Why the drugs don’t work
The problem isn't that doctors are too quick to prescribe anti-depressants, but that they have stretched the label of depression to cover the full range of human unhappiness.
According to new official guidelines issued by the UK’s National Institute for Clinical Excellence, GPs must be more cautious about prescribing anti-depressant medications (1).
Prescriptions for drugs in the Prozac group (selective serotonin reuptake inhibitors, SSRIs) increased from 6.5million in 1997 to 19million in 2003. These drugs should now be reserved for patients with moderate or severe or prolonged depression, while those with milder forms of melancholy or symptoms of anxiety should be referred for counselling or cognitive behavioural therapy.
In response, doctors’ representatives have complained about the chronic shortage of counsellors and psychotherapists. We leave aside here the considerable doubts whether such techniques are more effective than medication, and whether they have less adverse consequences, and instead focus on a prior consideration: the question of the diagnosis of depression and how widely it is applied (2).
In the new guidelines, the prevalence of depression is expressed in terms of the proportion of people who are believed to be affected ‘each year’: one in 15 women, one in 30 men. These figures stand in marked contrast to the headline-grabbing estimate of ‘one in four’ (the lifetime prevalence of depression) that featured in the 2003 Department of Health campaign Mind Out for Mental Health (3). If a quarter of the population is being urged into their GPs’ surgeries to seek treatment for depression, this is likely to lead to the excessive consumption of whatever form of treatment is available. Even if the adverse effects of any particular treatment are relatively rare, the number of people affected will inevitably be substantial.
The origins of the current situation can be traced to the launch in 1992 of the Defeat Depression campaign, sponsored jointly by the Royal College of Psychiatrists and the Royal College of General Practitioners (4). The main aims of this campaign were to ‘educate practitioners, particularly GPs, about the recognition and management of depression’; to ‘educate the general public about depression and the availability of treatment’; and to ‘reduce the stigma associated with depression’.
A diagnostic term formerly restricted to patients so severely afflicted by melancholy that they might require hospital admission was now adapted to cover a wide range of responses to existential distress, resulting from workplace dissatisfaction, marital disharmony, bereavement or other losses. According to David Healy, psychiatrist and historian of anti-depressants, ‘depression as it is known or understood by the public in the 1990s, was all but unknown as recently as 35 years ago’ (5). He estimates that the promotion of depression by the psychiatric profession – and its ready acceptance by the public – resulted in a one hundred-fold increase in prevalence over this period.
The Defeat Depression campaign, which was actively promoted by pharmaceutical companies, was particularly concerned to tackle the ‘public’s failure to recognise the value of drug treatments’. It produced some three million leaflets in its first two years, and though the campaign provided information about ‘talking treatments’ and ‘alternative treatments’ such as St John’s Wort, its main effect was to encourage both GPs and their patients towards anti-depressants. It was not surprising that sales of Prozac, first marketed in the late 1980s, grew exponentially in the 1990s, nor that this pharmaceutical blockbuster was rapidly followed by a range of similar SSRIs.
Though Defeat Depression was planned to last for only five years, its propaganda is still readily available on the internet. In 2001, it was complemented by a further Royal College of Psychiatrists campaign, Changing Minds, which focuses on the third aim of the earlier campaign – challenging the stigma of mental illness, which the psychiatrists claim still leads to the under-diagnosis of depression (6).
The compulsory admission to mental hospital of the former heavyweight boxing champion Frank Bruno in September 2003 provided a major boost to the campaign, when tabloid newspapers were obliged to withdraw disparaging comments. In fact, the Bruno episode confirmed that, far from being stigmatised, a diagnosis of depression is not only socially acceptable, but even creditable. (A cynical publicist to the stars might even recommend such a course of action as a way of rescuing a flagging celebrity career.)
In his 1963 classic Stigma: Notes on the Management of Spoiled Identity, the American sociologist Irving Goffman exposed the ways in which contemporary society discriminated against those who were different, regarding their differences as signs of moral inferiority (7). But today things have become reversed: we celebrate difference and particularly cherish the status of victimhood, which is held to confer a certain moral authority.
In popular culture, the outsider of the 1960s has become mainstream: the geek, the freak and the damaged have all now won public approval (8). From Princess Diana to Frank Bruno, celebrities who reveal their vulnerabilities and embrace psychological disorders are the authentic popular heroes. Now that even madness and disability have become fashionable, the campaign against stigma serves to promote the expansion of psychiatric diagnosis to cover more and more people and a wider range of behaviour.
Given the particular concerns expressed in the new guidelines about the prescription of anti-depressants to young people (because of an apparent increase in risk of self-harm and suicide), it is interesting to note that the Changing Minds campaign emphasised that doctors should be alert to the diagnosis of depression ‘at any age, even in children and young people’. Just as the Defeat Depression campaign encouraged GPs to prescribe anti-depressants to adults, the subsequent campaign had the effect of increasing the medication of children.
Having sponsored campaigns that encourage a substantial proportion of the population to embrace the labels of mental illness – and their doctors to treat them accordingly – the authorities are now baulking at some of the consequences. If millions of people are taking mind-altering drugs to help them to cope with every exigency of life, then it is inevitable that some will commit harm to themselves or others while they are taking these drugs.
It is unlikely that it will ever be resolved whether the drugs cause or increase the risk of such behaviours. But rather than now telling GPs to stop prescribing anti-depressants, it might be more constructive for doctors and psychiatrists to ask whether it is beneficial either to individuals or to society to label a quarter of the population as being mentally ill.
Dr Michael Fitzpatrick is the author of MMR and Autism: What Parents Need to Know, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA).
(1) GPs get new anti-depressant rules, BBC News, 6 December 2004
(2) Therapy Culture, Frank Furedi, 2004
(3) Therapeutic Pi, by Michael Fitzpatrick
(4) Defeat depression, on the Royal College of Psychiatrists website
(5) The Anti-Depressant Era, David Healy, 1997
(6) Changing minds, on the Royal College of Psychiatrists website
(7) Stigma: notes on the management of spoiled identity, Irving Goffman, 1963
(8) Arrested Development, Andrew Calcutt, 1998
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