Legacy of Slavery and Indentured Labour

Linking the Past with the FutureConference on Slavery, Indentured Labour, Migration, Diaspora

and Identity Formation.June 18th – 23th, 2018 , Paramaribo, Suriname

Org. IGSR& Faculty of Humanities and IMWO, in collaboration with Nat. Arch. Sur.

Diagnosing depression in Surinamese diasporaCynthia Blanker

AbstractDepression carries a high risk for suicide, is the leading cause of disability worldwide and is predicted to be the leading cause of disease burden in 2030. Depressive persons have an overall relative risk (RR) of dying of 1.81 (95% CI: 1.58–2.07) compared to non-depressed subjects. Suicide is also the second leading cause of death in the age range 15-29. Yearly, over 800.000 people die of suicide, while globally 350 million people are affected. The affirmation of depression is generally done by using the Diagnostic and Statistical Manual of mental disorders, version four and five, and the International Classification of Diseases, respectively DSM and ICD. While these mainstream instruments are being praised for enhancing the global communication and increasing the reliability of psychiatric diagnoses they have been criticized for their poor account of the variation in expression of depression due to race, gender and age. Both DSM and ICD suffer in their origin from intrinsic dilemmas concerning classification methods, validity and reliability. Also, both systems are to date subject to dispute regarding their confirmation, aetiology, pathogenesis and nomenclature. Groups that are neglected by DSM-ICD, like woman, children, elderly and non-Caucasians, suffer from these flaws in the instrument since they risk to remain unrecognized or to be misdiagnosed. Introducing an Outline For Cultural Formulation in DSM to deal with the cultural problem was only partially successful, in that it further increased the reliability of the instrument. The existing core-issues like validity and classification are however merely reiterated with each revisited version of DSM-ICD. This culminates in misdiagnosing depression in Non-Caucasians and increasing health hazards for these groups who are in general already challenged to begin with. Therefore, this paper aims to examine the construct of Allostatic Load Index (ALI) as an independent, biological marker for depression. The paper presents the results of a literature survey on ALI and depression. ALI is found to be a suitable biomarker for depression among elderly. However, ALI is not yet affirmed to be an appropriate indicator for depression for other groups. This paper

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proposes a reasoned set of biomarkers for ALI, which can be used to indicate depression and which is not hampered by age, gender and ethnicity.

1. IntroductionSurinam has since 2015 progressed from the sixth to the fifth place on the world-ranking list for suicide (WHO, 2017). According to this WHO report, Surinamese have a decreased life expectancy at birth from 69 years in respect of the globally reference 75years and a probability of dying between 15 and 60 years that is 1.7 times greater than average. Suicide has been claimed as a consequence of acute or chronic mental health disorder by the medical establishment. The American Psychiatric Association states that risk factors for attempting or committing suicide are the exposure to suicide (-attempts) by the self, family or others, psychiatric disorders or chronic physical illnesses, increased psychosocial adversities and access to lethal means. Surinam diaspora is characterized by enslavement or indentured labour, contingent followed by migration within the region or migration to the metropolis (Gowricharn, 2006).

A distinctive feature of the Surinam diaspora is its diversity with respect to the country of origin from the enslaved or indentured people. Surinamese people, consists of the indigenous people, the Surinamese Amerindians as well as enslaved African-Descendants and indented labourers like Indian, Asians and Chinese, all, except of the Surinamese Amerindians, in diaspora. Consequently Surinamese people represent a rich crucible, which nonetheless coexist in one country. Notwithstanding this diversity Surinamese also share their increased risks of diminished health outcomes typical for indigenous cultures. (United Nations, 2014; Kisely S., Alichniewicz K.K., Black E.B., Siskind D., Spurling G. & Toombs M. (2017). Aforementioned facts about Surinamese health challenges affirm literature review performed by Hickling, Gibson and Hutchinson in 2013 concerning epistemological, public policy and epidemiological challenges amongst Anglophone Caribbean. This confirmation is significant since Surinam is neither Anglophone nor strictly Caribbean but shares the colonial past so distinctive for the Caribbean. Hickling et al uncovered the effects of colonialism to play an important role in the mental health of Anglophone Caribbean’s.

