Over the last 10 years in Australia, public and professional reluctance to use specific medical and psychological treatments for depression has diminished.
My colleagues and I have been at the forefront of a 10-year campaign that resulted first in 2001 in limited Federal support for better integrated medical and psychological care (“Better Outcomes in Mental Health”). This was extended in 2006 to broad access to Medicare rebates for non-medical professionals who provide specific psychological treatments.
In recent months, however, we have seen a re-emergence of allegations that depression is over-diagnosed and over-treated and that the newer antidepressant medicines are extremely harmful (particularly when prescribed to young people), largely ineffective and/or grossly over-utilised. In recent years, we have also seen strong criticism of some of the specific psychological therapies by various Professors of Psychology and Psychiatry, arguing that they are no more effective than general counselling or social support.
The critiques of the new medicines, but not those of the psychological therapies, have been covered extensively by the general media. Collectively, the movement against the active treatment of depression represents a serious challenge to the public health and individual benefits that have flowed from a more open approach to the recognition and active treatment of these disabling conditions. To date, Australia has led the world in changing public and professional attitudes towards the acceptance of depression as a serious illness.
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The most obvious national benefit of our changed approach to the management of depression has been its contribution to the marked fall in suicides over the last decade, with a 43% reduction in youth suicide being the most remarkable outcome. Disappointingly, this good news story has not been widely covered. The evidence in Australia indicates that increased treatment of depression (not just use of medicines) was a key factor in the fall in suicide rates. This fact does not discount the likely contributions attributable to other health, social or demographic influences.
More recent international reviews* (see Baldessarini et al 2007) of population-based studies highlight two key issues. One is that there is no evidence that increased antidepressant use has resulted in increased suicides – a proposition commonly put by the more extreme critics. The second is that in 19 studies reviewed, the size of the relationship between increased antidepressant usage and reduction in suicide (averaging 14%) has varied markedly from country to country – with a key intervening issue likely to be whether different at-risk groups in different countries are able to access to diagnosis and treatment. In Australia, where attitudes are more positive and citizens have better access to primary care and medicines, one might generally expect a closer relationship.
The second part of the current argument concerns the more recent reports of increasing suicide rates in young people in the USA, Europe and Canada. This followed reduced use of antidepressant medicines in recent years, largely in response to strong advisories about potential dangers associated with use in younger persons. Again, these studies have not been widely reported in the general media. Similarly, reports from other population-based studies (e.g. Simon et al 2006) showing that most suicide attempts occur in the month before commencing treatment and then decline markedly for the next six months (in all age groups, and in young people) did not attract the attention of the critics.
These broad public health impacts of increased treatment of depression are not issues that can be examined critically by reference only to randomised controlled trials (RCTs) of individual interventions (of medicines or psychological or other social therapies). My colleagues and I will continue to focus not only on what we learn from RCTs but, as in many other key areas of public health, what we can also learn from time-series and cross-national comparative studies.
Finally, I do wonder whether the critics have ever considered the work of Geoffrey Rose (and the prevention paradox) – as described last week in Crikey by Fran Baum. Many more suicides (like most strokes and most heart attacks) occur in individuals who are at only “moderate” rather than “severe” levels of risk.
The key to ongoing suicide reduction in Australia will be a combination of relevant public health interventions combined with widespread provision of evidence-based medical or psychological therapies to those at increased risk. That is, we no longer wait for people to attempt suicide to prove they are “severe” and (for those who are still alive) in need of treatment. Some of us will continue to argue strongly that a return to that discredited approach is not in the national interest.