Photograph by Mary O’Connell

Ideas: Rethinking Depression (Parts 1 to 3)

Depression is an illness that people have been grappling with for as long as there has been a semblance of civilization. There have been many attempts to treat the sufferers of this malady from sending these patients to the seaside, to putting them in asylums, to electroconvulsive therapy to the even more extreme measure of a lobotomy. Psychotherapy and cognitive behavioral therapy enjoyed a period of popularity as well as some measure of success but the work required by both the patient and the practitioner was significant. The cost and availability of treatment also presented a significant barrier to access.

The 1960’s brought some new alternatives: drug therapy. First came tricyclic antidepressants. They were more targeted to treating depression but had pretty severe side-effects and could be used to overdose (something, unfortunately, very depressed patients were prone to do). Next, benzodiazepines became wildly popular. “Mother’s Little Helper”, as the Rolling Stones called it, was widely prescribed and set the precedent that it was okay to take a “pill” to treat your mental illness. It was no worse than treating a minor infection. Unfortunately, benzodiazepines, like Valium, are very addicting. Patients who started taking these medications found it increasingly difficult to stop (As a detailed case study, the book “I’m Dancing as Fast as I Can.” delves into this issue and is an interesting read.). From the point of view of the general practitioner and psychiatrist during the heyday of these drugs before their consequences became widely known, these medications represented an easy and effective treatment for most cases of depression. As a result, these drugs laid the groundwork for the preference for the treatment of depression with pharmaceuticals over anything else.

1988 brought the introduction of Prozac, or fluoxetine, to the market. This is where this podcast picks up the story in detail. Prozac was the first in a new class of drugs: the Selective Serotonin Reuptake Inhibitors (SSRIs). This class of antidepressants promised to be much more effective with less side effects and a much lower risk of overdose and addiction. Drug companies spent millions on slick marketing campaigns targeting both patients and physicians. The strategy worked and literally millions of prescriptions for these antidepressants were written annually.

The interesting question the series addresses is how legitimate were all these diagnoses? The diagnosis of Major Depression wasn’t very common in the decades prior to the Sixties. What happened then was a broadening of the definition of depression to include much less severe cases as well as cases where mild anxiety was the majority of the issue. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the major reference for practitioners of psychiatric medicine. It has been criticized for labelling many normal reactions to life as “mental disorders”. For example, in the DSM-IV-TR you will find Generalized Anxiety Disorder (GAD) which lists as a criterium, “Excessive anxiety and worry (apprehensive expectation), occurring more-days-than-not for at least 6 months, about a number of events or activities (such as work or school performance)”. Using vague, subjective language such as “excessive” and “more-days-than-not” virtually guarantees that large swaths of patients visiting their physicians can and will be diagnosed this way. In addition, in the first part of the series, Edward Shorter (Professor of the History of Medicine, Professor of Psychiatry, Faculty of Medicine, University of Toronto) describes [at 17:45 of Part 1] how editorial board members involved in the creation of 1980 version of the DSM engaged in “horse trading” to get their pet diagnoses put into the new version. Diagnosis based on anecdotal evidence from participating practitioners were given the air of legitimacy through the force of the personalities at the table rather than through the results of scientific study.  By dint of these diagnoses being in the DSM, more cases were labelled as such. Suddenly there’s an epidemic where none existed before. Epidemics, of course, need to be treated with drugs.

The efficacy of SSRIs have been called into question. In Part 2, it is revealed that up to 70% of the benefit of taking an SSRI can be attributed to the Placebo Effect. Furthermore, pharmaceutical companies only need to show two published studies demonstrating a significant benefit over placebo in order for a given drug to be approved. The company can run any number of trials in order to get the results they want. The ones that don’t hold up their hypothesis are just not published. Irving Kirsch (psychology professor, University of Hull, author of The Emperor’s New Drugs: Exploding the Antidepressant Myth, Yorkshire, UK) ran a meta-analysis that demonstrated the significant placebo effect of SSRIs as well as the strategy of pharmaceutical companies [starting at 12:05 of Part 2]. He showed that six commonly-used SSRIs had no “clinically meaningful” benefit over placebo. That is to say, the benefits experienced by patients were minimal at best. The podcast goes on to counter these findings with a partial rebuttal from Jordan Peterson (psychology professor, University of Toronto, author of Maps of Meaning:  Architecture of Belief, Toronto) stating that humans systems are too complicated to draw clear conclusions and that animal studies are much more reliable [at 20:20 of Part 2]. It is in the these animal studies (in the example stated, lobsters) that the clear benefits of SSRIs are demonstrated. The argument is also made that the slight benefit over placebo is still a benefit and, if taken into account with the significant placebo effect of taking an antidepressant, there is still justifiable reason to continue prescribing these medications. If you’ve hit rock bottom, to paraphrase Jordan Peterson, you’ll try anything that might help and outsiders should not judge. However, “hitting rock bottom” indicates a complete inability to cope with life which is a clear indication of a major depression. In such an extreme example you should try any and all the tools at your disposal as a clinician. The key is to try any and all the tools available. Psychiatrists seem to be exclusively favouring pharmaceutical treatments over all other available options.