Their postcolonial history, due to the inherent accompanying biological and psychological legacy, subjects Surinamese people to increased risks of having diminished health outcomes mainly because of adversities such as discrimination. They also risk neglect by the health system that is primarily designed to recognized and subsequently treat disorders in Caucasians, their former colonizers. To date available diagnostic means in particularly mental healthcare are based on Caucasian populations with psychiatrists worldwide relying on mainstream Western instruments like the Diagnostic and Statistical Manual of Mental disorders (DSM) and the International Classification of Diseases (ICD) to diagnose disorders. DSM-ICD deserves credit for standardizing medical practice in psychiatry but continue to have severe flaws concerning reliability, validity, generalizability and the equity of employed threshold values. (de Jong, 2012; Kirmayer, 2001; Kleinman & Good, 1985; Frances, 2013; van Os, 2014; Haroz, Ritchey, Bass, Kohrt, Augustinavicius, Michalopoulus, Burkey & Bolton 2017).

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The fact that diagnostic means and consequently also the therapeutic strategies are a priori administered through the Caucasian mainstream lens further aggravates the conditions of indigenous people. In cases where the public psychiatry was decolonized and policy was redirected to deinstitutionalization and innovative treatment was administered, Hickling found that health gains were achieved since Caribbean seem to have the potential to pull through the detrimental effects and repercussion of their colonial past provided the healing power of their resilience and understanding of their social capital is emphasized. Since Caribbean generally migrate to Europe and North- America and thus White and Western regions, they risk the exposure to societies, which lack the possibility to provide this empowering environment.

Problematic in DSM-ICD is also that it depends heavily on the subjective opinion of the professional, which adds to epidemiological differences across age, gender and race. The American Psychiatry Association (APA) acknowledges these problems and has continuously made adjustments in the consecutive versions of the manual, unfortunately to date with marginal success. A consequence of these flaws is that indigenous people are more prone to be diagnosed with a psychotic disorder than an affective disorder than Caucasians. Based on DSM-ICD the risk ratio for schizophrenia for African Caribbean in the UK is six to eighteen times higher than for the majority White British population (Bourque, van der Ven, & Malla, 2011; Cantor-Graae & Selten, 2005; McKenzie, Fearon, & Hutchison, 2008).

2. Limitations of DSM-ICD Besides the cross-cultural and methodological limitations hampering DSM-ICD there is also a problem with administered threshold values giving rise tot a high overlap of symptoms between different mental disorders in DSM-ICD and consequently a low specificity of these disorders. The developers of the instrument tried to settle these inconveniences by accentuating the concepts of comorbidity as well as diagnosis ‘not otherwise specified’ in DSM 5, the most recent edition of DSM (Regier, Kuhl & Kupfer, 2013). However, they hereby failed to acknowledge the role of a shared biological substrate for several symptoms and symptom-patterns. Symptoms of anxiety disorders for example, highly overlap with symptoms of depression, whereby questionnaires designed for depression also measure anxiety. Similarly, drugs designed to cure depression are used for treating anxiety disorders. Finally, the integration of culture in DSM is neglected. This neglect is considered an inexorable outcome of the assumed universality, while the DSM-ICD is initially based on and standardised for the Caucasian population.

Critical in the DSM-ICD discourse is the problem of reiteration in research (Hyman, 2010). Studies are still based on DSM and DSM-based questionnaires and narratives leading to similar outcomes in the past 60 years. While the intrinsic problems of DSM-ICD concerning generalization across age, gender and race are well documented in transcultural psychiatry, the field of science and public health tend to overlook the repercussions that comes with this notice. In so doing scholars persist that the contemporary higher incidence rates of psychotic disorders amongst black Caribbean ethnic groups, don’t have their origin in methodological biases but rather in aetiological explanations (Tortelli et al., 2013). These studies still speculate a genetic aetiology,

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notwithstanding the fact that the incidence and prevalence of psychotic disorders is lower in the Caribbean than in Europe or North America. (Hickling, 1991a; Royes, 1962).

Except from the construct problems obscuring depression, diagnosing depression is also faced with the fact that it has a multifactorial nature apparent in a comprehensive aetiology of internal as well as external factors. The multifactorial nature of depression is also pronounced in the expression of symptoms of the disorder. Epidemiologic research concerning the prevalence and incidence of depression consistently reveal pervasive differences regarding age, gender and race, in spite of extensive efforts to reduce these differences through substantiated research programs and adjustments to the DSM-ICD instrument. The NIMH suggests to overcome these construct issues by reinforcing the use of biological markers in the diagnostic process. Conform this advice this study will investigate biomarkers predicting depression in the Surinamese diaspora.

