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A MAJOR “quality gap” in the treatment of depression is seeing an increased use of antidepressants and psychological therapies without a commensurate improvement in outcomes, says a leading mental health expert.
Professor Anthony Jorm, head of the Population Mental Health group within the Centre for Mental Health at the Melbourne School of Population and Global Health, said Australia has seen a large increase in the treatment of depression but the outcomes have been underwhelming.
“We have had no population health gain in depression prevalence despite increases in both antidepressant treatment and psychological therapy. In theory, greater uptake should produce a population health gain … but because of a major ‘quality gap’ we have not seen the expected benefits,” Professor Jorm told MJA InSight.
Professor Jorm’s comments came as experts wrote in the MJA that the effectiveness of antidepressant medication had fallen short of initial expectations, despite around 1 in 10 Australians now taking an antidepressant. The authors noted that Australia had one of the highest rates of antidepressant prescribing in the world, with rates doubling since 2000.
“An unfortunate nexus has developed between the diagnosis of depression of any severity and the reflexive prescription of medications as monotherapy, for which the medical profession must accept some responsibility,” wrote Professors Christopher Davey and Andrew Chanen of Orygen, the National Centre of Excellence in Youth Mental Health.
They wrote that antidepressant medications had an important role in the treatment of mild-to-moderate depression, but they should be prescribed as part of an overall treatment plan.
“All patients should be offered psychotherapy where it is available, and medication should be considered if: the depression is of at least moderate severity; psychotherapy is refused; or psychotherapy has not been effective,” they wrote, adding that healthy eating and exercise should also be recommended.
Professor Jorm said that a greater use of combined treatment would make little difference without improvements in the targeting of pharmacotherapy and quality of psychological interventions.
“Much of the antidepressant use in Australia is for chronic mild depression, but randomised controlled trials do not support their effectiveness for this group,” he said.
“When we look at the distribution of use, we find that antidepressant use rises steadily with age, with older people being the heaviest users. However, epidemiological studies show that older people are at lower risk for depression than younger adults.
“Similarly, with psychological therapy, many people receive too few sessions to be effective and it is not clear that therapists implement the therapy to the standard of treatment manuals used in trials.”
Professor Harvey Whiteford, professor of Population Mental Health at the University of Queensland, agreed that there was work to be done in better targeting therapies.
“We still don’t have good alignment between the needs of the patient and the intervention which can effectively respond to that. We have an over-reliance on medication and an under-reliance on psychological therapies.”
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Professor Whitehead said the Better Access to Mental Health Care initiative was introduced in 2006 to improve access to psychological treatments and reduce unnecessary reliance on pharmacotherapy. He said that the initiative had successfully increased psychological treatment – with research conducted by Professor Whiteford and colleagues finding that treatment rates had grown from 37% in 2006-07 to 46% in 2009-10 – but the use of pharmacotherapy has also continued to rise.
“What appears to happen when you get to a GP is the GP would prescribe medication and refer to the Better Access program for psychological counselling,” he said.
Professor Whiteford hoped that, over time, a stepped approach to treatment for mild-to-moderate mental disorders would become more common, with self-help the first port of call, followed by referral for psychological treatment and then medication.
He agreed that greater emphasis was needed on the quality of psychological services.
“[We need to know] what happens once the person gets inside the psychologist’s consulting rooms – are they getting evidence-based psychological therapies? Or are they getting a non-evidence based counselling, which isn’t really going to treat their mental health problem,” he said.
Prevention also needed to be a focus, said Professor Jorm.
“We are putting all of our resources into treatment and very little into prevention,” he said. “It’s a big contrast to what you see with major physical diseases, like cancer and cardiovascular disease, where we do have a strong preventive arm as well as a treatment arm.”
Dr Natalie Parletta, Senior Research Fellow at the Centre for Population Health Research at the University of South Australia, said that the role of diet and exercise in mental health care prevention and treatment was often overlooked.
“There is good evidence now for whole diets being protective against developing depression, and conversely that unhealthy diets increase the risk of developing depression over time,” Dr Parletta told MJA InSight.
Dr Parletta said she was leading one of two randomised controlled trials currently underway in Australia to further investigate the role of diet in mental health.
“There is a strong underlying rationale for the role of diet and nutrients, not only for improving our inflammatory status, which is linked to depression, but also there are a range of nutrients that are important for healthy brain function,” she said, citing the crucial role of nutrients, such as vitamin E, various B vitamins, magnesium and zinc, in neurotransmission.
“Omega-3s, which are critical nutrients for brain function, have also received a lot of research interest in recent years with regard to mental health, including evidence for a role in reducing depressive symptoms,” she said.
“Additionally, there is a growing body of evidence around the role of the gut microbiome in the gut-brain axis which is opening up a whole new area of exploration with regard to mental health,” she said.
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As a Psychiatrist with over 40 years clinical experience I am concerned about the recent tendency to regard “depression” as one condition for which one treatment is best and then argue only about which treatment modality to use first. To some extent this is the result of the use of a classification set up in DSM and ICD which lumps all forms of depression together, and promotes the one illness concept.
My view is that there are at least three types of depression:
1. A state of grief or mourning or other distress reactive to current events, which may respond to counselling, or even just time.
2. A state reactive to past and/or ongoing events or trauma, which is likely to be more entrenched and need more intensive psychotherapy of one form or another, and possibly antidepressants.
3. A state which seems to have a life of its own usuallly associated with a strong family history of depressive illness, where medication may be an important part of treatment, or even the only option that works.
Of course these are not exclusive – you can have your own mix in your own proportions, and good clinical practice involves assessing which factors are most important in the presenting case on an individual basis.
Then we can consider Bipolar Depression where mood-stbilisers may be important. Again the family history is the important clue to the treatment method of choice.
