Don’t keep taking the tablets

The world’s rich nations have doubled their use of antidepressants in the past 10 years, according to the OECD’s annual health report (doi:10.1136/bmj.f7261). Based on estimates of the number of people receiving the average daily maintenance dose for major depression, Iceland has the highest consumption and Korea the lowest. The UK comes in somewhere in the middle. The report says the rise is due to the increased intensity and duration of drug treatment as well as the extension of treatment to milder forms of depression, anxiety, and social phobias.

The trend may come as no surprise to those who have been following this issue, but the actual numbers are impressive. The US National Center for Health Statistics reported that 11% of Americans aged 12 and over were taking antidepressants in 2011. The proportion will be higher than that now. And as Christopher Dowrick and Allen Frances explain, this increase in prescriptions has happened while the prevalence of depressive disorder is unchanged and even falling in community surveys (doi:10.1136/bmj.f7140). Overdiagnosis of depression is now more common than underdiagnosis, they say. This is because the diagnostic criteria are too loose and are too easily stretched. In one study only 38% of adults with “clinician identified depression” met diagnostic criteria for depression.

Other factors are also at play, of course. The authors mention drug company marketing, an “overstrong focus among many psychiatrists on the biological correlates of psychiatric symptoms rather than the psychological, social, and cultural,” and our Western assumption that we have the right to happiness. They suggest that general practitioners may find themselves diagnosing depression to manage uncertainty in the consultation, despite the weight of evidence against a clear benefit of drug treatment in mild depression. The costs include drug side effects and the financial burden on health systems, drawing attention and resources away from people with severe mental health problems.

The latest diagnostic criteria for depression will make things worse. DSM-5, published earlier this year, allows a diagnosis of major depression just two weeks after a bereavement. Turning grief into a mental disorder “substitutes a superficial medical ritual for deep and time honoured cultural ones,” the authors of the Analysis paper say.

What’s to be done? The authors call for the diagnostic criteria for “mild major depression” to be tightened, and for the existing criteria for moderate and severe major depression to be accurately applied. But they, and Stuart Jessup in his patient perspective (doi:10.1136/bmj.f7225), stress that patients with mild or loss related symptoms should not be dismissed or “sent away empty handed.” A diagnosis of depression may not be necessary. Instead they recommend a focus on shared decision making, watchful waiting, and support and information that helps patients to help themselves. And perhaps there is room to hope that the experts currently working on the diagnostic criteria for ICD-11 will show enough wisdom and independence to stem the tide.