The APA, aware of the shortcomings of DSM, in 2013 released a joint statement with the National Institute for mental Health (NIMH ) stating that while DSM remains the gold standard for clinical diagnosis, research beyond the constraints of DSM-categories might integrate behaviour and neuroscience. NIMH developed a framework called RD0C (Research Domain Criteria) that incorporate basic behavioural and neuroscience research as to enhance the understanding of normal and abnormal human behaviour. Following this strategy will free scientists from traditional categories that have proven to be heterogeneous. In this approach individuals are grouped based on their genomics, physiological traits, cognitive dimensions or imaging findings. NIMH’s premise is that mental illnesses are brain disorders expressed as complex cognitive, emotional, and social behavioural syndromes. NIMH aims to determine whether a diagnostic approach based on biology and behaviour will benefit the uniformity of diagnostics systems in Psychiatry. Researchers are encouraged to develop their studies according to this framework as to accumulate knowledge about neuroscience and its effect on behaviour. Conforming this suggestion this study will seek to propose a set of biomarkers that will predict depression among Surinamese in diaspora.

Unfortunately depression remains generally unrecognized due to construct problems resulting in the notion that depression is globally defined by DSM-ICD. The intrinsic problems of the DSM-ICD are to date most pregnant across age, race and gender. Efforts from scholars to repair this gap has to date only resulted in more research of the neglected groups using and adjusting DSM-ICD questionnaires and thus merely reiterating and not accumulating knowledge. Thus to date recognizing depression in children and elderly, in a non-Caucasian population and or female subjects remains problematic using DSM-ICD.Critics of DSM-ICD argue that above mentioned problems lead to misclassification of depression, which results in under- as well as over diagnosis and consequently mistreatment of patients.

Anthropologist and transcultural psychiatrist who acknowledge cultural differences in the diagnostic process mainly address the inconsistencies of DSM-ICD. In an attempt to repair the cultural neglect in DSM IV, the Outline of Cultural Formulation (OCF) was introduced. The OCF assists clinicians in evaluating the impact of a patient’s cultural background on psychiatric diagnosis by including sociocultural variables in the assessment of depression (Kirmayer, 2001; Mezzich et al., 1999). The OCF acknowledges

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the cultural background as well as the impact of migration, socio-political variables and power related issues. However, by merely translating the mainstream definition of depression to fit a heterogeneous cultural group, the OCF validates Dam’s tenets (Tsai and Chentsova-Dutton, 2002; Falicov, 2003; Kirmayer, 2001). Attempts to address these shortcomings via integrated addenda and revised versions, have to date not established a fix of the DSM-ICD model (Lilienfeld & Treadway; 2017).

We choose to debate the prediction of depression in the Surinamese diaspora because Depression is a serious and life-threatening disease that adds to overall mortality and at it worst leads to suicide as reported by the World Health Organization (WHO, 2017). While depression affects the general population, WHO findings state that elderly as well as adolescents, women and migrants are at a higher risk. Of all mental health problems the major depression accounts for the highest mortality and suicidality rates. This is in spite of the fact that depression when treated has a good prognosis in respect to health outcomes especially in comparison to other mental health disorders.

3. The Allostatic Load IndexA biological approach consistent with RDoC to diagnose depression is the Allostatic Load Index (ALI). Sterling and Eyer (1988) introduced the concept of Allostatic Load (AL) to describe the organism’s effort to maintain stability (homeostasis) through change. ALI is a multisystem complex, based on a composite score of biomarkers, representing and influencing different organs. The AL-concept explains physiological responses (allostasis) to stress. Stress in general is acknowledged as an essential risk factor for depression (Mann, 2013; Haler, 2010). AL in this sense, represents an accumulated manifestation of stress that wears the organisms down. The impact is measurable and enables the construction of an Allostatic Load Index (ALI). ALI consists of primary mediators (biomarkers in blood serum and in urine) and secondary outcomes (bodily measures like systolic and diastolic blood pressure and waist-hip ratio). Tertiary outcomes consist of morbidity and mortality from diseases like cardiovascular diseases, depression and chronic pain. Where DSM-ICD failed in operationalizing these symptoms, ALI is confirmed to be an adequate instrument to measure stress (Hintsa et al., 2016; Seeman et al., 2001, 2004; Goldman et al., 2005; Glover et al., 2006; Maselko et al., 2007; Leahy & Crews, 2012).