Part 3 looks at alternatives to drug therapy for treating clinical depression. Some of them are not any more effective than the SSRIs (e.g. homeopathy) but the underlying theme in the cases presented seems to be either discovering effective coping mechanisms or determining the root cause of the depression and dealing with that issue. Both take years of effort on the part of the patient in conjunction with a therapist to reach some sort of breakthrough and even then will likely require continued maintenance to remain effective. How is this any better than antidepressant therapy? I know of several cases through my work as a pharmacist of patients being told by their family physicians that they need to think of depression as a chronic illness, like diabetes, and that they need to accept the fact that they will need to take medication to treat it for the rest of their lives. There are significant problems with continuous and prolonged drug therapy. One is potential tolerance to a given antidepressant requiring increasing doses over time; another is major side-effects like weight gain and sexual dysfunction that persist, in some cases, long after an antidepressant is discontinued. The side-effects, if anything, exacerbate the depression the patient is experiencing by making them feel worse about themselves. However, the main and most serious problem is the fact that none of the issues that made the patient depressed in the first place is ever resolved.

How can one begin treatment of any depressive disorder without the patient discovering and coming to grips with the root causes of the depression? This is the major failing of psychiatry and family medicine today when it comes to depression. The first course of action is to prescribe an antidepressant without any other modes of treatment being explored, even as an adjunct therapy. It is easy to prescribe an antidepressant while there are significant barriers to obtaining other forms of treatment. Typically, most people first report their symptoms to a family physician. This practitioner may not be even aware of what other psychiatric services may be available to his or her patient. Even if they are, the barriers to obtaining “talk therapy” services are significant.

First, there is the availability of a compatible specialist. This is hard in a major urban area and nearly impossible in a smaller centre. Talk therapy involves the patient speaking about his or her innermost secrets and conflicts. These are emotions and life events that you may not reveal to anyone else in your life. A level of trust must be established between the therapist and the patient. On the therapist’s part, he or she must know when to ask questions, when to comment and when just to listen. All these factors must be established in order for talk therapy to be successful. As well, the amount of education and training a good therapist must have received to work with patients in this way is extensive. The result is that there are relatively few practitioners of this medical field. All these factors taken together make it very difficult to get into a regular talk therapy session with a qualified practitioner.

Second, there is the potential cost of making use of such services. Some are fortunate to live in a country with socialized medical care. Generally, these citizens don’t pay anything when they visit a doctor or a specialist. However, many of the clinicians practising talk therapy are either not covered under the government plan or they “extra bill” (e.g. Charge the patient a hourly fee above and beyond the rate paid to them by the government plan). In the case of a provider not covered by government insurance, a patient could be paying more than $200 per visit. In the case of extra billing, it is quite a bit less than that hourly figure but still significant. If the patient is fortunate to be covered by private insurance through his or her place of work then they may be spared the out-of-pocket expense. However, such private coverage is often limited to a set dollar amount per year and can be quickly exhausted by weekly visits. Because of the potentially prohibitive costs involved, a patient may opt out of receiving talk therapy even if they are able to find a suitable practitioner.

Our society has painted itself somewhat into a corner. While the introduction of pharmaceuticals into the treatment of depression has been an improvement of some of the more barbaric practices of the past, it has also lead to the over-prescribing of antidepressants. The symptoms of arguably treated while the root causes remain unaddressed. The pace of our society with its deluge of information has lead to people feeling anxious about everything. Access to adjunct or alternative forms of therapy is limited by availability and cost. Rather than determine why he or she are feeling anxious, a patient is encouraged to seek relief through one drug or another as it is the easiest tool to use for most practitioners. The anxiety and feelings of sadness are numbed but the reason for them being there are never explored. The patient is made dependent rather than empowered. If our society does not decide to invest in issues of mental health like depression, things will get worse for its citizens over the long run.