Tim Luckhurst : Resist the depression industry

'Just because physicians think they can now treat depression does not mean that a majority of their patients are depressed'
Click to follow
The Independent Online

Be miserable, be really miserable. The new generation of antidepressant pills, selective serotonin re-uptake inhibitors (SSRIs) such as Prozac and Zelmid, could ruin your life. SSRIs have been responsible for the biggest boom in depression ever. Millions of people who didn't even think they were glum have been diagnosed as clinically ill. I was one of them, and I resent it.

Eighteen months ago I knew I was unwell. I had bronchitis and hypertension. I was physically exhausted. It had not crossed my mind that I might be clinically depressed. In retrospect I know I was not. My doctors didn't see it that way and, since they seemed certain they could treat the condition, I accepted their diagnosis.

The same certainty is offered to millions of Britons every year. The Royal College of Psychiatrists (RCP) says that between six and seven million of us, approximately 10 per cent of the population, are clinically depressed. The World Health Organisation estimates the cost of the disease to the British economy at £3.4bn per annum, more than the cost of breast cancer or diabetes. If the experts are right, then the song is wrong. It is depression, not love, that is all around. But the crucial problem is that prevalence, even if it exists, does not make depression tolerated.

Dr Peter Byrne, a consultant psychiatrist with the East Kent Hospitals Trust and a member of the RCP campaign against stigma, is blunt. "If you tell your boss you've been treated for depression, you are worse off than someone who is caught with their hand in the till." Another expert says that "Employers still regard a history of depression as less desirable than a prison sentence." Having been sacked as a direct consequence of my diagnosis, I wholeheartedly agree.

Given the consequences, doctors ought to be very certain before diagnosing depression. But Dr Jim Bolton, lecturer in psychiatry at St George's Hospital, London, is candid. "There is no test for depression. Our understanding of the brain is simply not sophisticated enough. You diagnose from behaviour. Patients may well be depressed if they can't concentrate at work, their self-confidence has gone, they are having difficulties with their sex-life or are unable to sleep."

And Dr Bolton is in no doubt about why depression has become so prevalent. "We are more likely to diagnose depression because there are drugs available to treat it."

That's an understatement. Until the introduction of the first wave of tricyclic antidepressants in the late 1950s, clinical depression hardly existed. In the 19th century, melancholia was treated at spas in Switzerland and Germany, and was only available to the rich. In the 1860s opium was found to be an effective mood-enhancer, although the side-effects were considered risky even then. Electroconvulsive therapy of the type made famous in One Flew Over the Cuckoo's Nest was first attempted in 1938. None of these was cheap or effective enough to make depression popular. Drugs democratised it.

A growing number of doctors see the irony in the explosion of depression diagnoses. For them, the introduction of antidepressants in 1958 was of epochal significance. As soon as depression became treatable, its diagnosis rose in frequency. And that first expansion was massively accelerated in the 1980s when SSRIs arrived.

SSRIs avoid the side-effects of the old drugs. They don't make patients feel leaden or cause weight gain. They have become spectacularly popular. The British Medical Journal suggests that approximately 65 per cent of depressives are now treated with SSRIs. Since they hit the market there has been a 50 per cent increase in the number of patients deemed to be suffering from clinical depression. One psychiatrist told me that "depression may be common, but the irony is that the more successful the treatment, the commoner it becomes".

SSRIs work on the theory that depression is caused by a shortage of a chemical called serotonin in the brain. This deduction is based on science, but psychiatrists admit the drugs work by accident and came about by serendipity. One admits: "We can't say with hand on heart that serotonin shortage causes depression. We only know the drugs work from observing patients."

No patient who receives SSRIs from his doctor is ever tested to establish the serotonin level in his brain. The apparently precise formula "replace serotonin – feel better" that doctors use to explain the treatment is guesswork, not science.

And doctors face another dilemma. SSRIs must be taken for six months before they have any effect against relapse. Most sufferers from clinical depression will get better naturally in not much longer. Just 20 per cent of depressives stay unwell or get worse if they are not treated. The other 80 per cent start to get better in six weeks if they are treated and in between nine months and a year if they are not.

In other words, most of the patients the RCP believes are in danger of losing their jobs if their employers discover they are being treated for depression would recover if they were not treated. A minority would not, and 6 per cent of untreated clinical depressives commit suicide. But the majority of British citizens currently taking SSRIs would get better without them. If they rejected both the diagnosis and the prescription, they would avoid the risk of economic and social stigmatisation.

For some, the solution is to abolish stigma. Dr Byrne says: "When I was a kid, cancer was the biggest secret you could have. Now it's depression. I encourage openness and transparency because it matters, but I often recognise the reality of stigma by asking GPs to write sick notes saying the patient is suffering from something physical. Statistics for time off work in Britain significantly underestimate the real numbers suffering from depression because patients take in notes that say they have back-pain."

Back pain accounts for 119 million days off work every year – 25 per cent of absenteeism. If 25 per cent of back pain is really depression, this would appear to strengthen the argument that unrecognised depression is a bigger problem than false diagnosis or the over-prescribing of SSRIs.

But does it? Britain is facing a problem which hit America during the "Prozac craze" of the 1990s. A combination of humanitarian and commercial pressures has persuaded doctors to conflate two entirely separate phenomena; unhappiness and depression. There is an enormous burden of unhappiness. Some of it is clinical depression, but an awful lot is not. In the words of another expert, "We should not convert all human problems into illness. SSRIs make everyone feel good. They are for many a kind of magic pill for unhappiness caused by the structure of their lives. But it is not the job of psychiatry to lend the lustre of science to this kind of folkloric self-medication that is driven forward by commercial interests."

As the RCP's campaign against stigmatisation gathers strength, Dr Byrne insists that "there will be big test cases. Soon. Watch this space".

Sceptics are asking whether they might be avoided if doctors did less to confirm unhappy employees' suspicions that they are clinically ill. Physicians love to diagnose what they can treat, but the fact that they think they can now treat depression does not mean most patients are depressed.

Even if they are, the best advice, that few doctors will offer is this: reject the diagnosis. Throw away the the pills. Take a rest and get better naturally. For most people, that approach will work just fine. And it won't leave you unemployed. Believe me, it's a lot less depressing than suing.

TimLckhrst@aol.com

Comments