence. Elements in this level can create a
or postponed. At this stage the person may be able to supportive ecology around the person, to not only
recognize their vulnerability, and attempt to fight. They access care when needed, but to actually prevent or
may share and ventilate his feelings within their micro pre-empt episodes when appropriate. This may include
and mezzo systems, if those are supportive. Family is involving the depressed person in different activities
the closest unit here. However, if the family members and providing support and resources to the family to
lack the ability to recognize the person’s problem, if access medical and economic help as needed.
their different work routines and other family priorities Religious institutions may also play crucial role in
do not allow them enough time for this person, they helping the person with depressive symptoms
may transfer from a “fight” to “flight” mindset with the especially in case depression originated from a
ensuing physiological cascades. This process may catastrophic event such as loss of family member,
extend the issue from psychosocial to biological, natural disaster etc.
impacting various systems, including the immune and Exo- level, primarily deals with existing police, schemes,
nervous systems, triggering the biological aspects of rules, regulations and provisions. Members of both
depression such as the neuro-chemical pathways. The system (micro and mezzo) look out for this person and
individual may then begin to exhibit the more observable try to help him to access benefits from existing programs
indicators of depression, such as poor sleep, sad mood, and schemes. Implementing organization provides
no interest in recreational, pleasure, or work activities, training on advocacy skills that enable them to deal
decreased sex drive, and irritability in communication. with system, assert for rights and demand for provisions.
The main focus will be on accessibility, affordability and
Ecological components associated with depression
provision for quality care.
Three major social determinates of health a) socio-
economic status, b) social cohesion and c) negative Implementing organizations may conduct awareness
life events correlates with depression. [29] Other studies programs on depression. Mass media such as TV,
applied ecological approach have broken down these public announcements over radio, distribution of
determinates in more specific presenting features (Table pamphlets, talk show, and street plays may be
1). [1, 16, 19, 27] conducted in communities. Free screening and health
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Lakhan and Ekúndayò: Ecological approach in depression
checkups conducted in the community may enhance program successfully involved families, friends,
awareness and help determine true incidence and relatives, neighbours, colleagues, churches, school
prevalence for macro and mezzo level planning and teachers, temple priest at micro and mezzo level.
interventions. Thus community receives information Awareness programs were conducted in larger
from two sources, members of micro and mezzo system community. People with depression received psycho-
and directly through community awareness activities. social support through village group. At macro level,
This two-fold approach may generate attitudinal, village groups involved in advocacy and demanded for
behavioural, and practice related changes. [31] mental health facilities. However, implementing
organization of this program did not claim that their
In the chrono- domain, monitoring and evaluating the
approach revolved around ecological model. Patel et
cumulative impact of the ecology at all levels on
al, [52] advocated for community mental health program
morbidity and vice versa may help in developing long
(CMHP) for developing countries. CMHP highly
term critical interventions that will reduce incidence and
correlates with ecological model.
contain prevalence in the long run. This may involve
program monitoring, policy analysis, advocacy, and CONCLUSIONS:
research for solutions and innovations. Depression does not occur in isolation to one’s
Bronfenbrenner’s ecological theory revolves around environmental factors. There are family, relatives,
social perception and social engagements of people at friends, peers, colleagues, and community, work,
various levels of organization in addressing a health school, and neighbour, political, social and religious
issue. However, Bronfenbrenner’s theory was predated structures with whom a person interacts on a daily basis.
by others who had recognized the key role community This exposes the person to several daily challenges,
plays in health and illness. For example, Lambo, [32] while providing them with resources innate in their
developed a community approach to the management ecology. Although disharmony with any agent in the
of psychiatric disorders, understanding that the system can be a potential stimulation to trigger
configuration of communities and whole populations had disturbance in mental health functioning and lead to
a measurable effect on mental health. [32-38] Worldwide, depression, an awareness of the depressed person’s
there are evidences of partial use of this theory in ecology may provide additional resources for
depression. This model is discussed on the basis of management of the condition and person for higher
the evidence and in approaches of similar nature. levels of function and for primary, secondary or even
Socioeconomic status, social support, gender, location tertiary level prevention. Also, psychosocial and policy
and negative events are known risk factors for intervention operating at all five levels of the ecological
depression. [16, 39-41] These social risk factors can be model can aid the person with depression. We propose
addressed in micro and mezzo level by family, relatives, that the ecological model can play key roles in
neighbours and colleagues. In Uganda, people with secondary and tertiary prevention in depression while
depressive disorders were provided group interpersonal providing opportunities for beneficial effects in
psychotherapy involving community members. This addressing depression and other mental health issues
approach yielded reduction in prevalence and at the population level. In addition, the proposed
symptoms of depression. [42] Social support provided framework may be helpful in developing programs to
by members of micro-mezzo system yielded positive address mental health overall. However, this is an
experiences, reduction in depressive symptoms, and introduction of a concept which has been used in other
increase in self-esteem in rural youth and school fields. Moreover, this concept provides opportunities for
children. [43- 46] Few other studies have focused on research and review, to determine how care cost can
complex interrelationship of depression in ecological be reduced, more people can become more functional,
model and found that psycho-social intervention, and and intervention can be better organized and effective.
support provided through family members, peer, and However, further review and appropriate studies are
school have reduced significant symptoms of needed for refinement.
depression. [47,48] According to other researchers
Acknowledgements: Nil
ecological approach is capable of protecting individuals
against potential risk factors of depression, however Author information: Ram Lakhan received specialized
more research is needed to refine this idea. [27] undergraduate therapeutic training in mental retardation
at the National Institute for the Mentally Handicapped,
Chetterjjee et al, [49] implemented a community based Secunderabad, Andhra Pradesh, India, followed by
mental health project in rural setting in India. This graduate training in psychology at Madras University,
program closely revolved around the ecological Chennai, India. He also received hands on training in
approach of treatment and rehabilitation of people with psychiatric aspects in non-formal setting and served
psychiatric and developmental disorders. [50, 51] This people with intellectual disabilities and mental illness in
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Lakhan and Ekúndayò: Ecological approach in depression
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population of resource poor area in India for eight years. Patten SB, Vos T, et al. The epidemiological modelling
of major depressive disorder: application for the Global
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Conflict of Interest : None declared Source of Support : Nil
and depression prevalence across the United States:

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