Mental Health Treatment

Anger

Why drugs aren’t the answer

Antidepressant medication, used under the guidance of a mental health professional, may relieve some of your depression symptoms. But antidepressants also come with significant side effects and dangers. What’s more, recent studies have raised questions about their effectiveness. Most mental health experts agree that when depression is severe, medication can be helpful—even life saving. However, research shows that antidepressants fall short for many people.
A major 2006 U.S. government study showed that fewer than 50 percent of people become symptom-free on antidepressants, even after trying two different medications. Furthermore, many who do respond to medication soon slip back into depression, despite sticking with drug treatment. Other studies show that the benefits of depression medication have been exaggerated, with some researchers concluding that—when it comes to mild to moderate depression—antidepressants are only slightly more effective than placebos.

You’ve seen it in television ads, read it in newspaper articles, maybe even heard it from your doctor: depression is caused by a chemical imbalance in the brain that medication can correct. According to the theory of chemical imbalance, low levels of the brain chemical serotonin lead to depression and depression medication works by bringing serotonin levels back to normal.
The truth is that researchers know very little about how antidepressants work, as there is no test that can measure the amount of serotonin in the living brain. This means there is no way to even know what a low or normal level of serotonin is, or how depression medication can fix these levels.


While antidepressant drugs such as Prozac increase serotonin levels in the brain, this doesn’t mean that depression is caused by a serotonin shortage. After all, aspirin may cure a headache, but that doesn’t mean headaches are caused by an aspirin deficiency. Furthermore, many studies contradict the chemical imbalance theory of depression.
Medication may treat some symptoms of depression, but can’t change underlying contributions to depression in your life. Antidepressants are not a cure and won’t solve your problems if you’re depressed because of a dead-end job, a pessimistic outlook, or an unhealthy relationship. That’s where therapy and other lifestyle changes come in.
Studies show that therapy works just as well as antidepressants in treating depression, and it’s better at preventing relapse once treatment ends. While depression medication only helps as long as you’re taking it, the emotional insights and coping skills acquired during therapy can have a more lasting effect on depression. However, if your depression is so severe that you don't have the energy to pursue treatment, a brief trial of antidepressants may boost your mood to a level where you can focus on therapy.


Depression medication may be the most advertised treatment for depression, but that doesn’t mean it is the most effective. Depression is not just about a chemical imbalance in the brain. Medication may help relieve some of the symptoms of moderate and severe depression, but it doesn’t cure the underlying problem, and it’s usually not a long-term solution.  Antidepressant medications also come with side effects and safety concerns, and withdrawal can be very difficult.

Although medication can relieve the symptoms of depression, it is not usually suitable for long-term use. Studies show that other treatments, including exercise and therapy, can be just as effective as medication, often even more so, but don't come with unwanted side effects. If you do decide to try medication, remember that medication works best when you make healthy lifestyle changes as well.

Medication can reduce the symptoms of depression, but it doesn’t treat the underlying problem. Psychotherapy can help you get to the root of your depression, change negative thinking patterns, and learn new ways of coping. (http://www.helpguide.org/mental/medications_depression.htm)
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Government Investment


Adjunct Professor John Mendoza, Director of ConNetica and former Chair of the National Advisory Council on Mental Health, instigated the report in 2012. He now says: ‘The outcome is worse than I expected. The really disturbing finding is the fact that we have failed for more than a generation to implement the findings of inquiries, independent reviews, and plans over and over again.’
Despite numerous government plans, reports and reviews on mental health themes, increased attention and investment, and growing evidence about what treatments and strategies work, Australia still lacks an easily accessible mental health system. Important resources and funding are being wasted and the system is wanting in uniform quality of care.
Through the dozens of plans and policies created by state and federal governments since 1992, the OHD report finds that the same issues were identified as priorities over and over. It is difficult to assess the outcomes because very little data exists – as the report points out, a lack of accountability and outcomes data was a problem a hundred years ago and one that still persists. What data and reviews are actually available shows that policy implementation had largely failed.


Moreover, while the Federal Budget has increased funding for mental health in recent years, the rate of overall increase to the annual health budget means mental health’s share is declining.
On a state level, despite commitments from every state government towards deinstitutionalisation – that is, keeping people out of hospital and in the community as much as possible – there are still hundreds of people across the country, in all jurisdictions except Victoria, living in institutional settings, places that would have previously carried the label ‘asylum’. Many of those are there involuntarily and have been there for decades. Mendoza calls this ‘a national disgrace and a violation of human rights’.


