|Not quite as good as advertised.|
In the 1950s, Roland Kuhn identified an apparent antidepressant effect of the drug imipramine. Given what we know about depression in the 21st century, it's tempting to guess that the drug companies must have been over the moon with greedy excitement.
Not so. Clinical depression was regarded as a relatively small problem, unlikely to result in sufficient sales to recoup the costs of drug development and testing. Nevertheless, the pharmaceutical company Ciba went forward, and imipramine became the first of the tricyclic antidepressants on the market.
Since then, additional varieties of medication have been touted as antidepressant in action, and the antidepressants as a class have become some of the biggest moneymakers in pharmaceutical history. At the same time, numerous psychotherapies have been proposed and tested, and community mental health centres have sprung up across the developed world.
The aim of individual drugmakers may be to create profits, but the ultimate goal of the healthcare sector is the enhancement of human health and well-being and the minimization of illness, disability, and premature death. Tuberculosis, for example, was a major cause of disability, hospitalization, and death a hundred years ago. Today it remains a problem - but the sanataria have closed, hospitalizations are few, and deaths are a rarity. This is the mark of at least partial medical success.
After 60 years of intervention with depression, it’s reasonable to ask how we are doing.
To this end, we can look at a series of epidemiological markers that we might hope to improve with our efforts. We can classify each as successes, failures, or worse:
- Success: Improvement on a marker.
- Failure: Lack of movement on a marker that is clearly the target of intervention.
- Worse: Movement in the wrong direction.
Let’s take a quick look at several of the most important markers. I won't go into full detail about any of these, but there is quite good data out there to address most of them.
Incidence refers to the rate of new cases of a disorder appearing within a given period of time (often a year). As noted above, in the 1950s depression was regarded as a rare disorder. Relatively few people were hospitalized with it. Estimates ran as low as 100 cases per million population. Today, 10% or more of the population is predicted to develop a major depressive episode in their lifetime. This represents a lifetime incidence of up to 100,000 cases per million. As psychiatrist David Healy has said, "Something must surely be going wrong if our treatments are so good yet the frequency of depression jumps a thousand-fold since the discovery of the antidepressants."
This represents an extreme example of case inflation, and almost certainly we do not have 1000 times as many depressed people as before we developed effective treatment. No one, however, disputes the increased incidence of depression since the 1950s. Verdict: Worse.
Prevalence refers to the number of cases of a disorder present within a population at a given point of time. Community surveys in the 1930s and 1940s reported less than one case per thousand (Silverman, 1968). In the 1950s, relatively few cases were identified in any given population. Today, an estimated 3-5% of men and 8-10% of women experience a major depressive episode in any given year. Again, estimates vary, and it may well be that many cases were missed in the 1950s. Despite this, no one has mounted a persuasive argument that the prevalence has declined or remained stable. Verdict: Worse.
Age at First Onset
Some illnesses are common results of aging. Occasionally, for example, one will hear that the rate of prostate cancer in males is likely to be 100% - if you're male and live long enough, you will get it. One of the goals of care is to put off the development of these common disorders until later in life. If we could put off the appearance of arthritis until age 90, for example, champagne corks would be popping at celebration parties - even if no fewer people eventually developed the problem.
For most of the 20th century, depression was described as a relatively rare disorder that tended to strike in mid-life and beyond. Since the 1980s, the average age of onset has been placed in the 20s - particularly the late 20s. In the 21st century, increasingly first episodes of depression are regarded as being most common in the early 20s. Verdict: Worse.
One obvious problem in the comparison of modern-day statistics from those in the 1950s is that case-finding has changed. People may have suffered in silence formerly, never seeing their physician nor being counted in surveys. Today we have public education campaigns, and screening questions about depression are common in standard medical examinations. This would mean that the average severity today should be lower than in earlier times, when one had to be utterly undone in order to seek treatment. Indeed, many people today are described as depressed despite working and carrying on reasonably productive lives.
The number of people experiencing severe depressive episodes, however, has unquestionably gone up rather than down. Hospitalization for depression today is more common than it was in the middle of the last century, and tens of thousands are forced to leave work due to the magnitude of their symptoms. Verdict: Worse.
In Anatomy of an Epidemic, Robert Whitaker reviews descriptions of the normal course of depression in the past. Between 39% and 60% of the severe cases that sought care at that time never had another attack, and a chronic course characterized by multiple episodes and poor inter-episode recovery was apparently rare. Robins & Guze (1972) reported that 50% of people hospitalized for depression did not have a second episode within ten years. Between episodes, recovery was expected to be virtually complete, with few or no lasting effects.
Today, recurrence is common and expected, and people with chronic mood difficulty are commonly seen. Depression, it is said, is best regarded as a chronic condition characterized by multiple episodes and relapses. Verdict: Worse.
Number in Treatment
At one point smallpox was a major strain on medical resources. Today no living doctor has seen a case in many years. This can be a goal for medicine: to so thoroughly defeat a disorder that it no longer shows up in a population. For many problems, however, eradication is not a reasonable goal. Once we develop effective treatments, we hope that all those who have been suffering at home will come to have their problem dealt with.
It would be nice to see depression eradicated, but this is perhaps unrealistic. If we have effective treatments, however, we can expect that symptoms will be well managed and people will not need intensive, ongoing care. We can provide the odd prescription renewal, for example, and not have to do much more.
