Depression and whether a behavioral problem is mental illness

It has been said that depression is the epidemic of the 21st century. Certainly the rates of diagnosis have increased over the last 10-15 years. Some claim that this is due to better recognition of the issue and that actual rates are unchanged. Others feel that we are collectively more depressed than in years gone by.

The number of Americans prescribed an antidepressant doubled between 1996 and 2005 and those being treated took more tablets. Yet there is nothing to show that the population is better off. In fact the suicide rate has risen.

It is interesting to note that $1 billion is spent each year on promoting anti depressants. Between 1999 and 2005 the amount spent on direct to consumer advertising nearly quadrupled.

When one looks at the definition of depression in the DSM4 (the psychiatry reference manual) there are a number of criteria, which need to meet for a diagnosis of depression. Some, like a 5% change in weight are measurable; others like reduced concentration are subjective. There are nine criteria of which five need to be present for at least two weeks. There needs to be an impact on the person’s ability to function either at work or socially.

This area is a touchy one. Many people feel bad, feel stressed or have issues that trouble them. These people may need assistance to get through a difficult time. There is a tendency to label many of this group as being depressed. The rise in prescriptions in part represents a reclassification of stress as depression. The two may overlap but are not the same.

The de-stigmatizing of mental health has been a good thing. Mental health issues are no less real than any other. However, it has also led people to feel that having a bad hair day is somehow the same as having depression. I am staggered by the number of people who feel that because they are facing challenges in their life; feel that they have got “a bit of depression”.

When “bad” things happen it is as normal to feel down, as it is to feel happy when “good” things happen. To feel down after a relationship breakdown or job loss is no more abnormal than to feel happy after winning a lottery. There is a range of human emotion and feeling-all of which are valid.

We need to be careful about medicalizing the human condition. Claims that three year olds can have depression demonstrate this tendency.  Children, like adults can have emotional and behavioral problems and those problems need help. This is not the same as saying they have a medical illness requiring a drug.

It was Sigmund Freud, no less who in 1926 warned that if psychoanalysis fell into the hands of doctors that the human psyche and its nuances would be reduced to an illness to be treated. I suspect if he were alive today he would be horrified at how pharmacology now dominates the field of psychiatry.

Without the dark we could not understand light. We all have lessons to learn in our lives. It is from the hardest times that the greatest growth and learning’s come. Some people will need medication to get them through or at least started. For a reasonable number of people who are experiencing life’s “downs” the answer is more likely to lie in confronting and resolving the issues rather than in a tablet.

Joe Kosterich is a physician in Australia who blogs at Dr. Joe Today.

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  • Health n Fitness Care

    Depression has become a major problem in the recent years and it has been increasing at quite a pace.Though many alternative treatments have also come up to tackle the problem, like yoga and other exercises to keep oneself healthy and fit, still its increasing day by day. May be we have to rethink about the fast and stressful life that we are leading today.
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  • Anirudh

    It is very true, that from the hardest times the greatest growth and learning comes. Every human being is different and this difference can be genetic or emotional build up of the individual. Certain individuals can snap out of a major set backs or failures in a couple of hours and some just cannot let it go and wallow in their misery forever. A little help from Psycho-pharmacology for the later may definitely help them come out or cope with the set-back or grief that caused them to be depressed.
    The psycholgy part of the treatment is underated as today’s fast paced world needs instant solutions or the case would go to the next “shrink” down the street. So I feel that the psychiatrist are cornered in a way to prescribe medication to make their clients feel better faster. The media is the main culprit as it potrays to the young and this fast paced world that everything ought be “perfect”. The patients need to be educated that it is normal to be, down or low. Being down or depressed is not like a headache or pain that you pop a pill everytime you get it.

  • Heather Haley

    Wow, the facts about rising suicide rate are taken completely out of context here. 1) Elderly have the highest risk of suicide and what is the population demographic trend of the last 25 years?
    2) Actually, adolescent suicide rates increased after the addition of the black box warning on antidepressants because fewer people were receiving antidepressants.
    The author has some good points but also misses several key issues. Routine use of depression screening scales the PHQ-9 could reduce stress being diagnosed as depression. Good depression management overlaps with good stress management, which is multi-disciplinary, including exercise and psychotherapy.