It’s also expensive. The OHD report puts the cost to taxpayers on average at $10 million each week.
Some state budgets allocate half their mental health funding to acute hospital care. But there are other more cost-effective, sub-acute interventions which could prevent the need for hospitalisation in the first place. The strategy also ignores the nature of mental health. Unlike many other conditions, as John Feneley, the Mental Health Commissioner of NSW, points out in the report, ‘effective mental health care is not about administering treatment and hoping for a response; it needs to recognise the entire context of people’s lives.’ A tangible result of government failures is inadequate access to mental health treatment – over two million people with a clinical condition did not use any service in the last year. Many people with a severe mental illness – 40 percent – had little or no contact with services.
Given the alarming situation, and the prevalence of mental illness, the lack of research funding is startling. The OHD report includes a review of mental health research in Australia. It found that there is ‘little evidence of any increase in the allocation of funding for mental health research’.


The lack of research is stark given that, according to ABS figures, 45 percent of Australians will experience a mental illness at some point in their lives. Additionally, the OHD report found that suicide is the leading cause of death for those aged 16-25 years: for every Year 12 class in Australia, there will be one student who has attempted suicide. In the adult population, the prevalence of mental illness exceeds that of diabetes and all cancers combined.
Yet compared to other kinds of medical research, mental health receives a small share, only 8 per cent, of the total national research funding.
It’s difficult not to look at the current situation and not raise your hands in frustration, disgust, and despair. Mendoza says, ‘The failure to implement the recommendations over and over, was disturbing – it highlights a gross failure of governance.’ It looks like Abbott’s new government, which lacks an accountable minister for mental health, is set to deepen the chasm the OHD report has uncovered.
(http://overland.org.au/2013/10/australia-no-longer-has-a-minister-for-mental-health/)

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Inside many public hospitals, services are being cut, staff are being sacked and patients are being told they will wait longer for care. The news is frightening, particularly if you are sick or work in the system and know how stretched it already is. Depending on who you listen to right now, state and federal governments are both cutting health funding and lying about what the other is doing.
Three months ago the successful rural psychologist training program was presented with an award for excellence by the NSW Minister for Mental Health. This month, it will be forced to close because of lack of funding.
The closure of the Rural and Remote Area Psychologists Project could force much-needed psychologists from the bush, locals and psychologists say.
They hold grave concerns that the mental health of rural NSW will be forgotten now the decade-long drought has broken.
The award-winning program provided about one in five rural and regional NSW psychologists' continuing education, which the federal medical regulator says they need to practise. The closure comes after federal cuts to psychological services under the Better Access program.


Graham Parry, who helped develop the psychologists' project, said it cannot get funding from the NSW government, and funding from the Psychology Council of NSW - about $150,000 a year - could no longer be provided now the council has been absorbed into the federal medical registration system.
With Tony Abbott’s new cabinet ministry announced, Australia no longer has a Minister for Mental Health. This is far more than an aberration. A lack of accountability when it comes to mental health in this country constitutes a crisis, a crisis that has spanned decades. It is estimated more than 30,000 Australians were affected by the removal of the six extra ‘exceptional circumstances’ sessions included in the Better Access program in January 2013.
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Over-prescription – The “Yes” case

Antidepressant prescriptions in the UK jumped by 9.6% in 2011, to 46 million prescriptions. As a generalist prescribing antidepressants daily in primary care, I think that we use antidepressants too easily, for too long, and that they are effective for few people (if at all). But even questioning current care is considered “stigmatising” towards mental illness and “populist” anti-medicine rhetoric.2 The arguments put forward for using antidepressants are simple: depression is an important, often stigmatised, illness, for which antidepressants work; prescribing is supported by national guidelines; and long term treatment prevents relapse. But, regrettably, the argument is not that simple, and psychiatry’s defensiveness is stifling legitimate discussion.