The empirical research on the specific relation between AL and the construct depression, is poor. However, scholars have extensively examined the relation between AL and stress (Hintsa, 2016; McEwen, 2003, 2015; Pasquini, Berardelli & Bionic, 2014). These studies show a positive correlation between stress and AL. Stress is also the main etiological factor within depression. Since the manifestation of stress covers the lion's share of the criteria for depression in DSM-ICD, depression can be seen as a expression of physiological, psychological or sociological stress. Some groups are more vulnerable for stress. Several studies (Beatty, 2016; Mc Ewan, 2015; Moller-Leimkuhler, 2010; Theall, Drury & Shirtcliff 2012; Tomfohr, 2016) mention higher AL scores for women, adolescents, elderly and migrants. This suggests that the expression of the experienced stress (thus the main symptom of depression) varies with age, gender and ethnicity.

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Elderly usually suffer from multiple chronic somatic diseases, like chronic organic diseases, disabilities, musculoskeletal conditions and psychosocial adversities. These disabling diseases as well as the prescribed medication to treat them, can mimic or cause depression. Especially musculoskeletal conditions and severe trauma are notorious in this matter. This implies that the mentioned somatic diseases can obscure depression. Furthermore, the fact that elders tend to somatise and or don’t acknowledge feelings of depression, it is difficult to recognize depression among this group. Often, this leads to an under treatment of late life depression (Evans & Mottram, 2000). Next to the vulnerabilities and frailty of elderly, research show a significant association between an increased ALI and depression in this group (Gruenewald, Seeman, Karlamangla & Sarkisian, 2009; Kobrosly et al., 2014; Leahy, 2014; Seplaki et al., 2004). These studies also reveal modest gender differences: older depressive women have higher ALI than older depressive men.

However, Leahy (2014) attenuated the findings on age and ALI. Leahy also found higher ALI in the elderly, but a poor relation of ALI and age. Leahy states that the underlying senescence is accountable for the high ALI in the elderly. By senescence Leahy meant “the accumulated debilitating bodily injuries through continued exposure to environmental stressors” (p.5). However, Leahy agrees that elderly, women, low Socioeconomic status-groups and migrants are known for their high risks on health issues and psychosocial adversities. Yet, he states that, generally, accumulation of sustained stress should be much lower in adolescence and adulthood compared with elderly in similar conditions. The high prevalence of depression and accordingly suicide among adolescents (WHO, 2014) supports Leahy’s finding concerning the poor relationship of ALI with aging alone.

Depressive disorders have a complex and multifactorial aetiology with the involvement of (neuro-) biological as well as psychological and social factors and mechanisms. Some of these factors are known to individually increase the risk of developing a depression disorder. This is especially true for psychological and sociological risk factors. Research on (neuro)-biological factors on the other hand is still emerging and to date certainly not exclusive. However, the application of the ALI in comparative empirical research is hampered. This is due to the lack of a fix set or number of biomarkers with their clear-cut threshold values per syndrome, to calculate the ALI. So, in case of diagnosing a depression, it is unclear which set of biomarkers constitute of the best predictor for depression. Nevertheless, ALI for depression can be beneficial, particularly for the most vulnerable individuals who also are at risk to be neglected by DSM-ICD.

Jani has set groundbreaking work in 2016 by analyzing two seven-years longitudinal datasets. The first set, consisted of 35.537 patients with existing cardiometabolic diseases. The second dataset consisted of 666 patients recruited from the general population. From every patient biomarkers were collected. After extensive literature review Jani achieved 12 biomarkers with the highest association with depression. He subsequently analyzed these datasets using these achieved 12 biomarkers. The biomarkers consisted of bodily measures like systolic and diastolic blood pressure, Waist-Hip-Ratio, BMI as well as peripheral (blood based) biomarkers like HDL-cholesterol, Total cholesterol, triglycerides,

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glucose, HbA1C, fibrinogen, CRP and Interleukine-6. Except of Interleukine-6 all these biomarkers are of interest for cardiologist in their daily practice. Jani explored the relationship between these allostatic load biomarkers and prevalence of depression in patients with predominantly cardiovascular diseases and found a non-linear association with individual biomarkers.

