The Big Question: Is depression increasing, and what is the best way to treat it?
Why are we asking this now?
The National Institute for Clinical Excellence (Nice) yesterday published updated guidelines on the treatment of depression calling for extra focus on talking therapy, especially cognitive behaviour therapy, for depression and less focus on drugs. It also warned GPs to be more alert to depression in people with chronic health problems, amongst whom the condition is three times more common than in the general population.
Have anti-depressant prescriptions increased?
Yes, spectacularly. Prescriptions have more than doubled since the mid-1990s to over 36 million a year, leading to allegations that Britain has become a pill popping nation, addicted to "happiness" drugs. An estimated 3.5 million people take the drugs, collectively known as selective serotonin reuptake inhibitors (SSRIs), which include Prozac and Seroxat.
Their popularity soared after they were launched in the late 1980s, heavily promoted by drug companies as safer and having fewer side-effects than the older tricyclic antidepressants. The publication in 1994 of Listening To Prozac by Peter Kramer, in which he suggested anyone with too little "joy juice" might give themselves a dose of the "mood brightener" Prozac, lifted sales into the stratosphere.
Is that because more people are depressed?
Apparently not. The number of patients newly diagnosed with depression by GPs in the UK in the 11 years from 1993 to 2004 declined by 25 per cent, according to researchers at Southampton University. They based their calculation, published last week in the British Medical Journal, on results from 170 GP practices which showed the incidence among men declined from 7.83 to 5.97 cases per 1,000 patient years. Among women, who suffer more depression than men, the incidence declined from 15.83 cases to 10.06 per 1,000 patient years.
So why the rise in anti-depressants?
People are taking them for longer, according to the Southampton researchers. They found the average number of prescriptions issued per patient doubled from 2.8 in 1993 to 5.6 in 2004. The majority were given as long-term treatment or intermittently to patients with repeated episodes of depression. The researchers found 90 per cent of patients prescribed drugs for depression are now taking them continuously or as repeated courses over several years.
What is depression?
Loss of pleasure in things that were once enjoyable and in other people and your usual activities. Often accompanied by irritability, tiredness, feelings of worthlessness and thoughts of suicide, problems with sleep, concentration and memory. It affects nearly one in six people in the UK at some point in their life, according to Nice, and half of those affected will go on to have further episodes.
Should fewer people be on anti-depressants?
Not necessarily. Depression can be a serious illness which destroys a person's quality of life and imposes a huge burden on them, their families and society. It causes more deaths, by suicide, than any other psychiatric disorder. In severe cases drugs can be life-saving. In moderate cases, too, drugs can transform a person's outlook so that they are able to make changes to their life necessary to escape from depression, which seemed impossible while they were depressed. Depression has historically been under-treated and in the 1980s, the Royal College of Psychiatrists launched a campaign which ran for a decade to increase the numbers in treatment.
Should more people be taking anti-depressants?
Yes and no. There are many people who suffer with depression, sometimes for years, before seeking treatment, who would be better off on the pills. On the other hand, there are many with mild depression who are popping pills when talking therapy might have been a more effective way of dealing with their difficulties. In some GP practices in south Wales, for example, as many as one in 10 of the adult population are taking anti-depressants. This is medicalising social problems on a mass scale.
Is depression neglected?
Yes, because of the associated stigma. There was a comic acknowledgement of this – comic, if it weren't tragic – when No 10 last week ordered a change to a headline on its website that read "Battle to stop depression is being won – PM". No 10 officials, who were allegedly aghast when they saw it, ordered the immediate substitution of "downturn" for depression.
This reflected the extraordinary sensitivity over questions about the PM's state of mind – as controversially put by BBC presenter Andrew Marr two weeks ago – as compared with questions about his physical health (No 10 was happy to reveal Gordon Brown had received attention for a retinal tear to his eye). The episode highlights one of the biggest challenges faced by people with mental problems such as depression – coping with the stigma. If you break your leg, you have a problem with your leg. If you have depression there is a problem with you.
Do anti-depressants work?
Yes, according to most psychiatrists. Research suggests 70 per cent of people treated with anti-depressant drugs feel better as a result. But a controversial paper published last year questioned this view. Meta-analysis of 47 trials of six of the best known anti-depressant drugs, including some trials that were unpublished, concluded the drugs were no better than placebo in the vast majority of patients. Only in a very small group of the most extremely depressed were the drugs more effective than placebo. The findings by Professor Irving Hirsch of the University of Hull, published in the online journal Public Library of Science (PLoS) Medicine have been challenged by a number of researchers.
How should you treat it?
A couple of decades ago the advice to those who were depressed and out of work was to get "on yer bike". Today it is as likely to be to get on the couch. Cognitive behaviour therapy (CBT), in which patients are taught to break habitual ways of seeing things and to think positively, has revolutionised the way doctors approach the treatment of depression. Whereas in the past GPs might have prescribed Prozac or other anti-depressants, CBT is now the treatment of first choice – where it is available – for the millions who turn up complaining they cannot cope.
What does Nice recommend?
Nice says exercise combined with cognitive behaviour therapy (CBT) should be the first line of treatment for mild to moderate depression. Regular exercise is a good way of beating the blues and CBT is established as the most effective of the talking treatments. Many doctors worry that drugs create a dependency culture. The Nice guidance is aimed at helping people to develop the skills to overcome their depression. For people with moderate or severe depression, it says anti-depressants should be combined with CBT for the best results. In people who are severely depressed, drug treatment may be necessary initially to lift their mood sufficiently for them to respond to the CBT.
Should more people be prescribed drugs for depression?
* Depression can be a serious illness that causes more deaths than any other psychiatric disorder
* Anti-depressants are effective at lifting mood in 70 per cent of those who take them
* Many people suffer for years with depression before seeking help because of the stigma
* Prescribing drugs creates dependency without helping people to solve their problems
* In some parts of the country, prescribing is so widespread it amounts to mass medication
* Cognitive behaviour therapy is established as an effective treatment for depression
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