Depression is indeed an important illness; few of us are untouched. But the current definition of depression is too loose and is causing widespread medicalisation. The Diagnostic and Statistical Manual of Mental Disorders (both DSM-IV and the proposed DSM-5) suggests defining two weeks of low mood as “clinical depression,” irrespective of circumstance. Depression is depression. It even proposes that being low two weeks after bereavement should be considered depression. But with 75% of those who write these definitions having links to drug companies,4 is this a story of a specialty being too close to industry? Mental illness is the drug industry’s golden goose: incurable, common, long term, and involving multiple medications. This relation with industry has engrained a therapeutic drug mindset to treat mental illness. Today the Centers for Disease Control and Prevention reports that 25% of US citizens have a psychiatric illness. Isn’t this medicalising normality?


The National Institute for Health and Clinical Excellence guidelines do not support the use of antidepressant medication in mild depression, nor necessarily as first line treatment of moderate depression. Guidelines promote the use of psychological talk based interventions. Paradoxically, therefore, any increase in prescribing of antidepressants may reflect non-adherence to these guidelines. Indeed, some meta-analyses suggest antidepressants may not work at all in mild to moderate depression. But even if we accept that antidepressants are effective, a Cochrane review suggests that only one in seven people actually benefits. Thus millions of people are enduring at least six months of ineffective treatment. People who do not respond fare worse, with switches of medications and often multiple drug combinations. How often do we tell patients these undisputed facts?
We are assured that depression is undertreated, but this research dates to the 1990s and is no longer relevant. Other observational research reassures us that antidepressants are being used appropriately, but this research merely demonstrates that antidepressants are used in people with depressive symptoms, not whether they are used appropriately—that is, only in those with more severe symptoms. Although it has been suggested that the increase in prescriptions could be due to longer duration of treatment,2 this isn’t plausible. Since this research was published in 2006, prescriptions in England have increased by 17.3 million, a 59% increase. The only explanation is that we are prescribing more antidepressants to ever more people.


Even if longer prescribing does contribute to increasing prescription totals, there is no evidence to support this policy. The major systematic review of randomised trials of antidepressant drugs to prevent relapse in depression had only 500 patients taking selective serotonin reuptake inhibitors for up to three years. Another systematic review concludes that research “provides no guidance” to support long term treatment. A policy of ever lengthening courses of antidepressants is a product largely of “expert” opinion, not evidence.


Before we continue with this policy the psychiatric community must produce evidence of benefit. The internet is awash with harrowing patient stories of side effects such as gastrointestinal disturbances, hypersensitivity, anxiety, insomnia, tremor, hallucinations, drowsiness, sexual dysfunction, hypomania, and suicidal behaviour. Research also suggests that half of patients experience a withdrawal syndrome. Patients are reluctant to stop antidepressants, assuming these symptoms mark a return of their depression. Some even believe they will never feel “happy” without medication. The antidepressant approach is used to validate the “biochemical model”—depression is a mere chemical imbalance. This seems counterintuitive, reductionist, and dismissive of the human condition and is not supported by robust evidence. Lastly, it has been suggested that increased use of antidepressants is linked to a fall in suicide rates. But this doesn’t seem credible: suicide has increased sharply since the economic recession despite increasing antidepressant use. Ian Reid wrote of depression: “work, purpose, faith, family, friends and security can’t make it better.” I fundamentally disagree. Improving society’s wellbeing is not in the gift of medicine nor mere medication, and overprescribing of antidepressants serves as distraction from a wider debate about why we are so unhappy as a society. We are doing harm.
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Over-prescription – The “No” case


Des Spence (doi:10.1136/bmj.f191) believes that the rising prescription rates for antidepressants reflect over-medicalisation, but Ian Reid argues that prescribing is cautious and appropriate
The notion that antidepressants are overprescribed is certainly popular and hardly new. There is profound suspicion of them: antidepressants are regularly caricatured in the media as an addictive emotional anaesthetic, peddled by thoughtless general practitioners as a matter of convenience, and taken by credulous dupes who seek “a pill for every ill.” Little wonder that decrying antidepressant prescription is such a sure-fire crowd pleaser for the press (for example, “Ministers act to wean Scotland off £55m-a-year antidepressant habit,” Scotsman, 6 December, 2006).
The reality is very different. Depressive disorder is a common, recurrent, debilitating, and potentially lethal illness. Psychiatric drugs, including antidepressants, have equivalent effectiveness to drugs in other branches of medicine (as detailed in a review of 94 meta-analyses comparing drug effect sizes in medical disease with drugs in psychiatric disorder1). Given recent demonstrations that depression is still under-recognised and undertreated, the claim that antidepressants are over-prescribed is alarmist.
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The Power of the Lobby