This is not the situation in which we find ourselves. We have many more outpatient treatment resources than in the 1950s, but these are strained to the limit. Clinics everywhere have wait lists, and physicians report that the depressed make up a great deal of their clinic practice. Verdict: Certainly no better, and by most standards Worse.
As noted above, depression was formerly regarded as an episodic illness characterized by full inter-episode recovery. Although many people were disabled by other medical problems, once depression lifted most people returned to their regular life roles.
Since the 1980s, however, disability management organizations have noted that depression has leapt up the list of disability causes. Today, depression is regarded as the first or second most common cause of long term disability claims in Canada and elsewhere. Where it is not presently at the top of the list, most organizations expect it to take the lead within a few years based on current trends. Verdict: Worse.
If we treat a problem effectively, people should return to health and reasonably good life satisfaction, and they should live close to a normal lifespan. Recent studies of people with HIV, for example, suggest that with modern treatments the lifespan should approximate the population average.
Studies of lifespan for people with depression in the early 20th century either do not exist or I have not found them. Nevertheless, with the relatively good recovery between episodes reported at that time, it seems likely that average lifespan would not have been enormously impaired. It would not be surprising that with the more severe and disabling courses being described today, life expectancy had been reduced. And indeed, recent findings suggest that clinical depression can reduce life expectancy by 7 to 11 years (for a review, see here). Most of this is not due, as one might think, to suicide, which is not as common in major depressive disorder as commonly thought (see my previous blog post here for more on this issue). Something else is going on. Verdict: Difficult to evaluate with any certainty, but probably Worse.
What's Going On?
If the mark of successful medical intervention is that a disorder appears less often, is less prevalent in the population at large, appears later in life than previously, is less severe when it happens, if recurrence is less frequent and recovery is more complete, if the burden on the medical system is lower, if disability is minimized and mortality is reduced, then we consider the intervention a success. Sometimes we achieve gains on a few of these measures but not all of them.
In the case of depression, however, the problem has worsened on virtually all fronts. We are routinely told "The good news about depression is that we have safe, effective treatments. See your doctor!" But if this were true, surely we should see better results in the population.
The problem is clearly not that people go untreated. In British Columbia, a study in the early 2000s indicated that 19% of adult females had been prescribed an antidepressant in a single year. Over-diagnosis and over-treatment are increasingly being raised as significant problems (for an example, see here).
There is no doubt that many people have been helped by medication and other treatments for depression. But if this benefit is reliable and in any sense powerful, it should have an impact that can be seen in the population as a whole. To have no real sign of population-wide improvement and, instead, clear signs of population-wide worsening? This should sound warning bells that for the most part have remained silent.
We can sum up the possible problems in four main categories, while acknowledging that there may be more factors as well.
Cultural change. There have been vast changes in the way we live our lives since the 1950s. Our culture has devoted itself to the service of economic goals rather than life satisfaction and, perhaps not surprisingly, many of the changes have been in directions that likely contribute to the incidence of depression. These include reduced exercise, poor diet, less social contact, an increased emphasis on material success, and so on.
Border Creep. Over time, the range of mood and functioning that we consider to be normal has narrowed considerably, and the definitions of mental illnesses have correspondingly broadened. Each succeeding edition of the diagnostic manual (the DSM) has resulted in a larger proportion of the culture being diagnosable as ill. Depression is a much broader category than it was in the 1950s, so of course more people fit within it. This cannot explain the increases in severity, chronicity, or disability, however.
Profit Motive. One way to expand a problem is to make its treatment profitable. In the 1950s there were few products one could sell to the depressed; today there are many. Much of the drive to expand the number and scope of mental illness categories appears to have come from the pharmaceutical industry, which has grown enormously - in part by selling more products to the newly-labelled ill.
Iatrogenic Chronicity. A troubling possibility raised by recent research in the field suggests that the very medications we use to alleviate depression may, in the long run, cause a worsening of the problem in a subset of the individuals who take them. More on this in later posts.
Success, Failure, or Worse?
It would be difficult to declare the medicalization of mood a success, given the lack of improvement on any of the variables discussed. (Perhaps some glowing achievements have been missed, but these are not immediately apparent).
Failure would mean that the situation from the 1950s has remained unchanged. This doesn't seem true, given that things have become so markedly worse on so many fronts.
If, with all of our efforts, the burden of depression has not been even partially lifted, then we may need to face a difficult possibility. Maybe it's the healthcare system itself. Maybe we haven't just failed. Maybe something we are doing is making things worse.
Robins, E., & Guze, S. B. (1972). Classification of affective disorders: The primary-secondary, the endogenous-reactive, and the neurotic-psychotic concepts. In TA Williams, MM Katz, JA Shield (Eds) Recent Advances in Psychobiology of the Depressive Illness, 283-293.
Parker, G (2007). Is depression overdiagnosed? Yes. British Medical Journal, 335, 328. See also, however, Hickie, I (2007). Is depression over diagnosed? No. British Medical Journal, 335, 329.
Silverman, C (1968) The epidemiology of depression. Baltimore: Johns Hopkins Press.
University of Oxford. (2014, May 23). Many mental illnesses reduce life expectancy more than heavy smoking. ScienceDaily. Retrieved December 29, 2014 from www.sciencedaily.com/releases/2014/05/140523082934.htm
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