Vitamin D is another peripheral biomarker, not included in Jani’s study that seems promising as a predictor for the prevalence of depression. Vitamin D as a novel blood serum biomarker has a role in numerous chronic diseases, including mental disorders. Recent epidemiological research provides growing evidence for an increased positive relationship between Vitamin D-deficiency and depression (Frei et al., 2013; von Kanel et al., 2015; Wang, 2017; Welch, 2014). These studies present an inverse relationship of vitamin D with depression as well as an increased prevalence of hypovitaminosis D in Mediterranean and dark-skinned cultures who migrate to colder regions with a diminished exposure to sunlight. (Gutiérrez, Farwell, Kermah &Taylor, 2012). Elderly in geographical regions with diminished sun exposure are also known to be susceptible to lower vitamin D-levels. This is the reason why the National Health councils in many of these countries issued the prescription of Vitamin D to elderly. While there are multiple somatic possible causes for the existence of a Vitamin D deficiency in the elderly, studies also show there is a sound relationship with mental health problems like depression.

A biological basis for developing mental health problems is found in the hypothalamic-pituitary-adrenal axis (HPA-axis). Biological psychiatry consistently notices a malfunctioning HPA-axis in chronic stress as well as in depression. (Swaab, Bao, & Lucassen, 2005). The HPA-axis depicts the neuro-endocrine system’s reaction on stress. Essentially it means that whenever the organism experiences stress a cascade of hormones and neurotransmitters evolve with the hypothalamus excreting TRF, which activates the pituitary to produce ACTH, which in its turn stimulates the adrenal cortex to excrete the stress-hormone, cortisol. In order to prevent overdrive, the HPA-axis is equipped with negative feedback loops. Research shows that malfunctioning of the HPA-axes is detectable via amongst others biomarkers in serum, plasma, CSF, urine, measurement of the patients vital signs and questionnaires. Since the manifestation of stress covers the lion's share of the criteria for depression in DSM-ICD, depression can be seen as expressions of physiological, psychological or sociological stress. Some groups are more vulnerable for stress. Several studies (Benatti, 2016; Mc Ewen, 2015; Moller-Leimkuhler, 2010; Theall, Drury & Shirtcliff 2012; Tomfohr, 2016) mention higher AL scores for women, adolescents, elderly and migrants. This suggests that the expression of the experienced stress (thus the main symptom of depression) varies with age, gender and ethnicity.

While some methods of collecting biomarkers are non-invasive others take more toll on the patient and are more costly. A more sophisticated way to handle studying biomarkers based on the axioma of the dysfunctioning HPA-axis is the allostatic load index (ALI). This biological approach was introduced by Sterling and Eyer (1988) to describe the organism’s effort to maintain stability (homeostasis) through change. ALI is a multisystem complex, based on a composite score of biomarkers, representing and influencing different organs. The AL-concept explains physiological responses (allostatis)

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to stress. Stress in general is acknowledged as an essential risk factor for depression (Mann, 2013; Hasler, 2010). AL in this sense, represents an accumulated manifestation of stress that wears the organisms down. The impact is measurable and enables the construction of an Allostatic Load Index (ALI).

ALI consists of primary mediators (biomarkers in blood serum and in urine) and secondary outcomes (bodily measures like systolic and diastolic blood pressure and waist-hip ratio). Tertiary outcomes consist of morbidity and mortality from diseases like cardiovascular diseases, depression and chronic pain. Where DSM-ICD failed in operationalizing these symptoms, ALI is confirmed to be an adequate instrument to measure stress (Hintsa et al., 2016; Seeman et al., 2001, 2004; Goldman et al., 2005; Glover et al., 2006; Maselko et al., 2007; Leahy & Crews, 2012). The empirical research on the specific relation between AL and the construct depression, is poor. However, scholars have extensively examined the relation between AL and stress (Hintsa, 2016; McEwen, 2003, 2015; Pasquini, Berardelli & Biondi, 2014). These studies show a positive correlation between stress and AL. Stress is also the main etiological factor within depression.

Consistent with the definition of allostasis, the toll of sustained stress is manifested in physiological consequences as conceptualized in ALI. The quite specific profile of the elderly expressed in their aetiology, risk factors and presentation of depression seems comparable to the profile of migrants. The specific migration history of Surinamese people that has its roots predominantly in enslavery and indention-labour after have been transported from their original habitat sets Surinamese to fit the profile of migrants and people in diaspora. Surinamese in diaspora are thus at higher risk of exposure to higher levels of stress due to an overall lower socioeconomic status with inherent psychosocial distress and health hazards that increases stress (Menke & Binder, 2014). Like in the elderly, non-western migrants generally substitute expression of emotions by somatisation. Furthermore, as Ford & Mauss (2016) stipulate, non-western migrants often display a preferred emotional regulation that preserves social harmony. This may lead to suppression and endurance of stress in case the social harmony is threatened.