On 4 March 2004 Australia and the United States released the text of a bilateral trade agreement designed to reduce trade barriers between the countries. Surprisingly, the Australian pharmaceutical benefits scheme (the national drug subsidy programme operated by the federal government of Australia) was part of the deal, with Australian negotiators conceding to several US demands. These included the creation of an independent review body to examine drugs rejected by the Pharmaceutical Benefits Advisory Committee. Under existing legislation only the advisory committee can recommend listing of drugs for subsidy. However, the dissenting views of another review body, supported by publicity and lobbying, may undermine the famously tough stance of this committee concerning the cost effectiveness and prices of pharmaceutical products. In addition, Australia has agreed to changes in intellectual property protection that, among other things, increase the risk of delayed entry of generic drugs on to the Australian market. The use of the trade agreement to push the interests of US pharmaceutical companies is one in a long list of hostile moves that have included legal challenges to the decisions of the Pharmaceutical Benefits Advisory Committee to reject drugs for subsidy and political lobbying for removal of committee members.

Lobbying by Australia's drug industry association, Medicines Australia, has persuaded the Australian Competition and Consumer Commission (ACCC) to scrap a proposal to require public disclosure of drug companies' sponsorship of doctors' travel and accommodation and other promotional benefits. The commission, a government agency established to protect consumers from anticompetitive activity, had originally proposed accrediting a self regulatory code on the marketing of drugs developed by Medicines Australia member companies, subject to certain amendments. The first amendment laid down that Medicines Australia publish details of all breaches of the code on its website in full and in the annual report of its code of conduct committee. Medicines Australia found that amendment acceptable. The commission also recommended that member companies disclose planned sponsorship of events and travel for doctors, "to ensure that benefits are not provided which might affect doctors' prescribing habits." This proposal drew strong criticism from Medicines Australia and the Australian Medical Association, the biggest doctors' association.
In its submission to the commission the association claimed that disclosure "could serve to expose doctors and the pharmaceutical companies to public derision by people with unfounded prejudices and no real understanding of the complex educational framework and benefits involved in such educational meetings." The director of the international public health group Healthy Skepticism, Peter Mansfield, believes that patients should be told about drug companies' sponsorship deals. "If there is nothing wrong with what is going on, then there is no problem with everybody knowing about it," he said.
Medicines Australia complained that there was a "significant risk" that the availability of such information "will encourage overzealous critics of the pharmaceutical industry to seek to interfere in its normal and legitimate business activities.""The information may be misused by media or consumer groups, which could cause patients to question the value of their prescription and possibly lead them not to fill it," the group submitted to the commission.
Prior notification of events, they argued, could result in "uninvited parties (such as the media) to attend educational meetings for ulterior purposes," they submitted. "This risk could deter doctors from attending."


Instead Medicines Australia proposed that a three person committee, the code of conduct monitoring committee, seek information from member companies about materials and invitations to industry sponsored meetings and include a summary in its annual report. In its final determination the commission dropped its original proposal and opted for the alternative from Medicines Australia.
Martyn Goddard, senior policy officer with the Australian Consumers Association, was dismayed by the commission's retreat: "The ACCC have rolled over on their backs and had their tummies tickled by the drug companies . . . Medicines Australia still has total control. They decide what is going to be publicised and what isn't. They make the judgment about what falls outside the code and what doesn't."
The commission's final determination on the Medicines Australia application is available at http://www.accc.gov.au
Of course, most medical practioners rely upon medical journals for the latest information. But most journals face an ethical problem in being so closely associated with pharmaceutical companies. These companies are important in that almost all the new drugs of the past 50 years that have transformed medicine have been discovered or developed by them. But the interests of pharmaceutical companies and doctors, patients, and therefore journals (that should put doctors and patients first) are not always the same. A company might want patients to take its drug even though another drug might be better. Companies will push drug rather than non-drug treatments, even though for many conditions—e.g. diabetes—non-drug treatments are often more important.


Some journals have been captured by pharmaceutical companies because they have come to depend on them. Many, including some of the most prestigious journals, publish mostly trials that are funded by the industry. The results of these trials are rarely unfavourable to the companies. The journals depend on income from advertising and sales of reprints (a company might pay over $1m for reprints of one study, which it funded in the first place). Journals should not attempt to separate themselves from pharmaceutical companies, but the relationship should be more ethically sound.


