Treat­ment for de­pres­sion needs to be cou­pled with vig­i­lance

The Weekend Australian - Travel - - Health -

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.

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