Changing our minds about depression
Alastair Campbell, former Labour spin doctor and depression patient, thinks that mental and physical health should not be seen as separate things.
Speaking at The Economist’s Global Crisis of Depression summit in November, he equated people saying “I don’t see what you’ve got to be depressed about” to being told “I don’t see what you’ve got to be cancerous about, or broken-legged about, or diabetic about”.
This summed up one of the recurring themes of the day – that the two health areas should be getting equal priority from governments, doctors and pharmaceutical companies across the world.
“We’re held back by an imbalance of payment systems and rights between physical health and mental health,” Norman Lamb, the UK’s minister of state for care and support, said at the conference, “which means in the allocation of resources mental health tends to always lose out, and that, in my view, has to change.”
But when Pharmafile spoke to Campbell afterwards, he said that he thinks there is a long way to go to reach this goal.
“To my mind it is not a big enough priority. To be fair to Norman Lamb, he does really care about mental health, but the government as a whole? I don’t think they do.”
As Denmark’s minister of health Nick Hækkerup put it in his address on the day: “We need to create a healthcare system that does not discriminate, a system that takes and treats a broken mind and a broken leg on an equal basis.”
According to figures presented at the event, depression is the leading cause of disability worldwide, affecting 350 million people globally and more than 30 million people in Europe.
Yet despite this, over half (56%) of people with depression do not receive the treatment they need, and the mental health charity Mind recently found that local authorities in England only spend an average of 1.36% of their public health budget on mental health.
An All-Party Parliamentary Group report last year concluded that mental health “still remains an afterthought in most of the UK’s global health and development work”.
David Haslam, chairman of NICE, was clear that pharma companies also need to play their part. “If we see mental and physical health problems as equivalent – and the conference has demonstrated the enormous impact that mental health problems have on society and on individuals – then you would hope companies looking where to apply their research base would consider this to be an important area,” he told Pharmafile.
Talking after his speech, Hækkerup also told us: “I think that it is one of the corporate social responsibilities of pharmaceutical companies to not only sell drugs that can cure mental illnesses, but also lifting the responsibility of being able to prevent mental illnesses.”
However, Anders Gersel Pedersen, who is the head of R&D at mental health drug specialist and event-sponsor Lundbeck, said that government pricing regulations are restricting pharma’s ability to focus on depression and mental illness.
“Over the past five or six years, many of the major companies have actually pulled deliberately out of the area because they foresaw the systems that governments have to curtail their costs,” he pointed out to us. “They basically apply metrics that are not appropriate for mental health treatment.
“There has been no willingness to pay for the medication when it comes out. And if that’s the case then companies would obviously much rather research and invest in other therapeutic areas where there is an apparently higher appreciation of what we bring. That’s how simple it is.”
Haslam offered an alternative view, saying that there are myriad factors that are pulling attention away from the management of depression, some embedded deep in our culture.
“There is the reluctance of people to present with mental health issues, so there’s a lack of self-awareness of when help might be appropriate,” he said.
“There’s a degree of prejudice both by clinicians and by patients against the appropriate use of medication – and that isn’t to say that every case of depression needs medication, but certainly there are cases that very definitely would benefit, and people don’t understand that. And then there’s the quality and evidence base for the different drugs that are available.”
Stigma against antidepressants
Prejudice surrounding antidepressants came up often during the summit, with several speakers from across the healthcare sector saying they felt there are a lot of misconceptions among the public.
Haslam explained to Pharmafile that the issue is more complex than many people’s ‘almost theological’ views would suggest: “They either believe in antidepressants or they don’t believe in them. I think an awful lot of people see it as black and white – they’re either a good thing or a bad thing – without understanding the complexity of it.”
Campbell’s experiences with depression drugs fit with this greyer perspective.
“At various times in my life I’ve probably had half a dozen different antidepressants,” he told us. “Some of them I just knew straight away that they wouldn’t work, if they made me feel nauseous, or if they made me feel sick, or if I lost my appetite. There was one that left a really horrible feeling in my mouth all the time. So I just knew.
“I stuck with them for a bit, then gave it up. I eventually found one that I don’t mind. I wouldn’t say I like it, why would you? I don’t mind it. I’m afraid we have to be honest about the fact that there’s a hell of a lot of trial and error on these.”
The side effects of antidepressants are often one of the main reasons people criticise the drugs. Pedersen did not deny they exist, but instead argued that people should view the side effects as outbalanced by the benefits of treating mental health disorders.
“I think there have been a lot of scare campaigns, where people have had a difficult time discerning between what are the very severe consequences of having depression against what could be possible side effects of getting the medication. Because it’s obvious that there are side effects with every medication you take, including antidepressants.