  • David Behar, MD,EJD

    People who commit suicide almost never have anti-depressants in their blood. The likes of this article, discouraging adequate treatment, will promote suicide.

    The more severe, dangerous, and disabling the depression, the more of a candidate for medication treatment. Depression is a disinhibited brain condition, with emotions coming out for no environmental reason, along with measurable elevations of stress hormones.

    There is an insurance company funded witch hunt against brand name medications. Responsible doctors should not collaborate with it.

    • Dr Joe

      Use of antidepressants has increased over the last 15 years without any reduction in the suicide rate.It has also been shown that in mild and moderate depression SSRI’s are no more effective than placebo.
      Over diagnosis and over prescribing is not good medicine.

      • David Behar, MD,EJD

        There was a marked reduction of suicide rate in the US until the irresponsible decision of the FDA psychopharmacology committee to place a black box warning took place. They are responsible for the unnecessary deaths of 1000′s of people by suicide. I have called for the resignation of all of them, except for the statistician who voted against the warning.

  • Greg

    I don’t know what the situation is in Australia, where the author is from, but here in America, getting patients into psychotherapy treatment is a Sisyphean task. Especially for patients on public insurance (Medicaid/Medicare), my tasks of finding a therapist who will see a patient weekly usually ends poorly, with both the patient and myself frustrated at the system. When I talk to psychologists in the neighborhood, they tell me that since the govt and most insurance companies pay very little for psychotherapy treatment, to see Medicaid patients would pretty much put them out of business, and so they have to limit their practice to exceptionally “good” insurance and cash-only.

    While I agree that depression is a severe illness, and that medication has been a godsend for many people, I think most primary docs understand that the pill isn’t an answer to every question, especially mild cases. But the answer we want (psychotherapy) is unavailable to many of our patients, so sometimes we have to choose a different path out of necessity.

  • Peggi

    I’d sure like to know where Hayley and Dr. Behar get their “data”. I agree that suicide rates are likely to go up as the population ages, but I am not aware of data to support that fewer adolescents received medication when the black box warnings appeared or that medication would have helped them. I’d also like to know where the data is about which suicide victims have antidepressants in their systems of not. Sounds like a theory to me, not a fact.

  • L.

    “Every human being is different and this difference can be genetic or emotional build up of the individual. Certain individuals can snap out of a major set backs or failures in a couple of hours and some just cannot let it go and wallow in their misery forever.”

    It is this attitude that must be stopped. Real depression is an illness. A person can no more easily “snap out” of a depression than snap out of a cancer diagnosis. Not being able to “let it go” and continue to “wallow” are not CHOICES.

    The author implies that depressed individuals are weak because they cannot cure themselves.

    ANIRUDH : Educate yourself, or speak not of what you do not know.

    • Dr Joe

      No ,the author states that not all people who have issues to deal with in life suffer a medical disease needing medical treatment.Human emotion is not a disease.

      • David Behar, MD, EJD

        Dr. Joe: I plunk down a $million in cash. Could I get you to cut yourself or to kill yourself? Say, you were desperate for money and wanted to those acts, your brain would still put up a resistance, and you would have to force yourself to do so.

        The depressed commit suicide and injure themselves for no advantage. Their brains are quite different from yours and mine. Even if their suicide is well reasoned, the idea is the ultimate delusion and false belief. The suicidal patient requires treatment not just with anti-depressants, but with a more immediately acting neuroleptic tranquilizer. The latter would address impulsivity, the unifying feature of suicide across all diagnoses associated with suicide.

        • gzuckier

          Honestly, I’d rather have two broken legs and normal affect than be physically sound and have a depressive illness. Emotional illnesses not only don’t elicit the same sympathy as physical problems (and often tend to drive people away) but they really do hit YOU the person, not just your body which is kind of just the hardware.

