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Tuesday, 30 December 2014

The Medicalization of Mood: Worse Than Nothing, or Just Ineffective?

Not quite as good as advertised.
Sixty Years of Intervention

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.

Four Possibilities

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

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Tuesday, 23 December 2014

Screening for Childhood Mental Illness in BC: Good Idea or Pharma Marketing?

In recent years there have been many incidents of violence perpetrated by children and adolescents, many of them in the school system. Given the often-tragic results, there is an understandable lament that troubled youth could not be identified earlier and put into some form of treatment. Why not have an effective and comprehensive screening program in medical practices and in the schools to help identify problems before they become crises?

In British Columbia there is a proposal to do just that. The Practice Support Program for Child and Youth Mental Health (PSP-CYMH) trains physicians in the use of screening tools to help identify childhood mental illnesses. In its second phase, school personnel are to be included in some of the training.

This sounds like a good idea. When a tragedy happens, we often hear that the perpetrator turned out to be suffering from a mental illness. But we usually know this because the person was already in some form of mental health care: he or she had a therapist, a psychiatrist, was taking medication, and so on. Case-finding is irrelevant in such situations, as the case has already been found and action is being taken.

The implication seems to be that if we beef up the mental health service, fewer instances of violence will occur. But this begs a few questions:

  1. Given that most perpetrators are already in care and nevertheless offended, doesn't this call into the question the notion that treatment will prevent bad outcomes?
  2. If there was a better-funded service, would the perpetrators have been in two forms of therapy rather than one? Five, maybe? Ten? Is there any evidence that this would help?
  3. Is there any evidence that more elaborate mental health screening results in reduced levels of youth violence or better long-term mental health outcomes?

Mad in America ( is a website founded by Robert Whitaker, author of "Anatomy of an Epidemic," a remarkable book that examines the research literature on the long-term effectiveness of common mental health treatments. It hosts blogs and reporting from a wide variety of perspectives, most of which are skeptical of current mental health practices. Some of the posts are extreme and angry, most are not.

In July of this year, Rob Wipond, a Victoria-based freelance journalist, wrote about the PSP-CYMH that calls much of the program into question. See what you think:

One concern that is frequently raised about mental health screening initiatives is that they identify patients who can then be sold psychoactive medications. Authors of the initiatives almost always talk about the enhancement of social supports, the provision of psychotherapy, involvement with community, and so on. But in the real world of medical practice, screening usually translates into prescriptions written.

It is no wonder that so many of these initiatives have received generous financial support from the pharmaceutical companies whose products will be sold as a result. That said, I can find no evidence of direct pharmaceutical industry funding for the PSP-CYMH initiative.

It is possible, though, to look at the materials supplied to physicians as part of the program. Here they are:

You can even try them out for yourself. I was a sometimes anxious kid and have spent much of my life thanking the fates for not having my case found - believing as I do that things would have turned out much worse for me as a result. I was interested in the child form of the SCARED inventory of childhood anxiety, available here:

It's not a great measure, and hasn't been well thought through as published for BC Physicians. Look at the instructions, for example, which invite children to "fill in one circle that corresponds to the response that seems to describe you." There are no circles; the format has been changed to a table for checkmarks. This is an extremely minor problem, but one that suggests no one has even proofread the materials.

I thought back to one of the more anxious years of my own childhood and filled out the questionnaire as I believe I would have, had I been honest, back then. Sure enough, my score exceeded the screening cutoff. Try it yourself.

No problem, perhaps, if the help given as a result is useful, evidence-based, effective over both the short and long term, and aware of the context of the child's life. But if you are imagining legions of child and youth clinicians and support workers lolling about with nothing to do because not enough cases have been found, think again. Child and youth mental health services are already oversubscribed - not just in BC but in virtually every jurisdiction with which I am familiar.

It is very difficult to escape the notion that children identified through screening and subsequent assessment will be unable to access any resources other than medication, and that the result of the program will be even more children on psychoactive medication than there are now. Not such a bad outcome if the evidence supports the effectiveness of such an approach over the long term. But the evidence is fairly equivocal on this issue, to put it generously.

So what do you think? Should we be screening to find more cases of child and youth mental health problems? As I suggested at the outset, it doesn't sound like such a bad idea. But considering the state of the services available, the quality of the research on pharmacological interventions in children, and the criticisms levelled by Wipond and those he cites in the article, it's a bit hard to understand how violence might be reduced or the care of seriously ill children will be enhanced by the current initiative.