“We should be careful of that, we should be observant of that, and patients should be made aware of that. But they should not be scared by it, because in the assessments that both companies and health authorities do, if this risk-benefits scenario doesn’t look right it wouldn’t be there.
“If I have a heart problem and I take heart medication I will have side effects, but I will still take my heart medication because I know that it’s good for my heart and my survival, and I think people should be encouraged to look upon getting whatever therapy they get in the same way.”
Taking a more sceptical view during his speech was Christopher Dowrick, a GP and professor of primary care at the University of Liverpool. He said that the biggest issue with antidepressants is not the side effects, but how they are being prescribed to patients.
“In the West, the problem is not under-diagnosis of depression, the problem is over-diagnosis,” he said. “General practitioners 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.”
He also cited research that found antidepressant prescribing increased by 10% each year in England between 1998 and 2010, and that over 50 million prescriptions were issued in 2013. Meanwhile, 11% of people in the US over 12 take antidepressant drugs, including 23% of women in their 40s and 50s.
Dowrick partly blamed the misconception of depression as a disease rather than a symptom. “Most people given the diagnosis are not mentally ill, they are responding to life’s stresses and difficulties,” he added. “That’s why it’s more common during periods of economic turbulence or emergencies.”
He also said that assuming mild cases tend to become severe if left untreated could be a factor, as could the increasing number of natural responses like grief now being labelled as forms of depression – particularly in America since the publication of the DSM-5 psychiatry manual.
“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,” Dowrick concluded.
However, Campbell said that he worries about the effects of focussing too much on overprescription in discussions surrounding antidepressants.
“I totally got what [Dowrick] was saying, but you’ve got to be really careful,” he said.
“There is no doubt that there will be some people who are given drugs because GPs have got to give them something when they’re busy and tired and have a surgery full of people. But I think there’s a danger that when GPs say that, then people who really do need medication will think ‘I don’t want that’.
“I worry when anybody says [outright] ‘drugs are bad for you’. They might be, but they might not be.”
Simon Wessely, who is a professor of psychological medicine at the Institute of Psychiatry, argued in his talk that overprescription is actually a myth.
“Antidepressant prescriptions have gone up in this country, up to 50 million, but the number of people taking antidepressants is actually unknown. The main reason they’ve gone up is the evidence now that if you’re taking antidepressants and you’ve got better you should take them for six months and not one month. So the number of prescriptions increases partly to reflect better prescribing.
“It’s a knee-jerk reaction to go from the data, which shows that antidepressant prescriptions have gone up, and immediately jump to a conclusion that they are not actually merited.”
‘Openness is critical’
Perhaps the main problem, then, is the lack of open discussion and understanding of depression and antidepressants in society – something that Hækkerup believes will lead directly to better treatment.
“That could be done for instance in the workplace,” he told Pharmafile, “and in the dialogue that could help in bringing the subject of depression to people’s attention, and also destigmatising the question of mental illnesses – because the better we get to talk about mental illnesses the better we get to prevent mental illnesses. And also in the cases where there actually is mental illness or depression, the better we’ll get to treat it.”
Haslam offered us a few suggestions for how this can be achieved: “I think it’s helped by as many people as possible who have taken antidepressants talking about it, and particularly people in a leadership position.
“I suspect that there might be mileage in characters in soap operas and so on being diagnosed and treated with depression and there being no stigma about that.
“The very fact that we’re talking about it being an issue demonstrates how much of a stigma there is. You’d never invent a plotline in a soap for someone to be taking antibiotics, but you might because they’re on antidepressants.
“There might be mileage there in working with some of the mental health charities, organisations like Mind, in trying to address some of these issues. […] But I think openness by as many people as possible is critical.”
Just as several of the speakers argued for a view of depression that was no different from society’s view of physical illnesses, it also seems that pharma’s relationship with mental illness is much the same as in any other disease area.
There are companies complaining about government regulation, patients worried about side effects, debates about pharma’s true intentions, and stories and statistics that are both good and bad.
One thing that many of the speakers seem to agree on is the need for collaboration – there are big hurdles to tackle in depression and mental illness, and only through concentrated efforts can real progress be made.
“Where [government and pharma’s] interests coincide is in serving the public good, and that’s where I think there’s a mutual interest in them actually trying to have a better public understanding of drug companies and what they do,” said Campbell.
Haslam concluded: “They key issue is to recognise that there is a problem to be solved and recognise the extraordinary importance of mental health issues, particularly depression. And I think government understanding those issues and the industry demonstrating how they can best help address those issues must be the way forward.”
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