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Friday, 21 August 2009

Is the "depression epidemic" really as bad as it appears?

The World Health Organisation has stated that by 2020 depression will create the second largest "health burden" in the world after heart disease. This is a prediction made made on the basis of data analysed by Harvard University Faculty of Public Health. At first sight, this appears to match up with our perception of the society we live in and the clients we work with - more stress, greater unhappiness, increased social and family breakdown. But hold on a minute. Is it really that clear cut or does the WHO position hide a more worrying trend which a brief history tour should illuminate.

Since the marketing of diazepam (Valium) in 1963 for "anxiety disorders" in 1963, their prescription (along with other prescription of other benzodiazepine anxiolytics reached a peak of 24.5 million prescriptions in the UK 1982. In the late 1970s pharmaceutical companies decided that they wanted to replicate Valium's success with other psychiatric drugs. They knew that despite the drug's success, past experience indicated it would be self limiting and that criticism's of valium's "addictive qualities" were already arising in the literature. As a result, they lobbied the American Psychiatric Association, who were reconsidering diagnostic categorisation for DSM III. As a result the APA radically changed their definition of "depression", with the primary effect being to broaden it substantially in 1980. Valium prescriptions peeked in 1982. However the new definition of depression opened up a new huge market for antidepressants and the arrival of Prozac in 1988 cemented the new broader definition of depression into place. In other words, the broadening of the definition of depression has been largely driven by the need to market new drugs.

In practice, most psychologically distressed clients still present with a mixture of anxiety and depression, as they were in 1970s, except that medication driven diagnosis classifies it as "depression". Secondly, the relative lack of addictive properties of SSRIs has meant that their prescription has escalated beyond that that existed for the benzodiazepines. 31 million were prescribed in 2006. Many have seen this is an acceptable price to pay in order to destigmatise requesting help for psychological problems. The price has been a high one however. The medicalisation of psychological distress and unhappiness for large sections of the community has meant that it has disabled and disempowered such individuals and has often legitimised victim roles. It ultimately makes people less (rather than more) psychologically minded about their problems and averts our gaze from the more fundamental question of why are more of us feeling unhappy and stressed, and feel life lacks meaning. Using a medical diagnosis is inappropriate and unhelpful.

Our seminars on 'Working with Depression: New Thinking & Effective Interventions' give us an opportunity to discuss these and many other issues. I am sure they will be stimulating training days for all of us. However, I welcome any of your thoughts on the topic here.

Best Wishes
Paul Grantham

9 comments:

  1. My personal views on the above!!

    I don’t believe the “depression epidemic” is as bad as it appears, I think there are financial motives in encouraging us to believe this is the case. I agree with the statement “the medicalisation of psychological distress and unhappiness for large sections of the community has meant that it has disabled and disempowered such individuals and has often legitimised victim roles”. We appear to have lost sight of the fact that unhappiness and distress are normal human reactions to life events such as loss and bereavement, external disasters, catastrophic events and major changes in our life situation, that are often of our own making, e.g. divorce and debt. We have lost sight of the fact that some of us are more optimistic than others – the glass is half full, - the glass is half empty, that we are individuals with unique and different ways of coping with what life throws at us. Life appears to be too demanding and busy for us to offer support, understanding, encouragement and normalisation of the feelings experienced when someone is having a difficult time; we want an instant fix for it. The drug companies have encouraged us to believe that if we can’t cope it’s because we have a ‘problem’, i.e. depression, and they can fix it instantly with medication. The ‘victim’ no longer has to take responsibility for their actions and reactions, the drug companies have taken it even further an article in The Independent, 3 June 2008, reported on the drug companies marketing of medication for all manner of behavioural ‘problems’ from blushing, shopping, gambling, public speaking, poor social skills, and low sex drive amongst them. We have forgotten what it is to be human, the diversity and uniqueness of being an emotional human being. Yes there are people who suffer sever clinical depression and other psychological disorders that require medical or therapeutic intervention but why do we need to treat blushing with both surgery and medication? Throughout my teenage years and into my twenties and even still now occasionally I blush, it was embarrassing and yes I was teased sometimes but I would have objected strongly to being told it is anything other than normal, being part of me as an individual and the passage of moving through being an awkward, shy teenager to becoming a more confident, forthright adult.
    We are constantly bombarded with images by the advertisers on how we should look, how we should live, how we should behave, what we should aspire to and if we can’t achieve it then it’s not a problem that can’t be fixed by medical intervention whether that be surgery or medication. It encourages us to believe that we are no longer ‘normal’ and that experiencing the many facets of being the emotional humans that we are is not a necessary part of life, it will stunt our growth as individuals and limit our ability to learn and cope with the diversity of life, we will no longer be able to recognise our feelings and the difference between happiness, embarrassment, anger, sadness, shame and all the other ranges of emotion that we experience and learn from during our lifetime. It will alter the way we interact with one another the way we socialise, what we look for in potential partners, if left unchallenged eventually it will stop us being human we will be medicalised autonomens!

