September 2014

The Medicine

The pill problem

By Karen Hitchcock
Are GPs prescribing too many antidepressants?

I was at a party. The host stood up, thanked everyone for coming, toasted his family and then told us he had been diagnosed with depression. He turned his head away and pressed his fingers into his eyes. No one moved. “But it’s OK,” he said. “I understand that what I have is a disease, caused by a chemical imbalance in my brain.”

Worldwide sales of antidepressants make pharmaceutical companies tens of billions of dollars. Each year, 17 million scripts are written in Australia at a cost of more than $533 million. Eighty-five per cent of the scripts are written by GPs.

Many of the elderly patients on my ward, including those with severe dementia, are on antidepressants. Sometimes they have landed in my ward as a result of side effects: dizziness that leads to falls; delirium; precipitously low salt levels in their blood that can cause confusion, headaches and seizures. “You’re taking an antidepressant,” I’ll say. “Why was that prescribed to you?” They answer, “I’m taking a what?” or “My GP gave it to me years ago, when my husband died.” One of my in-patients was a man in his 50s who had suffered a major stroke and could no longer walk or speak with ease. He could no longer provide for his family. A doctor who covered the ward for me on the weekend suggested I start him on an antidepressant. “He was crying,” she said. “I think he’s depressed.”

As doctors, we want to be useful. Prescribing is a satisfying act: here I am, doing something. 

The story of how antidepressants became the most widely prescribed and profitable drugs in the history of medicine is an interesting one. In the 1950s, a collection of symptoms was given the name “depression” and defined as a disease. In the following decades, drugs to cure this disease were marketed heavily, mostly on the strength of their hypothesised mechanisms of action. Pharmaceutical companies funded clinical trials and published the results of the ones that showed statistically significant benefits of drug treatment. The disease model was promoted as patient-friendly because it apparently countered the view of depression as a moral or personal failing. Data that linked the widespread prescription of antidepressants with a decrease in suicide rates were repeatedly cited. Key opinion leaders championed the drugs. National guidelines recommended the drugs be prescribed for patients who suffered severe depression; doctors extrapolated from that and gave them to everyone.

In the United States, the drugs are advertised on TV. The viewer is invited to ask their doctor for a prescription to fix their brain’s chemical imbalance, their lack of serotonin, their pain and misery, so that they can once again run on the beach with bleached teeth and nicely blow-dried hair. Unfortunately, the advertisements’ cartoons that depict the drug racing through your blood and smashing like a piñata against starving nerve endings are bullshit. There is scant proof in the neurosciences that this reductionist theory of chemical imbalance is correct. It is closer to myth than science. As is the idea that massive antidepressant prescription has led to a decrease in the rate of suicide. There is hard evidence that the belief in the chemical imbalance theory increases social stigma and the duration of symptoms. Mild to moderate depression is generally a short-lived experience, which waxes and wanes.

Perhaps most importantly of all, recent re-evaluation of the trials has shown that these drugs do not work for the majority of patients who are prescribed them. Researchers used freedom of information laws in the US to uncover dozens of trials the pharmaceutical companies had suppressed. When they combined the published and unpublished trials, they found that half showed the drugs worked (barely) better than placebo and half showed they did nothing at all.

I do not think the psychic consequences of physical debility, loss, poverty or abuse are necessarily a disease called depression. I wish it were true that there was a safe pill that could ease ordinary misery. I’d prescribe it like crazy. I’d probably take it. But unfortunately the so-called antidepressant drugs have minimal benefit to the average individual that presents to a GP, have multiple side effects (including the possibility of a small increase in the risk of suicide) and are difficult to get off. I am glad that there are psychiatrists, because I’m not trained to treat people who cannot feel anything or cannot feel anything except pain – patients who want very much to die. If you feel this way, you should certainly seek help. If I think one of my patients is gravely depressed or suicidal, I ask my psychiatrist colleagues to see them as a matter of urgency. These are not the majority of the patients being prescribed antidepressants by their non-psychiatrist doctors and for whom – according to hard trial data – the drugs are as or less helpful than regular exercise, psychotherapy, St John’s wort or placebo. These patients may not need drugs. They may need social workers, psychologists, rehabilitation, a job, home help. Someone to talk to, someone who will listen.

There is another way to read the antidepressant story: pills mean big money for those who make and promote them, but for society they are cheap. If socially generated miseries are defined as diseases, the crushing responsibility of helping a country full of suffering citizens can be handballed to medicine. Social isolation, unemployment, violence, disability, poverty, racism or bullying need not be addressed. The cures for these causes of misery are neither simple nor easy, but our response to a person who has lost everything has become “give them a pill”. The page titled “What causes depression?” on the Beyond Blue website is illustrated with a large picture of an indigenous Australian man. He is quietly beaming.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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