Health

Global crisis of depression: reality or hype?

November 19, 2014

Africa

November 19, 2014

Africa
Christopher Dowrick

Professor of primary medical care

Christopher Dowrick is GP and Professor of Primary Medical Care in the University of Liverpool, Board Advisor for Mersey Care NHS Trust, NIHR Senior Investigator and Professorial Research Fellow in the University of Melbourne. He has more than 30 years of experience in the mental health field, with over 200 scholarly publications including Beyond Depression (2009). He believes that the current trend to medicalise unhappiness is too often an intrusion on personal emotions. It adds unnecessary medication and costs, and distracts attention and resources from those who really need them.

It is important to talk about the problem of depression. However, it is neither really a disease nor an epidemic, and over-diagnosis and over-medication are serious issues, argues Christopher Dowrick, a professor of primary medical care in Liverpool, UK.

It is important to talk about the problem of depression. However, it is neither really a disease nor an epidemic, and over-diagnosis and over-medication are serious issues, argues Christopher Dowrick, a professor of primary medical care in Liverpool, UK.

Depression is a serious problem. That sense of hopelessness, exhaustion and alienation is dreadful. But let’s not exaggerate its extent or severity—or the relevance of medical intervention.

Here are six key reasons:

  1. Depression is already the leading cause of disability worldwide. However, in my opinion, there is no epidemic. For example, the prevalence of depression stayed about the same in England during 1993–2007.

  2. The diagnosis of depression is a rag-bag of different conditions. It is not really a disease. Depression is better understood as a symptom, like fever or pain. Most people given the diagnosis are not mentally ill, they are responding to life’s stresses and difficulties. That’s why it’s more common during periods of economic turbulence or emergencies.

  3. The rag-bag has got bigger with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which now includes grief in the diagnostic framework. This will spuriously expand the apparent prevalence of depression. Turning grief and other responses to loss into a mental disorder is a medical intrusion into private emotions. It substitutes a superficial medical ritual for deep and time-honoured cultural ones and stigmatises the experience.

  4. It is wrong to assume that mild cases tend to become severe if left untreated, and that early intervention is needed to nip this problem in the bud. This assumption may sometimes work well for cancers but does not apply to depression. Most people who get depressed do so mildly—and mild depression usually resolves spontaneously.

  5. In the West, the problem is not under-diagnosis of depression. The problem is over-diagnosis. General practitioners (GPs) are 50% more likely to diagnose depression when it is not present than to identify a case correctly or miss a case when it is present.  In a recent US study, only 38% of adults with clinician-identified depression met formal diagnostic criteria.

  6. We also over-medicate. In the US, 11% of people aged 12 and above take antidepressant drugs, including 23% of women in their 40s and 50s.  Antidepressant prescribing increased by 10% each year in England between 1998 and 2010; 53m prescriptions were issued in 2013. However, antidepressant drugs do not help most people. Only in severe cases are they demonstrably more effective than placebos. The main beneficiary of this boom in antidepressant prescribing is not the patient, but the pharmaceutical industry.

We are diverting attention—and resources—from those who most need help.
 
So what should we do?
  • People with mild or loss-related symptoms need innovative responses, such as the Bounce Back project in Liverpool, offering care-full listening and encouraging strategies of personal resilience.

  • GPs should focus on identifying people with complex depression who experience socio-economic disadvantage, abuse, physical morbidity or disability. We must act together with health and social care professionals, and with our local communities, to provide evidence-based interventions, including psychological therapies and collaborative care.

  • And we must avoid using the notion of a global depression crisis to ignore the grave social injustices that make people miserable.

 

Christopher Dowrick will be one of the speakers at an upcoming Economist conference, The Global Crisis of Depression.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of The Economist Intelligence Unit Limited (EIU) or any other member of The Economist Group. The Economist Group (including the EIU) cannot accept any responsibility or liability for reliance by any person on this article or any of the information, opinions or conclusions set out in the article.

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