The GP’s and the Drug Companies


Pharmaceutical companies are the primary customers for prescribing data, which are used both to identify “high-prescribers” and to track the effects of promotion. Physicians are ranked on a scale from one to ten based on how many prescriptions they write. Reps lavish high-prescribers with attention, gifts, and unrestricted “educational” grants Cardiologists and other specialists write relatively few prescriptions, but are targeted because specialist prescriptions are perpetuated for years by primary care physicians, thus affecting market share.
Reps use prescribing data to see how many of a physician's patients receive specific drugs, how many prescriptions the physician writes for targeted and competing drugs, and how a physician's prescribing habits change over time. One training guide states that an “individual market share report for each physician…pinpoints a prescriber's current habits” and is “used to identify which products are currently in favour with the physician in order to develop a strategy to change those prescriptions into Merck prescriptions”
While it's the doctors' job to treat patients and not to justify their actions, it's my job to constantly sway the doctors. It's a job I'm paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don't even realize that's what they're doing…” - Shahram Ahari, a drug company representative.
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The Quick Fix


Depressive- and anxiety disorders are among the most prevalent disorders, with lifetime prevalence rates of 19% for both. Most patients with depressive- and anxiety disorders are treated in general practice. In the last decade of the 20th century, prescription rates for antidepressants have increased 4 to 10 times in general practice. Currently, 2.1–2.5% of patients treated in primary care receive antidepressants for 9 months or longer, i.e. 50–60 patients per average Dutch general practice with 2350 patients. The appropriateness of long-term antidepressant usage is a matter of debate. From a patient perspective, inappropriate use of antidepressants has serious consequences for safety, wellbeing and daily functioning. Also there are negative side effects such as sexual disorder, emotional flattening, interaction with other drugs and sedation. From an economic perspective, inappropriate use of antidepressants is expensive considering the high costs of modern antidepressant drugs in the case of overtreatment and the high costs for productivity loss due to depressive and anxiety disorders in the case of undertreatment. Although the Dutch NEMESIS data show that half of the identified antidepressant drug users still suffered from a depressive or anxiety disorder and are thus in need of subsequent treatment steps we considered this type of inappropriate treatment beyond the scope of the study reported here.


Current guidelines advise to continue treatment with antidepressants for 6 months after remission for a first or second depressive episode or a successfully treated anxiety disorder, which means a total treatment duration of approximately 9 months. Overtreatment is therefore defined as the continued prescription of antidepressants without an appropriate indication at start or continued prescription during more than 6 months after remission of the index disorder. There is evidence of overtreatment in primary care. Antidepressants are often initiated during the first consultation with the general practitioner (GP) about emotional symptoms. Moreover, up to 80% of the users receive antidepressants for mild to moderate depressions, while 60% of these depressions remit spontaneously within 6 months. The Netherlands Mental Health Survey and Incidence Study, has shown that about half of the antidepressant drug users in the community did not meet the criteria for a depressive or anxiety disorder in the past six months. Similar results were found in chart-review studies, showing that GPs had not registered a psychiatric diagnosis in nearly 40% of patients receiving prescriptions for antidepressant drugs. Furthermore, 10–15% of long-term antidepressant drug users continue usage after remission without trying to discontinue it.
I, Geoff Mooney, have had no revision of my need to take anti-depressants, or the appropriateness of the particular medication, in the last TEN years.
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The Elephant in the Room

The mental health of our society is diminishing at an alarming rate. Yet, while we fiddle with the most efficient way to treat the symptoms, Rome burns. Child psychologists say increasing numbers of children are presenting with mental disorders, such as severe anxiety, which have led to a record number of suicides. The very latest research shows that a predisposition to mental illness is genetic, but that it is environmental factors that trigger it. There is, I believe, an urgent need for a massive injection of funds and medical expertise into researching the reasons for the decline. Why isn’t this being done? What are the contributing environmental factors? Is it because it’s too hard? Or is it that we are afraid of the answers? New research shows that stress blocks a gene called neutrin that protects the brain from mental disorders. Yet we simply accept as fact that increased stress levels are a natural part of modern life.  Perhaps we need to seriously question that assumption.

There is no “quick-fix” to depression or anxiety. But that is what we have largely adopted.

Geoff Mooney