  • Peggi

    To L: certainly your position that depression is an illness is one that deserves respect but that does not mean ANIRUDH’s opinion is to be denigrated. While depression may be an illness or a disease, I don’t think we yet have any biologic markers or indicators for that any more than we have them for schizophrenia so it seems important to me to be open to different opinions on this. There is no blood test, no Xray, no MRI, no CAT scan…no anotomical or physiciological “proof” at this point. The work of Dr. Peter Breggin and the work of Dr. Thomas Szasz deserve as much consideration as the prevailing “medical model”. Just saying.

  • Alice

    I thought exercise was the most potent prescription a doctor can recommend? I have read tests that showed when a person exercises consistently after three months they are in better shape mentally than the medicated patients. But it’s a profitable business, and it’s all about treating the intangible. Ultimately, I think our expectations are far too high. We are seeking materialism which rarely pans out on an emotional level…….it’s just wallpaper on life.

    • T

      Well I exercise 6 to 7 days a week, and while I feel great WHILE I am exercising it does little to help me overall. Maybe it does and I’d be a mess if I didn’t exercise, but I get mildly depressed in the fall/winter and I def have anxiety. However, I don’t want to take medication and I have seen psychologists, which really didn’t help. I just deal with it as best I can.

  • David Behar, MD,EJD
  • Peggi

    Dr. Behar, thank you for the link but I gather that it indicates PLANS for a toxicology test on suicide victims to conduct a sturdy….a plan I think is an excellent one…but I gather we don’t yet have statistically valid data about whether or not victims have psychotropics in their system or not. Right? Certainly would be helpful to know.

  • PharmD

    As I heard at a recent symposium by a neurologist “You cant medicate reality”

  • Peggi

    PharmD: we sure do try though, don’t we?

    • Dr Joe

      Sad but true Peggi.

  • Alice

    Such truth in that statement…reality is what it is and no drug can change that….yet…..when my daughter was diagnosed with cancer and doctor error caused a spread….I watched her drink the promising radiation…it did not work….my mind went into a high gear….I could not sleep…. lost weight. …anxiety to the max…dreaded doctor appointments….I actually considered street drugs just to stop my brain and have one day of not watching my daughter suffer. I, obviously, wouldn’t do that but the agony felt like a fulltime torture of the mind.

    I believe drugs are a last choice (and sometimes counseling works well to learn how to cope), but even though you cannot change reality, you can give a crutch to help the brain deal with those unchangeable circumstanced.


    “Is surveillance of postmortem toxicology a useful way”

    As Peggi said…this article provides a potential hypothesis only. It does not seem to address whether antidepressants were prescibed but not taken………or present in post mortem toxicology by not take appropriately.

  • horseshrink

    I find the model of hypertension to fit depression/anxiety well.
    * Heritable vulnerability
    * Variable phenotypic expression – usually dependent upon lifestyle factors
    * Both somatic and cognitive-behavioral interventions work. For many, the latter obviates the former, but is less utilized because more effort is required from the patient (and doctor.)

    In contemplating lifestyle factors, and evolutionary variables, I’ve come to conclude that much morbidity is fundamentally related to a mismatch between atavistic wiring and the qualities of our modern lifestyles that we’ve accepted as “normal” through recent generational habituation. Trouble is, our wiring didn’t change to match our lifestyles.

    Thus, the recently evolving “discoveries” that social connectivity, purpose and regular exercise mitigate depression and anxiety! Once upon a time, we spent our days in tribes with generational histories and stories, scouring the land for our next meals (while avoiding becoming a meal ourselves.) For that we are still wired, for better and for worse.

    We are not wired to sit at keyboards in grey cubicles for 40.0 hours a week, stuffing our insatiable bellies with candy bars and sodas, and then hiding in our houses, where we hold down couches that we might spend hours staring at TVs. And from the resulting angst emerges a hope that the good doctor will restore happiness … with a pill, just like the TV says.

    • Dr Joe

      Very astute observations. Your last sentence is poetic and sums up the problem.

      • horseshrink

        Finished psychiatry residency in ’92.

        Many thousands of patients’ stories and much difficulty in my own life (largely self-inflicted) was required to formulate that opinion.

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