Post No.: 0204
The diagnosis of depression has increased over the past few decades (in the ‘West’ at least). Is this due to an over-diagnosis or due to better awareness of the disease? And is there an increasing over-use of antidepressant medications and an increasing under-use of psychotherapies (in the ‘West’ again at least)?
Antidepressants, in general, have become safer over time, with fewer side-effects than before, and because they don’t require time or skill to administer (compared with psychotherapies), because they’ve been aggressively marketed by pharmaceutical companies (including directly to consumers) and because there’s a growing recognition of major depression as an illness (and as a biologically-based illness) – antidepressants have been increasingly prescribed.
Yet currently, although they work well for some – antidepressants are ineffective for a lot of people and they still come with a lot of potential side-effects. (If you are currently taking any antidepressants – monitor for any side-effects and how long you have been taking them if they’re not quite working for you or indeed if you are now feeling much better.) Although it’s good news that more people are seeking treatment and that more treatment is being offered, there’s a question over the quality of depression care in care settings (especially in primary/non-specialist care).
Post No.: 0187 highlighted that there are other types of treatments available instead of or along with medications, but they do generally require more time, skill and/or other resources to administer compared to a prescription of pills. And where public health funding is tight, medications are often seen as more attractive than psychosocial solutions, even though the latter are more effective and also safer for some.
The awareness of depression, and other mental health conditions like anxiety and anorexia, has indeed increased over the past few years, and this is a positive thing so that people are more educated about mental health, the social stigma should decrease for those experiencing it, and more people can get treatment for it. But does receiving a diagnosis always help? A diagnosis will help for moderate to severe sufferers because they can then receive treatment, but arguably not for mild sufferers (who should still learn to recognise their fuzzy symptoms and prevent them from escalating though e.g. by improving their work-life balance).
Some people self-diagnose their depression but the majority of cases are diagnosed and treated by general practitioners/primary care physicians – rather than by specialist psychiatrists. So there may be problems in the accuracy of diagnosis according to the ‘gold standard’ of diagnosis, with many false negatives and false positives being produced – as worked out by the sensitivity rate (the chance of obtaining a true positive) and the specificity rate (the chance of obtaining a true negative). How many people this means in absolute terms, and whether more people are being falsely misdiagnosed or falsely diagnosed, or vice-versa, also depends on the prevalence rate (the percentage of people in the total population who have the condition) too. And even if/when diagnosed, only a small fraction of sufferers are seen by a mental health specialist or get given appropriate medication or psychotherapy for an adequate duration of time (the current proper guidelines are to continue treatment for a few months after the remission of symptoms, but most people stop medications before 90 days). So there could still be a gap in the diagnosis of depression, as well as a gap in the quality of the treatment and follow-up of depression.
Many mental health illnesses are spectrum conditions i.e. essentially everyone lies on the spectrum but where do we draw the line between what’s considered ‘normal’ and ‘disordered’? Ultimately, the symptoms (whatever they are) should substantially negatively interfere with one’s life for a reasonable length of time, regardless of one’s apparent risk genetic or apparent risk environmental factors (e.g. stress or loss). Having said that, a negative life event that has caused/is causing stress or loss is frequently present shortly before an episode of depression. In almost all cases, only a short period of therapy or discussion will reveal that the individual suffered from a stressful life event relatively shortly before experiencing depressive symptoms, such as after a bereavement, break-up, job loss or leaving home – it’ll typically be some kind of loss event. Less common, although still reasonably common, is an abusive or neglectful upbringing – to those who did experience such events when young, it is a major contributing stressor. Of course, simultaneously experiencing a combination of risk factors/stressors amplifies the total risk of depression (e.g. a job loss and a relationship break-up at the same time).
When mental health professionals ask depression sufferers, after they seek help, when they first felt their symptoms – many reveal that the onset was many years or even decades ago (the prodrome is the period of time after a disease/disorder has begun but before it is diagnosed). The problem with realising there is a problem in the first place is that, for some, the symptoms can creep up on them incredibly slowly and insidiously, and observers may therefore attribute the symptoms as merely being someone’s ‘personality’. Sufferers can hide their problems in private too well too, and the prolonged depression can be mistaken for a short period of sadness that’ll soon pass but doesn’t.
We’re quite poor at intuitively detecting very slow changes (e.g. gradually becoming overweight, changes to our eyesight, climate change, noticing that the light bulbs are getting dimmer with age until one fails and gets replaced with a fresh one of the same wattage). Often it’s clear when looking back over many years or decades and comparing the differences in a person, and maybe working out roughly the period in time these changes happened, but it’s sometimes difficult to detect such changes looking at someone by comparing their day-to-day or even year-to-year differences in real-time, or of course if one hasn’t known someone for very long.
The symptoms of dysphoria (a profound state of unease or dissatisfaction) and suicidal ideation may last for many years before one seeks help. But with symptoms like anhedonia (an inability to feel pleasure in normally pleasurable activities), a loss of appetite or sleep disorders – sufferers tend to seek help after ‘only’ a couple of years on average. Episodes of depression can last for several months but the variance is vast. The recurrence rate after remission is just under 50% for major depressive disorder, thus over 50% only ever experience one episode in their lifetimes. ~15% of cases are unremitting (episodes occurring every year). And the other ~35% of cases have a relapsing and remitting course (they recover then recur repeatedly but over many years).
One reassuring pattern is that people who’ve been through, and survived, an episode of depression are more likely to recover (technically this means going for one whole year without another episode) and recover more quickly from another episode if they have one again. This is possibly because the first time they suffer from depression they don’t know that they have a problem hence take a long time before they seek help, whilst the second time around they’ll recognise the signs and so will seek help far sooner and therefore increase their chances of recovery, as well as speed up their recovery (from, say, taking 3 years to taking 1 year to recover).
So overall, it seems that, for most people, it’s better to receive a diagnosis of depression than to not, because, like for probably any kind of problem in any context one can think of – attending to a problem sooner is better than attending to it later. ‘A stitch in time saves nine’ – it’s better to tackle something when it’s just small rather than when it potentially gets bigger.
But an obstacle with many public mental health services across the world is that they won’t help people until they’re considered sick enough to need help! This approach saves money in the short-term (maybe long enough for the duration of an elected state leader’s term to end – after which, the statistics won’t get recorded on their ‘personal score card’ and the problem will be passed onto future politicians at the nation’s helm) but this uses more public resources and produces more societal costs (e.g. to national productivity, which will negatively affect the economy) in the long-term when such problems become worse. So this myopic approach is something that really needs to change from the top!