    B.N., Primary Care Mental Health Team, Leeds

    ReplyDelete
  2. Dear Paul,
    Thank you for your message, I am a counsellor working with women who are in
    or just out of a domestic abusive situation. I find that at the beginning
    these women ask or are given anti depressants. As I do not promote for them
    to come off them as I am not medically trained, I do find it hard to work as
    well as I would like to with these ladies, as I find that there moods are
    restrained, which I mean that they don't have up's or down's I don't see the
    anger there fears or there worries and even the happy times, as I feel that
    some of these tablets might hold them back from expressing these feelings.
    Which I feel that these ladies could do with expressing fully to be able to
    move on in some cases.
    I look forward to the course.

    J.S.

    ReplyDelete
  3. Hi Paul
    I found the content of your recent post interesting and thought-provoking.
    I would just like to say that I work in a University Student Counselling
    Service and have been finding that among my client group there is generally
    a strong reluctance to see their GP about their situation in the belief that
    they will be 'persuaded' to take anti-depressants. So maybe the tide is
    turning, particularly in young people.....??? I find they often experience
    great relief when they find I am willing to work with them just as they are,
    without medication , as long as they are well enough to engage with me and
    the counselling process. I do, of course, recognise that for some clients
    who are too deeply distressed for this to be possible the best way forward
    is to make an informed choice about medication with their GP support with a
    view to enabling them to be in a better place to address their issues in
    counselling. Even so, we focus on the ultimate goal being empowering them,
    not medicalising their unhappiness.

    Looking forward to the seminar!

    V.T.
    -------------------

    ReplyDelete
  4. I totally agree the question is very much "Why?" I can see a collection of reasons; the errosion of connectedness, identity and moral vision that our modern comercially driven society causes, the proliferation of mental pain due to, attachment dissorders and other mental disorders and physical pain due chronoc illness and accident victims carrying on some sort of a life also has a part to play. We are sold the dream that physical existence is everything and that you can buy fixes to all the problems of prolonging of life. Beauty youth and self gratification are on the alter in the Church of
    commerse.

    S.W., Adoption Support Social Worker
    ________________________________

    ReplyDelete
  5. Very briefly. I think this is a hot topic and it is one that is dear to my
    heart.
    I see a large number of people whose problems lie in the development of
    their personality who have been wrongly diagnosed as suffering from
    "depression" and as a result have languished in psychiatric outpatient
    clienics for a decade or more. They are constatntly tried on new medications
    which, unsurprisingly, never achieve the desired result. The service user
    complains that they are still no better and feels increasingly hopeless.
    It's a disgrace.

    N.R., Consultant Clinical Psychologist.

    ReplyDelete
  6. Hi Paul

    I have read your post with interest, as a practicing therapist I see many
    clients who express the symptoms you list in your article, anxiety, stress,
    depression and most curious of all a lack of purpose. Clients who freely
    offer the information that they have the perfect life, wonderful spouse,
    beautiful home, high standard of living and a job which inspires them
    frequently tell me that they have no purpose in their lives and feel that
    something is missing, this is obviously important enough for them to seek
    help. It can be difficult to work with these clients as they are frequently
    unable to contact emotions, memories or be able to visualise. As the main
    part of my practice is hypnotherapy it is important to find ways of working
    with these clients to enable them to contact their emotions and discover
    what it is that they want from life. Fortunately I have been able, by
    thinking laterally, to discover ways of empowering these clients and freeing
    them to experience their own emotions and contacting their memories. I am
    curious if this relates to Maslow's Hierarchy of needs and would be
    interested if you have a different view.

    I am looking forward to the course and to meeting others who are interested
    in this challenging area of therapy.

    Regards,
    A.H.

    ReplyDelete
  7. Dear Paul,

    Thanks for that, it raises several interesting questions.

