Some 35 million American adults struggle with depression. The World Health Organization projects that by 2030, the amount of disability and life lost due to depression will be greater than that of any other condition, including accidents, war, suicide, cancer, and stroke.
How have we responded to this gathering danger? Our main response has been biomedical, departing from the premise that depression is a chemical imbalance to be corrected with antidepressant medications. Such an intuitive notion sounds reassuring, yet depression's toll has only risen with the ascendance of antidepressants. Perhaps it is time to rethink our approach.
In this spirit, I submit 10 concerning facts, which, taken together, suggest that antidepressants are not an adequate response to the depression epidemic.
1. Between 1996 and 2005, the overall annual rate of antidepressant treatment among persons 6 years and older soared dramatically -- to 1 of every 10 persons in the United States. This translates to 250 million prescriptions a year, with antidepressants the most prescribed drug class for people aged 18 to 45. These statistics evidence staggeringly high antidepressant prescription rates.
2. A recent study found that pharmaceutical companies spent $5 billion on direct-to-consumer advertising on antidepressants in a single year. One reason behind high prescription rates: The customer asks for it by name.
3. Only 20 percent of antidepressant prescriptions are written by psychiatrists -- a huge volume, and certainly the majority of prescriptions, are written by professionals who have little specialized training in mental health.
4. One in six people who receive antidepressants do not have depression, nor do they have any other psychiatric diagnosis. Another large study found that a minority of people who had been told by their clinician that they suffered from depression actually met full criteria for the diagnosis when they were carefully assessed. Nearly 80 percent of this group was prescribed a psychiatric medication. These data show patterns where real-world assessments of depression are cursory and drug prescription verges on the indiscriminate.
5. One of the main selling points of the disease model of depression is that it reduces stigma, yet major scientific reviews have not found that adopting a biological view of depression has increased social acceptance of persons with the condition. Far from it, recent experiments show that presenting depressed people with the idea that they have a chemical imbalance makes them more pessimistic about the future, does not reduce self-blame, and undercuts their view about whether psychological therapy will help.
6. When FDA clinical trial data are aggregated, antidepressants do outperform placebo pills for people who have severe depression, but there is minimal benefit for mild or moderate depression. Although this result has been reported in major news outlets, the average person continues to be unaware of the modest efficacy of antidepressants for mild to moderate depression.
7. Large reviews show that the efficacy of antidepressants for depression is lower in children and adolescents than it is for adults.Despite this data, national surveys show large increases in the number of children being prescribed antidepressants. In fact, a national sample of children found that over half of children treated for depression received antidepressants.
8. No data demonstrate increases in the clinical efficacy of antidepressants over time. Despite the fact that 26 different antidepressants have been brought to market since imipramine was developed in the 1950s, contemporary antidepressants work about as well as imipramine!
9. According to the largest antidepressant effectiveness study ever conducted, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the majority of depressed patients do not experience long-term remission with antidepressant treatment.
10. As reported by the New York Times and industry sources, pharmaceutical companies have radically scaled back on antidepressant drug development. With few prospects in the pipeline, a breakthrough antidepressant is unlikely to be forthcoming anytime soon.
These are troubling facts. But what to do? Should everyone pour out their pill bottles? Absolutely not.
Antidepressants have had a role to play in the treatment of depression and they should continue to play a role. But the data suggests that we have been expecting far too much. In fact, when it comes to pondering solutions for depression, we've mostly been listening to Prozac. And all this listening has not produced a convincing answer.
We can no longer afford to allow antidepressants to be our sole response to the raging depression epidemic. We must pursue a broader range of solutions.