The worried well


It is perhaps useful to remember that until the nineteenth century the general community, and micro-communities like the family, dealt with ‘mad’, ‘bad’ and ‘sad’ people. Gaols or religious institutions housed the socially outcast. The profoundly melancholic might have been bled by a physician, or sent to the country for a taste of farm life and fresh air to doctor their sullen ruminations.

Increasingly, emotional disease has migrated from the aegis of traditional healers and listeners into the offices of medical practitioners whose capacity to hear out the complex unfolding of stories of anguish or loss is limited by time constraints and the pressure of a full waiting room.

Quarterly Essay Issue 18

Quarterly Essay Issue 18

Making an appointment with your GP may not be the definitive answer to the question where do I go when I feel depressed?, but it’s the best address on offer at the moment. Most episodes of depression are diagnosed and treated in a primary care facility. Eighty-five per cent of PBS-subsidised prescriptions for antidepressants are written in general practice rooms.

There is an anomaly in this state of affairs. ‘There is no evidence to support the use of antidepressants in general practice patients who do not meet the criteria for major depression or dysthymia.’ And yet the type of depression that arrives in a GP’s office is rarely ‘major’ in the strict sense of the definition. The patient may be ‘flat as a piece of paper’, ‘weepy’, ‘sleep-deprived’, ‘lacking in libido’ ‘socially withdrawn’, but is not, in the main, the deeply depressed patient seen in secondary and tertiary care facilities. A quick check in the PBS Guidelines shows clearly that SSRIs (Selective Serotonin Re-uptake Inhibitors) and the newer drugs are only licensed for major depression and a few variants like obsessive-compulsive disorder (OCD). In fact, Kelsey Hegarty writes in Australian Prescriber, ‘all the testing on the efficacy of antidepressants was done on patients in secondary and tertiary settings who had major depression,’ and further, ‘there is no good evidence to support the use of antidepressants in minor depression’.

And yet the stratospheric increase in antidepressant prescribing tells us that doctors (and patients) have enthusiastically bought into the message that drugs defeat depression. The loop that begins in scientific research, winds through drug company development and spin, snakes into the doctor’s surgery, and lassos the patient in the chair, is pulled outside into the community where it is threaded from hand to hand, as happy patients tell others that a drug has fixed their lives. Few people argue with the results of SSRI drug therapy. It seems to work for mild depression “ the sort of normal sadness that afflicts us all, the people with low-level sorrow. Sometimes, a course or two will act as a bridge for someone who cannot find his way out of the mire, and physicians report that they are happy to discontinue the drugs when their patients are stable again.

Digging a little deeper one finds that each transformed patient has paid a small price for mood enhancement “ not a large dollar price compared to, say, the United States, but in the form of ‘start-up’ side effects. Each has accommodated up to two weeks of nausea, trouble falling asleep or staying awake, constipation and sometimes its opposite, waning of an already underactive libido and perhaps an increase in anxiety. This spectrum of complaints is marketed to the patient as a kind of endurance test. Are you man or woman enough to put up with a bit of initial discomfort for the ultimate good that awaits you after six to twelve months of daily tablet swallowing? For some, the start-up effects are so awful they prefer to revert to the vague sense of unhappiness that brought them to the doctor in the first place. Feeling ‘lost and flat’ is suddenly preferable to feeling ‘weird’ because of a drug.

In my own questioning of the anomaly I’ve yet to find an answer that isn’t contradictory. Yes, say the prescribing doctors, strictly speaking it is true that we should only use SSRIs for major depression; yes, it’s true they’re not licensed for minor to moderate depression; yes, we use them for minor to moderate cases; yes, they work, and no, we are not breaking any rules.

The contradiction seems to be semantic: the word ‘major’ has taken on another meaning in the general practice setting. A depression qualifies as major if it has gone on for longer than two weeks, is interfering with the patient’s daily life, and is physically manifested by sleeping problems, appetite changes and libido swings.

All those symptoms, I contend, could be ascribed to falling in or out of love, facing end-of-year exams, growing older or getting hung-up on office politics. This is ordinary life angst repackaged in a medical presentation. Giving a patient a potent drug to soothe what are often transient worries is the legacy of listening too attentively to the lesser things that commend its use (once-a-day dosage, kind to the stomach, PBS-listed, longer-acting, shorter-acting, faster excretion “ all of which are noteworthy and attractive in and of themselves) at the expense of what is essential and absolute about a drug: its need to exist in the first place, and its necessary and proven applicability to a pathological condition.

This is an edited extract from Quarterly Essay 18, The Worried Well: The Depression Epidemic and the Medicalisation of Our Sorrows, by Gail Bell ($13.95, Black Inc.). Visit Quarterly Essay here.

Launched in 2004, New Matilda is one of Australia's oldest online independent publications. It's focus is on investigative journalism and analysis, with occasional smart arsery thrown in for reasons of sanity. New Matilda is owned and edited by Walkley Award and Human Rights Award winning journalist Chris Graham.