Treatment for depression needs to be coupled with vigilance
ONE of the major priorities in Australia is to reduce the deaths due to suicide. Although there are now more than 2000 each year, this represents a significant improvement since the mid-1990s when the figure peaked at about 2500. Some groups remain at particularly high risk, notably indigenous Australians and men aged 25 to 45.
While the risk factors for suicide include a wide range of personal mental health, alcohol and drug use and broader demographic, social and economic factors, a large body of international evidence indicates that one of the most effective ways to reduce suicide is to promote the widespread treatment of common mental health problems such as anxiety and depression. This process took off in Australia in the early 1990s with the introduction of the new Prozac-like antidepressants.
It was then intensified by broader national education and awareness campaigns such as beyondblue, the national depression initiative and, more recently, the Howard Government’s key decision to broaden Medicare-based access to psychological services.
From a public perspective, the biggest issue has been whether this widespread promotion of the active treatment of depression might not do more harm than good.
The public’s fears about antidepressant medicines, however, include a fundamental paradox. Some professionals promote the concept that they are no more effective than placebos (or sugar pills), while some antipsychiatry groups argue that they are so powerful that they cause major side effects such as increased suicidal behaviour, violence or long-term addiction.
With regard to efficacy, there is no doubt that those who have more severe or persistent depressive episodes demonstrate the best response to medicines. For those with less severe illnesses, responses to medicines or psychological therapies (at least in the shortterm) are roughly equivalent. This evidence is frequently misinterpreted to mean that only those with the most severe illnesses should be prescribed antidepressants.
As with other common medical problems, such as high blood pressure, high cholesterol levels or raised blood sugars, for very good reasons we do not only restrict treatments to those with very abnormal results.
If you wish to prevent as many heart attacks or strokes as possible, then you need to ensure that effective treatments (lifestyle adjustments and/or medicines) are used by as many of those people who are at risk as possible.
The same principle is true for prevention of suicide. That is, we need to treat (with psychological therapies and/or medicines) as many of those people with depression as possible. Data from Australia, and confirmed across 27 other countries, is that the increased access to antidepressant treatments over the last decade has resulted in falls in suicide.
When the work was done right across this country largely by general practitioners (rather than specialist psychiatrists or psychologists), the big winners were our communities.
The second major concern, commonly expressed by some specialists and antipsychiatry advocates, is that antidepressant therapies increase the chances of a person committing suicide. Over the last two years, extensive data from large population-based studies indicates that the greatest risk of attempting suicide is in the month before commencing antidepressant therapy, and that this risk drops sharply on starting treatment.
This effect is evident across all age groups and is especially relevant to young people where the benefits of medicines are less evident than in older adults. In the US, where concerns about possible harms of antidepressant therapy to young persons were greatly exaggerated and, consequently, prescribing rates fell, suicides among young persons have started to rise again.
By contrast, much more limited data from clinical trials has suggested that there is an increase in suicidal thoughts (but not actual attempts or deaths) in a very small number of individuals in the first two weeks of treatment.
This is reported by up to 5 per cent of people receiving medicines, which is about twice the rate in those who receive placebo tablets. So, while we can conclude that in most cases the prescription of antidepressant medicines leads to a marked fall in actual suicides and related suicide attempts, doctors and patients still need to be vigilant in the early stages of treatment.
Perhaps the most important change in recent years is the increased community awareness of the dangers associated with not treating depression. Those who get care are more likely to be alive and back at work or school. Those who do not, , particularly young and middle-aged men, are more likely to die or suffer the extensive medical and social consequences of untreated illness.
In Australia we now need to match our destigmatisation efforts with the provision of more accessible and more affordable mental health services. Most importantly, it is time to stop demonising the medicines and recognise the courage it takes to come forward and get treatment. Professor Hickie is executive director of the Brain & Mind Research Institute at the University of Sydney. He was previously CEO and then clinical adviser to beyondblue: the national depression initiative.