Although ALI is considered a viable and independent diagnostic instrument to measure stress, some considerations have to be taken into account (Gallo, 2014). The fact that allostatic load is a dynamic and multifactorial construct, leads to some unclarities in the operationalisation. As mentioned earlier, there is no consensus as to which (set of) biomarkers should be minimally included to measure the allostatic load in specific groups or disorders. Nor is there consensus as to when and how to correct for medication or other biological influences. A further unclear issue is presented by setting of threshold values to define the clinical findings. Scholars have extensively addressed these problems, but have not reached consensus as to how to address these shortcomings.

Nevertheless, Allostatic Load offers an opportunity to further disclose biological indicators for depression since it is de facto a multi-system biomarker and as such a proxy of multi-system physiological impairment. Considering that the linear association between allostatic load and depression has already been established (Kobrosly et al., 2014), testing this association in a general population is an obvious next step. To date there is no empirical study available of allostatic load assessment that compares mood with allostatic

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load across age and gender in a population homogenous for race. Race in this sense will constitute the Surinamese in diaspora although this group does not technically meet the criteria to fit the definition. Kobrosly et al. (2014) as well as Leahy (2014) confirmed a gender difference with women having higher allostatic loads than men. Seplaki et al. (2004) and Gruenewald et al. (2009) also found that adverse socio-demographic variables are correlated with a higher allostatic load. However, there is ample literature of depression in adolescents, women and migrants from an allostatic point of view.

Concerning the above mentioned, we expect a variation of ALI across the biologic variables age, race and gender. In a follow-up prospective study we will subsequently stratify the Surinamese in diaspora in ethnic strata. By analyzing the consistency in these variables, we aim to unfold the relationships between age race and gender with ALI. More specifically we will try to understand which variables best predicts ALI in the Surinamese community. With this understanding we to be able to design an enhanced method to measure depression, which will add to the DSM-ICD that incorporates this biological variability.

4. ConclusionThis study will provide theoretical and empirical stock of knowledge to diminish the gap in diagnosing depression in Non-Caucasians with a post-colonial legacy resulting in biological and psychological disparity compared with Caucasians. The case in this study will be Surinamese people, recognized as the indigenous people, the Surinamese Amerindians as well as the African-Descendants, Indian, Asians and Chinese, all in diaspora. To date depression is defined by the clinical evaluation of the mental health professional combined with the outcomes of DSM-ICD questionnaires. The theoretical relevance of this study encompasses an adjustment of the concept depression by introducing the allostatic load model to acknowledge the complexity of the aetiology and presentation of depression. Combining the clinical view, demographics, biological measures, and standardized questionnaires offers a bypass for the current construct problems inherent in the DSM-ICD. This presents the field with an opportunity to mitigate the contemporary neglect by exclusion of subgroups that do not fit the mainstream classification system. This will increase the availability of proper diagnostics for women, migrants, elderly and adolescents, subgroups yet at risk.

The allostatic load model may provide mental health professionals with a tool to approach individuals without being distracted by cultural differences in presentation of their problems. The clinical relevance of this research is that introducing the allostatic load in mental health might reduce the risk of misdiagnosis of depression as demonstrated by Kobrosly (2014) in an elderly population. It will enhance diagnostic accuracy, treatment options and health outcomes in groups that are not yet adequately served by contemporary measures. An established generalizability of the model to a heterogeneous population will provide an increase of detection of depressive cases with subsequently increased possibilities for effective treatment and thus to an increased health outcome, reduced morbidity and mortality for namely patients from more collectivistic cultures since they are overlooked in the current construct.

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Including Vitamin D as biomarker in the allostatic load model expands the diagnostic arsenal of the professionals and reveals the impact and meaning of somatic problems in respect to mental health and vice versa. The expected improved health outcomes will reduce the societal costs that accompany an untreated depression. The expectation is that the financial costs of applying the allostatic load model will be negligible compared to the financial costs of persisting untreated diseases as depression is known for its comorbidity with a variety of chronic somatic, psychological and psychiatric diseases, as well as with high psychosocial adversities.

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Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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