Depression is an industry

The piece below below comes from Libby Purves writing in the Times.

It’s interesting to note that the mainstream media is catching up, albeit slowly, with what’s been happening in the past 15 years or so.

Ten years of rising prosperity, ten years’ boom in prescriptions for Prozac. Interesting. This week’s news that Britain is on antidepressants (31 million prescriptions a year) is a bit like hearing that a crutch-and-splint factory has doubled its profits. You’re glad all those people are being helped to walk upright, but wonder why so many are getting hurt. And as pills are a mental rather than physical crutch, another question pops up.

Is the hunger for antidepressants caused by social change: different expectations, different philosophies of life, different doctoring, different demands? And, given that it is never good news to know that more people are taking expensive mind-altering substances, what’s to be done about it? The National Institute for Health and Clinical Excellence (NICE) says that drugs should not be a first-stop remedy for depression, and tries to restrict them for under18s, but there is little evidence that anybody listens. Surveys of doctors suggest that many know perfectly well they prescribe too often, but that patients demand pills and there is little funding for talking therapies. One doctor added that antidepressants “seem to have lost the stigma they once had”.

He’s right there. Astonishingly, they have actually become smart. This is since the advent of new generation pills, SSRIs (selective serotonin reuptake inhibitors) like Prozac and Seroxat. Books celebrate the new drugs, dangerously conflating their image with a modish, Manhattanish fast-lane cachet; celebrity depressives happily talk about them, and mad claims are made for their ability to improve personality. Unlike the previous generation of tricyclic antidepressants, which tended to make people fat and sluggish and therefore ipso facto unfashionable, SSRIs have no such effect. In real depression, they seem merely to lift the mood enough to restore the earlier personality, enabling it to think its way out of whatever caused the dip.

So the stigma is gone. Hoorah for that: I had six months of Prozac about 14 years ago, when it was not at all fashionable. I wrote in its defence, saying it was a perfectly useful temporary crutch when a serious depression would not respond to sensible stuff – exercise, light, friendship, counselling. I did not dream that people would take Prozac for decades, or describe it – as one weekend writer did – as “a pharmaceutical Fendi bag, the It-drug of the Nineties”. Nor did I think people would demand it to cure quirks like shyness or lack of ambition. But I did want to help to remove the stigma, because stigma is never helpful where mental disorders are concerned.

On the other hand, a drug is a drug, and should not be the automatic treatment for anything mental or behavioural. Too many children are put on Ritalin merely because they have too much energy and originality to fit the narrow mould of school or the confined space of home. And too many adults (and teenagers) are getting Prozac or its sister drugs when what they really need is emotional support, understanding, exercise or a psychiatrist. Or – it was suggested yesterday – country walks. In six European countries, depressives are prescribed agricultural work. Well, you can see that this would be difficult in Southwark. And doctors – both regular GPs and the locum services that now run most out-of-hours care – know perfectly well that they can’t prescribe psychiatric help because there isn’t enough on the NHS (and even some of that is woefully low-grade tickbox “counselling”). So out comes the prescription pad, and too often the repeat prescription is automatic, and the monitoring inadequate.

That does matter, especially in the early stages. There have been court cases, especially in the US, where people on newly prescribed SSRIs have suddenly killed others or themselves. Eli Lilly, the manufacturer, has made several settlements out of court. The problem may be overrated: in natural recoveries from depression suicide often happens during an apparent upward slope. Lifting depression may lift lethargy and reveal – alongside rising energy and resolution – a more serious condition, or a deeper despair. Early-treatment suicide was not unknown in the old days of tricyclics, but was probably impeded because as one psychiatrist put it, “those things knock you flat at first, so they fell asleep instead”.

However, it seems to me downright wicked that any psychoactive drug should ever be given without making sure that the patient has close family or friends who are specifically told to watch out for agitation in the first weeks. A really good doctor gives a short run of capsules and insists on seeing the patient again very soon. Not all doctors are that good. Not all patients cooperate.

As to the wider reasons for national depression, glance at the first comment posted yesterday on Times Online, from a peppery character called Bill in China: “Drastically reducing the hours that televison is broadcast would be a good place to start. Without that addiction keeping them glued to their sofas watching the so-called success stories of the tribe of celebrities that infest modern life they might find time to get off their totties and DO something.”

Simplistic but bracing. You can’t help noticing that these worried news items about depression are generally surrounded, in all media, by a sea of gloom about house prices, terrorism and new diseases, and further decorated with ridiculous stuff about “must-have” handbags and how contemptible it is to be a bit fat and not yet famous. And note also that when the University of Essex tested country walks versus shopping-mall walks as an exercise cure, 50 per cent of the shopping-centre walkers were more depressed afterwards than before. Depression is an industry, in more ways than one.

You can read a companion article, Britain becomes a Prozac nation, also from the Times here.

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