2011-10-20

What's the Over/Under on Depression?

The health blog over at Time Magazine's website has a fascinating analysis of the trend in prescription antidepressant use in America. In it, Maia Szalavitz does an excellent job of explaining why, despite a 400% increase in antidepressant prescriptions over the past 23 years, depression continues to be an under-treated medical problem in North America. As Ms. Szalavitz wisely remarks,
The real story here is that depression is depressingly common in America and that depression sufferers aren't getting adequate treatment, especially if they are young, poor or members of a minority group. The study also found that less than a third of those taking the medications had seen a mental health professional within the last year, which means that they probably get their prescriptions as their only treatment from a primary care doctor.
 But our overburdened mental health system isn't a sexy story — at least not compared to tales about heedless, pill-popping hedonists and the antidepressant-makers who supply them.
Now, I should add a caveat here: I don't think under-supply of mental health care is the main culprit in this case. Clearly, prescription rates for antidepressants have been increasing for a long time.

Instead, I think the culprit is under-utilization of mental health care. For decades people have been trying to de-stigmatize mental illness in an effort to reach out to those suffering from it and treat them. But it is an uphill battle. People - even patients currently receiving treatment - tend to convince themselves that suffering from a mental illness like depression equates with being "totally crazy," whatever that really means.

As much as we like to demonize medicine-makers - and as easy as it is to make a target out of anyone who needs psychiatric medication - the truth of the matter is that these medications are a boon to society. We have no good estimates of what the depression rates were, say, 200 years ago. If you believe in clinical depression at all, you have to acknowledge that prior to the invention of antidepressants, no one who suffered from depression received adequate treatment for their condition.

That's relevant because this article, along with many others, repeatedly point out that depression is more common in North America than elsewhere, implying that there is something about the North American way of life that makes us all depressed. In truth, cultures outside of North America are far less tolerant of the concept of depression, to the point that many cultures even refuse to recognize it as a real condition.

Outside of North America, many people suffer violent blowback from their lifestyle choices, women have acid thrown on them or are prevented from educating themselves, poverty and starvation are ever-present threats, bad marriages continue for lifetimes, and so on and so forth.

We know these things happen, and yet somehow when we take a look at our own depression rates, we blame ourselves, musing that it is our wealth, our economic systems, and so forth that cause our depression prevalence. But of course we do - those suffering from depression are so sadly inclined to blame themselves for everything.

So I guess the real question is, what is "crazy?" What is "mental health?" Who gets to decide what mental health is? The mental health community is typically pretty good at defining these concepts in terms of "that which obstructs your life and your happiness is mental illness, that which makes you happy and lets you pursue your life relentlessly is mental health." The problem with that is that a truly deranged person who wishes for nothing else in life than to hurt others would have values exactly opposite to that of everyone else, and the standard of mental health for that person would have to be revised.

There are no easy answers here. Depression is a real problem that millions struggle to overcome. In general, though, I would suggest, as Ms. Szalavitz suggests, that depression is under-treated in this culture and elsewhere.