I agree rating scales are of little use in diagnosis or assessing treatment type required. their pupose is to reassure doctors and bureacrats that we can prove we took the standard steps in case there is a suicide, and reduce OUR anxiety.
The failure of the dumbed-down, tick the box and prescribe the drug, modern psychiatry is clearly revealed in the rising prevalence of diagnoses of depression in Australia. Older psychiatrists were taught to take a psychiatric history in the same way as any good doctor takes a patient’s history. When did you last feel well, what happened then etc. And the older psychiatrists were more interested in the human condition, the patient’s belief system, and listening to the patient’s description of their suffering. The idea of ticking the boxes, adding up the score, and then TELLING the patient what their problem is: “a chemical imbalance in your brain” was enathema.
If you want to find out what’s going on in mental health in Australia, don’t ask the professors. They don’t know what the problem is because they caused it in the first place. Ask the patients, and perhaps the few doctors who listen to them. You will hear horror story after horror story of people being spoken to like second-class citizens, not listened to, assigned demeaning diagnoses and having their belief systems ridiculed.
If you want to fix the mess, you’ll have to start again in the medical and nursing schools and the teaching of clinical psychology in the universities.
If you’re happy with the status quo, keep teaching the same rubbish to the students and keep blaming the patients.
Dear Editor
I am a nurse. I have experience in ED and then moved into forensic mental health specialty. I now have a Graduate Diploma in mental health nursing. I am a ‘peer’ user of mental health services and therefore see two sides to the issue under discussion.
Despite the public being under the impression that we are attempting to reduce stigma in mental health care I question the reality of this occurring. When you attend a GP for a number of years with complex mental health issues they eventually are rendered ‘helpless’ without being able find a solution and ‘handball’ you to the next GP. When I have entered into the services of a psychologist (and I have seen seven over the last 8 years) there was a wide clinical practice variationand some providers were downright inappropriate.
I cannot count the times my medication has been altered. I cannot count the times that I have felt a burden to my health care provider. I cannot count the times I have ceased my attendance with therapy and I take partial responsibility for this. I am not however, ‘not commited to the process’ as one charming psychiatrist termed me in relation to non-attendance to one appointment due to illness.
I cannot emphasise enough the stigma and lack of support that I was subjected to from colleagues who were purportedly advocates for mental health and a management system who was happy to see me leave.
We are just too difficult and prescribing medication is a simple and handy solution when the cognitive process of problem solving is absent.
The mental health system for me as a worker and consumer is sub-optimal and beyond disappointing with only lip service paid towards improving services.
I have to seriously wonder about anti-depressants as yes they may stop you from feeling fully depressed but it really is only one part of the problem isn’t it? As they (scientists/Doctors) actually can’t measure the quantity of chemicals in the brain you have to seriously wonder about it. As I said they may stop you from killing yourself but they are a long way from making you feel you have something to live for.
With depression becoming less stigmatised, and the population becomeing more aware of it, you would expect the apparent rate in the population to increase, wouldn’t you? Furthermore, how do they know that the antidepressants were not prescribed for, say, anxiety? I’m not saying there are not answers to these questions, but it would be nice to know what they are.
Dear Editor,
For over 10 years we have witnessed systematic and evidence-biased publications, often from psychologist academics like Prof Jorm, condeming use of antidepressants and lobbying for indescriminant provision of CBT, Mindfulness, or other poorly defined talking interventions. These services have been assumed to be exclusively provided by psychologists, and in fact, have low or non-existent efficacy when evaluated independently. The mental health referral system ( GP mental health careplan etc) has been also introduced to most GPs with the understanding that it would have to lead to referral to psychologists.
Treatment of depression is often urgent, with lives at stakes, and high morbidity and suffering not just for patients, but their families and colleagues. There is also abundant neuroscience evidence that the longer depression is undertreated, the more treatment resistant it is. In practice, most clinicans including many psychologists are well aware of the need for antidepressants and there is now a common practice of psychologists advising GPs on type of antipressants and dose based on hearsay from past patients. The psychiatrists, the most trained and experienced mental health professional in prescribing, and often in psychotherapy, are therefore by-passed altogether.
The value of antidepressants have been purposely underplayed by psychologist-lobbiest-academics especially since the early 2000s. Lets not forget that when antidpressant prescriptions increased sharply from 1996-2006, with the introduction of SSRI’s, the suicide rate in Australia in fact dropped by 40%. Indeed, there is no panecea in mental health, but what we have is a continuing indiscrimante promotion of psychologists at serious cost to the community.
So the increasing use of antidepressants has not provided a population health gain and/or reduction in depression prevalence and this is because….. of a quality gap of over reliance on medication and under reliance on psychotherapeutic usage – even though psychotherapy is not effective in this group unless “appropriately targetted”. And amongst these mixed messages from the experts, doctors, presumably front line doctors like GPs have to take some of the blame? Really? Are we guarantors of the mental well being of an aging community who are approaching death with less supports as our communities splinter, health care is more about expensive drugs and surgeries than humane contact with caring humans. Moreover the values of the elderly,among them many survivors of hardship and world wars spent fighting for their community, are increasingly rubbished as racist, misogynist, bigotted and abusive. Maybe drugs and frontline staff have succeeded in stoping a wave of depression becoming a tsunami?
Time long overdue to stop treating depression as a biological illness and to start treating it as a contextual problem requiring holistic attention to the person in their place. We have known this fact for decades but the politics and economics of mental health being what they are, we have been forced to live with this absurd fantasy that depression emerges magically from within. I have rarely seen a client whose depression or other mental health problem seemed to lack background, causative factors. These take a pill and/or have a chat interventions are failing for the obvious reason that they leave the context, untouched.