Many years ago my husband and I were the proprietors of a small rural motel near a ski mountain. We rented rooms and studio apartments to tourists on the weekends and some of the studios were rented by the week to seasonal workers or local people who appreciated a small, affordable apartment. I would sometimes ask the residents, "How is your truck running?", which was my proxy question for "How are YOU doing?".
I recently had a similar conversation with a family member.
"How is your car running?"
"Great!" he said, "It has 219,000 miles and it's running well."
Good! If he had responded, "Oh, I just had an unexpected repair bill of $1700 but I cannot afford a new car right now", it might have indicated he is stressed about finances. Complaining about all the small things that can go wrong with a 10-year-old-car would have provided a different insight.
Are we asking the right questions to know how people are doing?
Health providers may use a depression screening tool and then refer to an algorithm to determine whether the patient should be prescribed an anti-depressant, or SSRI (selective serotonin reuptake inhibitor) drug. The clinician might also make a referral for the patient to see a mental health provider, who would spend more time asking questions through a series of Cognitive Behavioral Therapy sessions or CBT, but taking a pill is more convenient, economical, and private than more appointments. Business Insider reported in 2016 that more than two-thirds of Americans taking anti-depressants have not had an appointment with a mental health specialist in the last 12 months.
The long term effects of using SSRI's are being studied. In 2014, the New Zealand Mental Health Foundation asked more than 1800 people how they felt when they were taking anti-depressants in an on-line questionnaire. Eighty-two percent said the drugs reduced their depression, but many reported side effects of sexual dysfunction (62%) and feeling emotionally numb (60%).
The World Health Organization listed the rate of depression reported around the world pretty consistently between four and six percent of all adults, with some higher exceptions in areas of conflict (e.g., Ukraine) and lower exceptions (South Pacific Islands). The rate of use of anti-depressants, however, varies greatly as shown in Table 1:
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| Table 1 |
Anti-depressants may also be prescribed for non-depression diagnoses, such as anxiety, sleeplessness, and neuropathic pain. The use of anti-depressants may depend on wealth, health coverage, and availability of treatment. Not surprisingly, anti-depressants tend to be more prescribed in countries with fewer mental health providers, as seen in Table 2:
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Table 2
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What are reasons for varied rates of use of anti-depressants? Here are some insights for the three highest consumers of anti-depressants.
Australia
The Australian government recognizes a key barrier to accessing services is the scarcity of mental health professionals. In November 2017, access to mental health services was expanded to include telehealth consultations for people in regional, rural, and remote Australia.
The telehealth consultations are a psychological therapy service that is delivered via video conference where both a visual and audio link have been established between a patient and their treating health professional. Telehealth services can be delivered by psychologists, social workers, and occupational therapists. Telehealth removes the travel barrier for patients and clinicians and will be discussed in a later blog post.
United States
In 2017, Time Magazine reported that about eighty percent of anti-depressant patients in the US are receiving care from someone other than a psychiatrist. The article also said during the last decade the number of mental health professionals in the US has been steadily declining due to aging of the current workforce, low rates of reimbursement, burnout and burdensome documentation requirements. The World Health Organization reports the number of mental health providers per capita in the US is now below economically-devastated Greece.
Or perhaps the US patient asked for a drug they saw advertised on television or in a magazine. Prohibited by thirty-three OECD (Organization for Economic Co-operation and Development) countries, the US and New Zealand both allow pharmaceutical companies' Direct-to-Consumer Advertising (DTCA). Almost all DTCA is for patented or branded medications. In August 2014, The New Zealand Medical Journal reported that American pharmaceutical companies spent more than US$4 billion in Direct-to-Consumer Advertising, more than ten times the entire Food and Drug Administration annual budget for evaluation of new drugs. And this cost is paid by whom?
Iceland
Multiple sources in Iceland attribute the high rate of anti-depressants to limited access to alternative treatment like psychotherapy. A 2004 study by the National Institutes of Health studied Iceland during a period of rising use of anti-depressants from 1975 to 2000 when the daily defined doses per 1000 inhabitants climbed from 8.4 to 72.7. The study was unable to see a reduction in the suicide rate or disability due to depression during this period despite the eight-fold increase in use of anti-depressants and concluded, "The dramatic increase in the sales of anti-depressants has not had any marked impact on the selected public health measures [suicide and disability-adjusted life years]. Obviously, better treatment for depressive disorders is still needed in order to reduce the burden caused by them."
The right questions, asked by the right people, at the right time
Cognitive Behavioral Therapy can work as well or better than medication to treat mild or moderate depression and it can also help with more severe cases if the therapist is highly skilled. It is based on the idea that problems are not caused by situation themselves, but rather how we interpret them, which can then affect thoughts, feelings and actions. CBT aims to break negative cycles by identifying unhelpful ways of reacting and replacing them with more useful or realistic ones.
The CBT approach is not new. In fact, it reflects the ancient Greek philosopher, Epictectus, who famously said, "Men are disturbed not by events but by their opinion about events." Epictectus was a Stoic philosopher in the first century AD who grew up as a slave in the Roman Empire, so he was keenly aware of how little we control in life. He divided events into two categories: what can be controlled and what cannot be controlled, and suggested managing only what was within one's control, since problems begin when we try to control what is not within our control. He optimistically felt that we can all change our habits with practice.
Giving an anti-depressant is treating a symptom or effect, not the cause. Without accompaniment of a mental health provider, it is like putting the ambulance at the bottom of the cliff. Access to mental health providers is needed for better long term care.
PS: Happy 2018 International Stoic Week, which begins Monday, 1 October.