    What evidence is there that people are 'less psychologically aware' as a result of the medicalisation of their distress? Many people are reluctant to take medication but come to see it as one of the tools to help them reduce their distress. It doesn't mean they will not look at the causes of their distress (and actually become more psychologically aware) just because a GP labels it and offers a prescription.

    Doesn't medication have an important role in enabling people to engage in therapy or find their own answers to their issues? I think it's a shame to suggest too strongly that medication stops people working through things as I see many people courageously taking steps in this direction.

    Have individuals become disempowered? What about the argument that the fact that there is some effective relief for their distress enabled them to focus their energies on making changes in their life that are beneficial?

    I'm currently very interested in mindfulness and hope that this can be of help to many people who struggle with distress of any kind.

    I'll look forward to the course.

    Best wishes,

    J.B., Hearing Therapist, London

    ReplyDelete
  8. Dear Paul,

    In response to your message regarding depression, I have many thoughts on the subject. Society on a whole are becoming less psychologically equipped to deal with the increasing internal and external stressors society place on us. The quick fix solution offered by pharmocological model seeks to reafirm my thoughts on this. Although anti-depressants are perceived to be less "chemically addictive" I would argue that the quick fix solution offered to patients and clients disables them to the point that they cannot see themselves coping without the use of medications.

    When a client realises they cannot problem solve effectively and require help, they are subsequently classed as depressed, the client at that time experiences sleep disturbances, appetite disruption and lack of motivation thus prohibiting activities they may have once enjoyed. This symptomology is well known to decrease serotonin levels even further. I would suggest that a client that already has a depleted serotonin level is further exacerbated by the afore mentioned symptomology. On receipt of anti-depressants which can take upto 21-days to reach any form of therapeutic level, I would suggest that a restoration/replacement of serotonin levels will reduce the severity of symptoms and allow the client to restore diet, sleep and activities thus adding to the depleted store of serotonin. Therefore I do not necessarily believe that clients require the anti-depressants for the duration they are prescribed. I have heard doctors state that clients need to be on medications for at least two years. The client becomes dependent on the need to take medications as they feel they cannot cope without them thus emphasising my belief that anti-depressants are equally as addictive. Not only that but some medications actually make the problem worse, mirtazapine (Zispin) was used by female prisoners to produce feelings of high, some side effects include weight gain (lowering already low self-esteem). Is the prescribing of antidepressants therefore compounding the problems the individual feels.
    (cont...)

    ReplyDelete
  9. (...cont)
    When the client starts to reduce medication it stands to reason that they may initially feel discomfort however the anxiety they present with will often lead to a reinstatement of medication. The antidepressants often prescribed to alleviate depressive, anxyiolitic symptoms often have side effects which can be equally distressing for the client therefore creating a rebound effect in that the client will either feel they require more medications or do not wish to continue with medications. The result of this is the self- medication route for the particular type of client that may have some addictive personality traites.

    In response to the use of benzodiazepines, many of todays clients have been prescribed benzodiazepines for long periods of time. Tolerance to the medications develop and the need for increased dosages ensues, however with all medications benzodiazepines can also have a paradoxical effect in that anxiety may increase with the use of the medications again further increasing the clients perceptions that they require stronger doses. When reducing benzodiazepines the anxiety a client feels can become so overwhelming (panic attacks at the thought of not being able to cope) they are fearful of discontinuing medications and will if not prescribed attempt to find alternative methods to combat anxious state for instance procurring medications on the internet, from drug dealers, using alcohol etc. Not being able to cope can lead to perceived depressive symptoms, self-harm, suicide attempts etc.

    In essence, I feel that the continued prescription for anti-depressants and anxiolytics compounds the problems for the client. When not on medications how will they ever combat or come to terms with life's issues. The person on antidepressants or anxiolytics may feel ill equipped to deal with their problems and by prescribing medications we as a society are reinforcing that belief. We have to ask ourselves is depression an illness or a social construct arising from a society that no longer has the time or the inclination to spend time with the individual that feels low. Instead I find that a lot of people due to their own personal life stressors neither have the time or inclination for the rest of society.

    Currently the Government and Department of Health are arguing that Clients should have more access to talking therapies and yet, access to training and ability to deliver time with patients are not readily available also patients are sceptical about their ability to overcome their problems without access to medications.

    I apologise for the long winded email but I have lots of thoughts on this subject and these are but just a few. If you have any counter points you wish to discuss please feel free to email me.

    Yours sincerely

    S.J.

    ReplyDelete

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