One of Wipond's sources is University of Victoria-affiliated drug policy researcher Alan Cassels, whose recent TEDx Victoria talk can be found here:

Tuesday, 16 December 2014

Snapshot Versus Movie: Two Ways of Thinking

Too many passengers, too small a boat.
Missionaries, Cannibals, and Problem Solving

In the Missionaries and Cannibals problem, three missionaries and three cannibals must cross a river in a boat that can only hold two people - and the cannibals must never outnumber the missionaries.

It’s tempting to try to advance one's position with every move, never returning the boat with more than a single occupant. In most versions of the problem, however, this won’t yield a solution. At some point, two people have to move back across the river.

The puzzle is interesting from a psychological perspective because it requires a shift from move-by-move to longer-term planning - a process that the mind often rebels against. It appears that our default wiring causes us to look for linear solutions - a tendency that can blind us to
alternatives and to the negative consequences of our best intentions.

We might think of our default mode as "snapshot" thinking. We look at the current problem and try to find a solution that takes us a step in the right direction.

The alternative is "movie" thinking, in which we examine the consequences of our immediate actions and look a few steps down the road. In effect, we view the problem as an ecological system in which our own inputs alter the problem space and lead often to unexpected shifts.

Who really cares? 

The type of thinking we employ governs our responses to problems, and often determines whether our solutions work, prove ineffective, or make things worse. Many of our most pressing problems can only be solved with "movie" thinking, but our bias causes us to attempt to employ snapshot thinking.

Consider a few examples.

Invasive species.
Australia is well-known for the introduction of new species with unforeseen consequences. In the 1930s, hoping to battle the native cane beetle, cane toads from the Americas were released in Queensland. From a snapshot perspective, this made sense. Lacking natural predators, however, the toads spread uncontrollably across the state, causing greater problems than the one they were intended to solve. Similar eye-rolling foul-ups were caused by the introduction of foxes, rabbits, housecats, camels, goats, pigs, and deer.

Every school child learns about the ecological catastrophes visited upon Australia by naive snapshot-thinkers. We know and accept that it is generally a bad idea to introduce foreign species into an ecological system. This has not stopped us, however, from developing entirely new organisms and releasing them into the environment as though the lessons of Australia had never been taught.

Genetically modified corn is a good example of snapshot thinking. Developed to be resistant to widely-used herbicides or to express proteins that are poisonous to insect pests, these varieties produce healthier and more abundant crops. Switch to movie-style thinking, however, and the problem readily becomes apparent. A new selection environment has been introduced, and unexpected shifts in ecological systems will result. Already, some pests have evolved resistance to the supposedly insect-resistant strains, potentially resulting in greater insect problems than the strains were originally developed to address.

What about foreign policy initiatives? Imagine that you have intelligence indicating that there are 1000 terrorists operating in a given region. Using snapshot thinking the solution seems obvious. Invade, target the terrorists, and eliminate them one by one. Movie thinking would ask how those individuals became terrorists, and would wonder whether an invasion might inadvertently spawn more terrorists than it eliminates. Having armed and trained Osama bin Laden to fight Soviets in Afghanistan, for example, movie thinking might ask whether the creation of a band of Islamist fighters could cause more problems than it solves.

Snapshot thinking also bedevils our personal lives. We see the immediate problem that our spouse disagrees with our plans to renovate the garage, and press our point relentlessly. Although this might succeed in the short term, movie thinking might look a few steps down the road to see whether our browbeating style could have further-reaching consequences. Rushing to solve our children's problems, we might inadvertently undermine their ability to perceive and deal with the consequences of their own actions.

What about the field of mental health? Snapshot thinking would lead us to attempt the solution of an immediate problem using seemingly common-sense strategies. If depression is believed to be the result of insufficient neural transmission within serotonergic systems (an admittedly bad example, because this widely-believed notion has found little empirical support), then introducing medications to promote serotonergic action seems an obvious move. If some people with depression fail to seek medical assistance, then public education campaigns should surely help some of them to see their physician. If anxiety is a problem, then the administration of antianxiety medication is a no-brainer.

But all of these are the products of snapshot thinking. And like the environmental problems of Australia, the challenges of a GMO-infested world, the terrorist situation of a post-9/11 world, each of them suffers from the law of unintended consequences. Serotonin reuptake blockade may ultimately impair previously-functional serotonergic systems. Public education campaigns may cause epidemics of overdiagnosis and overmedication. And benzodiazepine dependence may ultimately be worse than the anxiety these drugs are intended to treat.

In coming weeks we will take a closer look at just a few of these issues within mental health - and examine whether a system designed to improve human welfare may have accidentally amplified the problem.